Physician-Patient Alliance for Health & Safety: Don’t Post-Surgical Patients Deserve Better Care?: Patient Deaths Underscore Need for Continuous Electronic Monitoring

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Physician-Patient Alliance for Health & Safety encourages the adoption of the Anesthesia Patient Safety Foundation (APSF) recently released recommendations to improve the safety of patients by continuously monitoring patients following surgery. Patients recovering from surgery are often put on patient-controlled analgesia (PCA) pumps to manage their pain. Unfortunately, the same monitoring standards that are observed in operating rooms are not always applied post-surgically. Tragically, for example, Louise Batz died from a preventable medical error after recovering knee surgery and 11-year old Leah Coufal died after elective surgery for fairly common condition caused by an overgrowth of cartilage. Both of their PCA pumps were not continuously electronically monitored.

Real-Time Monitoring Would Have Saved Leah

“Continuous respiratory monitoring, including the use of both capnography and pulse oximetry, is essential for the safe administration of patient-controlled analgesics,” explains Dr. Daniel Sessler.

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The Physician-Patient Alliance for Health & Safety (PPAHS) encourages the adoption of newly released guidelines by the Anesthesia Patient Safety Foundation (APSF) to improve the safety of patients following surgery. Patient deaths underscore need for continuous electronic monitoring of post-surgical patients.

Patients recovering from surgery are often put on patient-controlled analgesia (PCA) pumps to manage their pain. Unfortunately, the same monitoring standards that are observed in operating rooms are not always applied post-surgically. Tragically, for example, Louise Batz died from a preventable medical error after recovering knee surgery and 11-year old Leah Coufal died after elective surgery for fairly common condition caused by an overgrowth of cartilage. Both of their PCA pumps were not continuously electronically monitored.

According to the HealthGrades study of patient safety in American hospitals, “failure to rescue” and postoperative respiratory failure (also known as “Code Blue”) are the first and third most common patient safety related adverse events affecting Medicare patients accounting for 113 events per 1,000 at-risk patient admissions.

“These adverse events which affect both Medicare and non-Medicare patients result in death or anoxic brain injury in the majority of cases,” observes Dr. Daniel Sessler, who is Professor and Chair of the Department of Outcomes Research at the Cleveland Clinic, and Director of the Outcomes Research Consortium which is anesthesia’s largest academic research organization. The Consortium conducts research in anesthesia, critical care, and comprehensive pain management.

“Continuous respiratory monitoring, including the use of both capnography and pulse oximetry, is essential for the safe administration of patient-controlled analgesics,” explains Professor Sessler. “A patient experiencing respiratory depression, if undetected, can easily progress to respiratory arrest and consequent brain damage or death."

A capnograph is a monitoring device that measures the concentration of carbon dioxide" that a person breathes out in exhaled air and displays on a numerical readout and waveform tracing; and a pulse oximeter is a device for measuring the amount of oxygen in blood.

To improve patient safety and health outcomes, the Anesthesia Patient Safety Foundation recently released recommendations calling for continuous electronic monitoring of oxygenation and ventilation.

As Dr Robert Stoelting (President, Anesthesia Patient Safety Foundation) explains, “Clinically significant drug-induced respiratory depression (oxygenation and/or ventilation) in the postoperative period remains a serious patient safety risk that continues to be associated with significant morbidity and mortality.”

How monitoring is currently conducted on postoperative patients may not be enough. As the APSF recommendations state, “Intermittent ‘spot checks’ of oxygenation (pulse oximetry) and ventilation (nursing assessment) are not adequate for reliably recognizing clinically significant evolving drug-induced respiratory depression in the postoperative period.” In other words, better monitoring for patient safety is needed and APSF recommends that use of current technology to improve patient safety.

Moreover, as the APSF guidelines provide, using capnography and oximetry monitoring on all postoperative patients is recommended, and not just for patients who may have an obvious increased risk of postoperative respiratory insufficiency (such as those with obstructive sleep apnea, obesity, or chronic opioid therapy).

Observes Dr. Frank Overdyk (Professor of Anesthesiology and Perioperative Medicine at the Medical University of South Carolina), “Serious postoperative adverse events such as deaths and anoxic brain injuries due to opioid acute pain management are a significant and preventable threat to patients, for which all institutions and healthcare providers must have zero tolerance".

However, waiting for future technology to manage this issue is not acceptable. As Dr Stoelting explains, “Future technology developments may improve the ability to more effectively utilize continuous electronic monitoring of oxygenation and ventilation in the postoperative period. However, maintaining the status quo while awaiting newer technology is not acceptable” [Dr. Stoelting’s emphasis].

About Physician-Patient Alliance for Health and Safety

The Physician-Patient Alliance for Health and Safety (PPAHS) is an advocacy group devoted to improving patient health and safety.

PPAHS is currently developing a safety checklist targeting the use of patient-controlled analgesia (PCA) pumps: http://wp.me/p1JikT-8O

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