Preventing opioid-induced respiratory distress in an outpatient setting

With the increasing volume of procedures being moved to outpatient settings, procedures and processes need to be in place to make ensure patient safety.

The Society of Hospital Medicine has released a set of guidelines to reduce opioid-related adverse events in a clinical setting titled the Reducing Adverse Drug Events related to Opioids (RADEO) Implementation Guide. I had the pleasure of leading the expert panel tasked with developing the guide. The manual is designed as a resource to help clinicians successfully implement a quality improvement program.

In this article, I want to focus on some key precautions to take during procedures in the outpatient setting, as well as upon patient discharge.

Policies:

Outpatient surgery centers need policies that risk reduction for patients receiving general anesthesia and conscious sedation in the outpatient setting. Policies should include pre-operative screening for risk factors including chronic medical conditions, chronic pain and opioid use, and sleep disordered breathing including sleep apnea. In addition, evidenced based guidelines should govern the involvement in anesthesia in the care of patients receiving outpatient surgery.

During Procedures:

Assess and identify at-risk patients for respiratory compromise.

Obstructive sleep apnea (OSA) is a key risk factor for patients receiving opioids. OSA is both extremely common (between 7% and 22%), and often undiagnosed. Because of this, it's important to assess all patients for risk before procedures. I recommend the STOPBang tool as an effective pre-operative evaluation; it's an 11-question checklist with a high sensitivity for detecting OSA.

This assessment goes hand-in-hand with the patient's chronic diagnoses and medication lists, and needs to be communicated to patient providers. Consultation with a qualified anesthesiologist or nurse anesthetist further reduces the risk of opioid induced respiratory failure.

Finally, when dealing with this subset of patients, including those habituated to opioids, multi-modal or opioid-sparing techniques need to be employed.

Employ a continuous monitoring strategy, including capnography.

Significant caution and monitoring is required for any patient receiving oral and IV opioid medications, especially in combination with benzodiazepine medications.

Intermittent pulse oximetry checks are not sufficient to detect the signs of respiratory depression for patients undergoing sedation. We found that pulse oximetry is a lagging indicator of impending respiratory failure, particularly when supplemental oxygen is deployed. This risk is compounded by the likelihood of pulse oximetry to trigger false alarms.

In contrast, monitoring with capnography detects the signs of respiratory depression faster; one study has shown capnography to be 3.7 minutes faster than pulse oximetry. At the St. Joseph/Candler Hospital system, Harold Oglseby, RRT, says that continuous monitoring with capnography gave up to an hour earlier indication of respiratory distress and has provided his hospitals with more than 12 years of event-free use of opioids (listen to the latest interview with Mr. Oglseby here).

Upon Discharge:

Ensure that the patient understands instructions.

Effective prevention of opioid-related adverse events extends beyond the clinical setting. Patients who have received opioids need to be educated that they are at a greater risk, and how to care for themselves at home. The RADEO Guide stressed that the likelihood of patient compliance post-discharge is much greater if education for safe opioid use is started before discharge. This can take the form of pamphlets, handouts, or TV program in patient rooms. Other aspects of a safe discharge include communication with the patient's primary outpatient provider, especially if the patient is chronically on opioids

Conclusion

Above all, protecting patients in an outpatient setting involves a systematic approach to quality improvement that starts with making it easy for clinicians to do the right thing through appropriate tools and interventions. The medicine and the patients can be complicated and clinicians need to have it easy for them to make good decisions and to treat their patients in a way that is going to be effective but safe. This includes successful implementation of procedures, policy, and clinical culture geared towards patient safety.

Clinicians and hospital executives interested in quality improvement and reducing adverse events due to opioids should refer to the RADEO Implementation Guide and to two podcasts I did with the Physician-Patient Alliance for Health & Safety - one on assessing patients and one on continuous electronic monitoring.

The views, opinions and positions expressed within these guest posts are those of the author alone and do not represent those of Becker's Hospital Review/Becker's Healthcare. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them.

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