Opioid use results in decreased respiratory rate, low oxygen saturation, and sedation, a condition known as opioid-induced respiratory depression (OIRD), which may result in serious harm—including death or brain damage. About 300,000 in-hospital cardiopulmonary arrests (IHCAs) occur each year, and in nearly half of those cases, opioids had been administered to patients. Recognizing the risk of inaccurate respiratory monitoring of medical-surgical patients, an interdisciplinary team at a medical center studied OIRD events involving post-orthopedic surgery patients receiving opioids. They discovered that in these cases, monitoring respiratory function via capnography (ETCO2 monitoring) detected 146 episodes of OIRD while pulse oximetry only detected six episodes. To address this problem, they embarked on a two-year project to develop a novel assessment tool to screen med-surg patients for risk of OIRD.
The screening instrument they developed combines preexisting, evidence-based assessment tools and is integrated into the electronic health record (HER). It was piloted in April 2017, introducing a new protocol and providing online, hands-on, and simulation training to 50 staff nurses and respiratory therapists in using the EHR tool, capnography during opioid delivery, using new monitoring equipment, and interpreting the results. Overall, 98% education compliance was achieved prior to go-live for frontline staff and data collected throughout the pilot was used to adjust the process measures of the OIRD screening tool and the implementation of capnography. At the end of the 90-day pilot, there were zero code blue/rapid response team events, zero unplanned intubations, zero administration of reversal agents such as naloxone, and zero unplanned transfers to the intensive care unit. When data was compared to the same 90-day period of the previous year, there was at least an overall reduction of 46% of the four outcome measures. The nursing and respiratory staff have integrated the assessment and protocol as part of the standard of care.