Continuous monitoring of patients receiving opioid therapy to prevent opioid-related respiratory depression certainly offers the hope of reducing devastating outcomes from our well-intended efforts to assure patient comfort. However, in this climate of rapid, high-tech, outcomes-driven healthcare, it is essential to keep in mind the end user—particularly the bedside nurse.
In most hospitals, nurses employed in critical care settings are very comfortable with monitors and more advanced forms of technology. Critical care nurses generally have extensive classroom and clinical orientations to the care of the critically ill patient. Patient assignments are usually limited to two to three patients per nurse as the patient requires closer assessment and more frequent interventions. Even non-intubated patients are often sedated slightly, allowing for compliance with the use of monitoring equipment such as nasal cannula capnograms. In this environment, there is ample opportunity for daily exposure to monitoring techniques, ample interaction with clinical resource staff, including advanced practice nurses and physicians to support knowledge gaps and provide guidance. Thus, continuous monitoring directed at preventing respiratory distress can be well integrated into routine patient care and may be valued by the nurse as an assessment tool that contributes to clinical decision making.
Contrast this situation with continuous monitoring on the general floor. These nurses often have less classroom instruction and shorter clinical orientation periods, less clinical experience than their critical care counterparts, have patient assignment ratios of five (or more) patients to one nurse, are less experienced with monitoring devices, and have less direct daily contact with resource staff. The activities involved in caring for multiple patients often distract the nurse from individual patient’s needs and monitoring activities. Alarm fatigue is a well-recognized phenomenon: Infusion pump alarms, venous compression device alarms, bed alarms, patient call bell systems, as well as oxygen saturation and capnography alarms contribute to what may become white noise for the nurse who is focusing on accomplishing assigned tasks, as well as responding to unplanned patient and patient family requests in a timely fashion. In such a situation, continuous monitoring may be regarded as a nuisance, particularly if accompanied by frequent false alarms, patient complaints, and complex data.
Certainly, continuous monitoring of patients receiving opioid therapy may be equally or even more beneficial on the general floors where patients are less likely to be in the nurses’ “line of sight” at all times. The challenge is to equip the nurses, who are the least comfortable and familiar with technology, with the knowledge and skills necessary to use the technology and critically analyze the data in assessing patients and in taking action when warranted. It is imperative that the monitoring systems be simple to set up, acceptable to patients, and provide data that is easily viewed and interpreted, with history retrieval and trend information.
Nurses need to view particular monitoring practices as useful in order to advocate for the use of such monitoring. In a recent survey of pain management nurses who are members of the American Society for Pain Management Nursing (ASPMN), 75% of the respondents reported continuous pulse oximetry monitoring as useful and 48%of the respondents said the same for end tidal carbon dioxide monitoring, while 98% described a nurse’s ability to see the patient and use a sedation assessment scale as a useful monitoring practice (Junquist et al., 2014). If monitoring devices fail to provide data that is useful or easily viewed and interpreted, it is unlikely that they will be employed as intended. If patients are dissatisfied by monitoring tubing or probes, wires, and false alarms, they will not comply with the use, therefore contributing to both patient and nurse dissatisfaction.
In this same survey, nurses reported that in the previous two years, they had noted an increase in screening for patients at high risk for advancing sedation and respiratory depression and an increase in measures to better identify and monitor these patients. This increased focus is perceived by 78% of the survey respondents as having resulted in improved patient care, yet some reported concerns that the increased focus on risk has made providers more reluctant to prescribe opioids (23%) and has created obstacles that lead to poor pain control (17%).
So, is continuous monitoring really the answer? What is really needed is integration. There is no one clear answer here. Education is essential. A culture that highly values safety is critical, and an environment that supports the use of technology in optimizing patient safety is of great importance. Technology which supports nurses’ efforts to provide effective and safe patient care may be well within our grasp, but first and foremost, efforts to support the nurses’ recognition of the patient with advancing sedation are essential. If false alarms, complex screens, meaningless data, and patients with complaints about alarms and tubing distract the nurse from assessing the patient who has recently been given an opioid, the value of such technology will be lost. It is imperative for industry to partner with nurses, the end users, in educational efforts and other endeavors to develop accurate, cost effective continuous monitoring devices. Continued development of technology which retains data to support research efforts aimed at recognition and prevention of opioid induced respiratory depression is necessary.
Maureen F. Cooney, DNP,FNP,BC, is a nurse practitioner in pain management at Westchester Medical Center in Valhalla, NY. She spoke at the Nov. 14 inaugural meeting of the National Coalition to Promote Continuous Monitoring of Patients on Opioids, organized by the Healthcare Technology Safety Institute.