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Culture of Safety Includes Capnography

Capnography becomes an evidence-based standard of care at one large hospital.

The culture at St. Cloud Hospital in St. Cloud, Minn. invites each of us to ask questions, discuss patient safety action plans and develop caregiver safety When an educator in the imaging department read current articles relating to procedural sedation in imaging and asked a few very important questions, capnography soon became an evidence-based project, with staged implementation, that was completed in March 2014.

We have used capnography as a standard of care in anesthesia cases and ventilator management for many years and now non-invasive use of capnography is a standard of monitoring at our institution. This article examines our process and the value of the modality. We looked at patient monitoring practices in the outpatient procedural areas and we addressed the very real issue of too many alarms on the hospital patient floor. We also undertook a literature review for the project as we prepared to consider implementing capnography outside the operating room at our institution. The articles we consulted were:

  • The Joint Commission's Sentinel Event Alert in August 2012 "Safe Use of Opioids in Hospitals."
  • The American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists' Practice Guidelines for Sedation and Analgesia .
  • "Information from Monitoring Opioid-Induced Sedation and Respiratory Depression," by Jarzyna et al.

Capnography Application & Utility
We know that narcotics and sedatives can cause respiratory depression in post-operative patients and during recovery periods. The goal of the capnography project was to decrease the number of medication-induced respiratory events. 

Pulse oximetry is a great tool but healthcare professionals must understand its purposes and limitations.  Pulse oximetry is measured as a saturation of hemoglobin and this may take minutes to get a more accurate reading after oxygen delivery changes.  I believe  caregivers often turn up oxygen flow to get a saturation reading they like and don't always consider the reasons for the patient's physiological responses such as a drop in saturation.

Pulse oximetry is a late sign for a concern in a patient.  The patient's metabolism, respiratory system and circulatory system all play a role in ventilation and perfusion.  Nurses are excellent at medication administration and all caregivers may benefit from tools that show the clinical changes in real time.  One key point we have seen is the importance of knowing sedation medications: the onset of action, the half life, the duration, and reversal agents. 

SEE ALSO: Remote Pulse Oximetry

When a patient is given hydromorphone and the end tidal monitoring drops below the alarm limit in fifteen minutes, the caregiver should evaluate the medication delivered and the possible respiratory depression effect on the patient.  The widespread use of electronic medical record (EMR) now facilitates the opportunity to tie data together and connect the puzzle pieces for teams working on shifts.

Implementing Monitoring Practices
Monitoring patients, especially when their breathing is shallow, can get tricky.  In my practice, I have had to focus on chest rise to see if the patient is taking a breath, and always consider any upper airway obstruction in the respiratory assessment.  While impedance devices will continue to show normal breathing, they do not capture airflow events from obstructed airways. 

For caregivers, it's important to understand that capnography is not meant to be more work but an additional tool in monitoring patients.  It cannot replace nursing vigilance and critical thinking. Other levels of caregivers often have job responsibilities to gather vital signs and it is important to have all clinical staff partner in patient monitoring.  Capnography is an additional tool for early recognition and intervention before serious events occur.

"Capnography is an additional tool for early recognition and intervention before serious events occur."

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It's imperative to understand the use of trending in the patient data.  Interventions need to be documented so shift to shift we have consistent reports and messages. Our policy allows an RN or RT to implement capnography if there are concerns with a patient.   In my mind, any patient care unit that is monitoring patients becomes similar to the "intensive" care environment for the period of time that monitoring is occurring and all of us need to be vigilant until the patient is back to baseline. Devices with advanced alarm technology can provide information as to the specific alarm when caregivers are outside of the room. 

Optimal Alarm Environment
We are sensitive to alarm fatigue for the clinical staff and we set out to examine the problem.  We were able to work with a surgical care unit for a trial period. During the trial, we met every afternoon, reviewed concerns, and welcomed all input.  We used our trial comments, gathered literature, and reviewed manufacturer's guidelines to determine the optimal alarm values for our organization.  Nurses are able to adjust individual alarm values for specific patient conditions. 

Like many other organizations, we are reviewing literature, the Joint Commission's sentinel event alert on alarm fatigue, manufacturer's recommendations, and collaborating with a multidisciplinary team to evaluate our alarm practices.  Currently the progressive care units are talking with providers about actions for the alarm settings of PVCs.  

Here is an example that resulted in fewer alarms occurred after an evidence-based practice project on oximetry: Traditionally with SpO2 alarm management, the monitor will alarm when the saturation falls outside of the alarm threshold - no matter how minor or short the duration. Most users do not want alarm notification to occur for very brief or small changes in saturation.  We needed to review our alarm management system that analyzes SpO2 events to avoid triggering alarms unnecessarily.   It is an alarm management system that calculates the duration of the event multiplied by the number of percentage points that SpO2 falls outside of the saturation alarm threshold.

We evaluated the "SatSeconds" default set on bedside pulse oximeters and saw that we could increase the SatSeconds, experience fewer alarms without negatively affecting patient care or outcomes.

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Capnography Improves Patient Outcomes
I do not believe that one tool alone can make all the difference, but feel we should embrace monitoring tools that complement our vigilance for patient safety. Providers, caregivers, patients and families need to understand the dangers of opioid treatments that we provide.  While none of us carry a sign that says "I am at risk", using appropriate monitoring tools, on selected patients, may save a number of lives.  

For instance, an intubated patient in the recovery room was extubated when he was clinically observed to be stable.  After extubation , the ETCO2 reading was low,  and combined with a full respiratory assessment showed the patient was not maintaining his airway and needed to be reintubated.  He remained intubated for a few hours and ultimately had a normal length of stay.

In another situation, when the patient's ETCO2 reading was low, the nurse monitored the patient closer, adjusted medications, educated the patient and family on the reasons for the alarms, gained the patient's confidence, and met the patient's satisfaction goals.

Our hospitalists use capnography and find it useful in balancing pain and sedation, especially in the opioid tolerant patient.   After careful deliberation, our experience shows that capnography should be a standard of care at our institution.

Peggy Lange is a registered respiratory therapist at St. Cloud Hospital, St. Cloud, Minn.

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