Have we gone overboard in hospitals in our desire to minimize pain? Several years ago, there was a lot of effort to require hospitals to inquire of patients where on the 0-10 pain scale they fell. This was a good idea for many reasons.
But has it led to overuse of opiates like morphine, particularly those self-administered using patient-
There have many articles on this topic expressing concern about depression of respiration to the point that the patient dies. The Happy Hospitalist explains:
Why is PCA morphine dangerous? Too much medication can cause patients to stop breathing. Opiates, often inappropriately referred to as narcotics by doctors and nurses, suppress the central nervous system's respiratory drive and increases the risk of life threatening apnea. This is the cause of death in a heroin overdose. This is the cause of death in the epidemic of prescription opiate drug overdoses heard about on the news. Many PCA morphine order sets require continuous oxygen saturation monitoring and frequent documentation of respiratory rate as safety mechanisms. This is to protect the patient from experiencing prolonged hypoxemia as a result of too much sedation when no family is available at the bedside.
The Joint Commission published a sentinel event alert on the matter in August 2012. The JC addresses the question of monitoring by suggesting that hospitals should:
Create and implement policies and procedures for the ongoing clinical monitoring of patients receiving opioid therapy by performing serial assessments of the quality and adequacy of respiration and the depth of sedation. The organization will need to determine how often the assessments should take place and define the period of time that is appropriate to adequately observe trends. Monitoring should be individualized according to the patient’s response.
We have to recognize, though, that while ICU patients might have continuous monitoring of respiration, the vast majority of patients on PCA pumps are those on the regular medical/surgical floors of the hospital. They include "normal" (i.e., otherwise healthy) people recovering from orthopaedic surgery and other procedures. But that normality does not exempt them from the kind of respiratory depression cited in the literature.
What is the systemic solution to ensure that the possibility of such a result is minimized? The patients with PCA pumps might have continuous oxygen saturation monitoring, but most certainly do not have continuous respiratory monitoring. The "frequent documentation of respiratory rate" can fall victim to the many other responsibilities and distractions that nurses face. (It was Anita Tucker at Harvard, I believe, who documented that nurses only spend 20% of their time at the bedside. As this article reports, "She learned that nurses' time ticks by in minutes or fractions of minutes; their average task took just two minutes.") Given the demands on nurses and the poor design of work flows with which most of them live, there is a some probability that a percentage of nurses will not accurately assess patients' respiratory rates.
While there are technical fixes to the problem of continuous respiratory monitoring that might prove useful*, I wonder how much of this problem is related to the antecedent decision to reduce pain to a very low level. Is there a standard of care that is presumed to be appropriate by hospitals? Is the goal to drive the pain level down to a 1 or 2, or is the goal to reach a level of 3 or 4? Is there a thought given to the relative risks of different doses for a patient on a PAC morphine pump when the two goals are compared? For sure, reaching a pain level of 0 is noteworthy, but not if it is achieved by killing the patient.
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Disclosure: I am on the advisory board of a company that makes and sells instruments of this sort.
But has it led to overuse of opiates like morphine, particularly those self-administered using patient-
There have many articles on this topic expressing concern about depression of respiration to the point that the patient dies. The Happy Hospitalist explains:
Why is PCA morphine dangerous? Too much medication can cause patients to stop breathing. Opiates, often inappropriately referred to as narcotics by doctors and nurses, suppress the central nervous system's respiratory drive and increases the risk of life threatening apnea. This is the cause of death in a heroin overdose. This is the cause of death in the epidemic of prescription opiate drug overdoses heard about on the news. Many PCA morphine order sets require continuous oxygen saturation monitoring and frequent documentation of respiratory rate as safety mechanisms. This is to protect the patient from experiencing prolonged hypoxemia as a result of too much sedation when no family is available at the bedside.
The Joint Commission published a sentinel event alert on the matter in August 2012. The JC addresses the question of monitoring by suggesting that hospitals should:
Create and implement policies and procedures for the ongoing clinical monitoring of patients receiving opioid therapy by performing serial assessments of the quality and adequacy of respiration and the depth of sedation. The organization will need to determine how often the assessments should take place and define the period of time that is appropriate to adequately observe trends. Monitoring should be individualized according to the patient’s response.
We have to recognize, though, that while ICU patients might have continuous monitoring of respiration, the vast majority of patients on PCA pumps are those on the regular medical/surgical floors of the hospital. They include "normal" (i.e., otherwise healthy) people recovering from orthopaedic surgery and other procedures. But that normality does not exempt them from the kind of respiratory depression cited in the literature.
What is the systemic solution to ensure that the possibility of such a result is minimized? The patients with PCA pumps might have continuous oxygen saturation monitoring, but most certainly do not have continuous respiratory monitoring. The "frequent documentation of respiratory rate" can fall victim to the many other responsibilities and distractions that nurses face. (It was Anita Tucker at Harvard, I believe, who documented that nurses only spend 20% of their time at the bedside. As this article reports, "She learned that nurses' time ticks by in minutes or fractions of minutes; their average task took just two minutes.") Given the demands on nurses and the poor design of work flows with which most of them live, there is a some probability that a percentage of nurses will not accurately assess patients' respiratory rates.
While there are technical fixes to the problem of continuous respiratory monitoring that might prove useful*, I wonder how much of this problem is related to the antecedent decision to reduce pain to a very low level. Is there a standard of care that is presumed to be appropriate by hospitals? Is the goal to drive the pain level down to a 1 or 2, or is the goal to reach a level of 3 or 4? Is there a thought given to the relative risks of different doses for a patient on a PAC morphine pump when the two goals are compared? For sure, reaching a pain level of 0 is noteworthy, but not if it is achieved by killing the patient.
---
Disclosure: I am on the advisory board of a company that makes and sells instruments of this sort.