St Joseph’s Hospital and Candler Hospital, a 644-bed tertiary care hospital system and the main facilities of St Joseph’s/Candler Health System (SJCHS) in Savannah, Ga, are two of the oldest continuously operating hospitals in the United States. Both hospitals are individually accredited by The Joint Commission, and the health system is one of a select few in the country to have achieved network accreditation status. Additionally, SJCHS is the only health provider in the region to have achieved Magnet Recognition Program status for nursing excellence and is noted as one of the country's top 100 integrated health care systems by Modern Healthcare. It is a medical teaching site for Georgia Health Sciences University and is affiliated with several universities for the education of pharmacists, nurses, and other health-related professionals.
Based on information from the Institute for Safe Medication Practices (ISMP) regarding patient controlled analgesia (PCA) safety and after three opioid-related events with serious outcomes in the preceding 2 years, SJCHS embarked on a multiyear process of implementing an advanced IV medication safety system. The team recognized that safe use of PCA requires both correct pump programming and monitoring of patients’ individual respiratory response to opioids. A beta test of monitoring modules integrated with the IV platform was begun in June 2004. Beta testing revealed the difficulty of predicting which patients actually were high-risk and that capnography, not pulse oximetry, provided the first indication of opioid-related respiratory depression. As a result, the decision was made to require a capnography module for each PCA infusion and to use a pulse oximetry module for selected patients receiving PCA analgesics who have preexisting comorbidities.
In June 2012, SJCHS celebrated its eighth anniversary of being "event free" regarding opioid oversedation on patients monitored with capnography, setting a standard for other hospitals to emulate. In this interview, Harold Oglesby, RRT, manager of respiratory care at Candler Hospital, talks about the facility's experience with capnography.
We use it in several different ways. We use it in both nonintubated and intubated patients. We use it in our ICU to monitor patients’ ventilation during the intubation or ventilation process. We use nonintubated capnography out on the floors on patients who are receiving opioids. We also use it in our emergency department and on patients who are having procedural sedation.
A lot of the information comes from the research that we've done that has been focused on PCA patients monitored with capnography and the effectiveness gained in monitoring ventilation versus oxygenation. What we found is that we have an earlier recognition of any patient deterioration using capnography versus using oximetry alone. We also have looked at several case studies of patients, and we noted that by the use of capnography, we’ve recognized deteriorating patients early; so it gives us the leeway to take actions before those patients get into any trouble.
Capnography provides a very useful and effective tool to continuously monitor the adequacy of ventilation. Other methods for monitoring a patient’s ventilation don’t give you that same value. When you're looking at capnography, you can see what the patient’s ventilation is actually doing. When you're measuring respiratory rate, be it by direct observation, impedance, or acoustic respiratory rates, you're only getting breaths per minute. It doesn’t tell you the effectiveness or adequacy of ventilation. It doesn’t tell you what minute ventilation that patient is moving. So you can have a patient with a respiratory rate of 12 or 14, but if they’re moving very small tidal volumes, they’re ineffectively ventilating and respiratory rate monitors won’t tell you that. With capnography, you can see what's actually happening with CO2 and whether your patient is being adequately ventilated.
We found it to be a reliable tool for monitoring our noninvasive patients. We found that not only can we monitor changes in the trends, but we can see changes before they’re actively affecting the patients. We can monitor those changes and see what’s happening with ventilation. Not only can we look at trends, but we also can look at waveforms. The waveform gives us details that we don’t get from a blood gas. A blood gas is just a snapshot of what's happening in a patient in a moment.
One of the things we recognized when we started using capnography was the many patients who had unrecognized obstructive sleep apnea (OSA). That was discovered by looking at the capnography waveforms when the patients were being monitored. When we first started, a lot of complaints came about nuisance alarms, but when the therapists went to the bedside to assess the patients, they weren't nuisance alarms—patients were actually experiencing OSA that hadn’t been recognized previously.
Staff education is crucial to making sure they understand what may or may not be a true alarm. When we initially started using capnography, we got a lot of complaints about nuisance alarms. When we actually went to the bedside to work with the clinicians who were new to the system, we were finding that what they were considering a nuisance alarm wasn't really a nuisance alarm. It was an actual problem. Also important is setting the alarms properly. On the postoperative floor, we learned that alarms had to be set differently than we would set them in high acuity environments like the ICU. On our opioid patients, we set our low respiratory rate at six breaths per minute, and it’s set to automatically shut off the PCA at four.
One of the keys to having a successful program was the fact that the respiratory therapy staff was brought in early in the process. For our facility, using capnography was always restricted to the ICU. So when we started to expand it outside of the ICU, we were dealing with novice users of capnography. On the general care area, it wasn’t something that medical/surgical nurses were familiar with. The respiratory therapists were very familiar with it. The bedside education by respiratory therapists and the medical staff was a key component. When nurses had issues at the bedside, the therapists could tell them what was going on. They could look at the trends and waveforms together. The same thing happened with physicians who were less familiar with capnography on nonintubated patients.
We had courses that provided a lot of detail to help the nurses get familiar with capnography, but a lot of the education, a lot of the "ah-hah" moments, occurred at the bedside. So if the patient was experiencing difficulties, the nurse and a "super user" (internal expert like the RTs) could look at the trends, look at the waveforms, look at the values, put those tools together, make their assessment, and make decisions about what to do for the patient. The same thing happened with some of our physicians. We actually had pulmonologists who were questioning whether noninvasive capnography was of use in their patients. One of our pulmonologists with the most questions used capnography on a patient he was nervous about. He said, “Well, let's try capnography on this patient and see if it’s going to work.” Well, not only did it work, but when his patient deteriorated on the floor, it was caught early. After that, the physician wanted all of his patients on capnography.
I think of a 32-year-old guy who came in and was a user of high doses of hydromorphone (Dilaudid) for sickle cell. The benefit for him using capnography was that a nurse was better able to meet his pain needs because she had the backup of capnography. She had a good understanding of monitoring that patient’s trend. She could monitor his ventilation. So there was less fear of oversedating him, because if she had gotten to that point, she would have seen changes in the capnography.
We had another patient who was a post-op and had no significant comorbidities. This should have been a clean postoperative recovery, but the patient started showing changes with increased respiratory rate and decreased end-tidal CO2. Then we noted that the patient’s saturations had started to drop—the patient had a pulmonary embolism. So it gave us an early indication of what was going on with this patient, a lot earlier than what would have been recognized without having capnography in use.
It’s really important for us because the earlier we recognize it, the earlier we can intervene. If we are intervening earlier, usually we can use less invasive modalities to rescue the patient. We won't have to intubate the patient. We could do noninvasive ventilation. We can resolve the problem before it becomes something that requires the patient to move to a higher level of care. We don't want to intubate a patient and put him on a mechanical ventilator unless we have to. We don’t want to do CPR unless we have to. We want to avoid those things.
When we first started discussing monitoring patients with capnography, it was a question of do we really want to monitor everyone with capnography or do we want to monitor everybody with oximetry and only certain patients with capnography. So we tried to come up with algorithms of who would be monitored with capnography versus who would be monitored with oximetry. The issue became we don't know who is going to go bad. We don't know whether it’s going to be the 23-year-old guy who came in for knee surgery or if it’s going to be the 62-year-old COPD patient. From a respiratory standpoint, the first question we were asked was what would be a better tool for monitoring ventilation.
For patient safety, capnography was felt to be the best. And when we put it into action, we saw the benefits fairly early on. There were a number of cases. We talk about ah-hah moments all the time here at our facility; we had a lot of ah-hah moments on patients who we did not think would need capnography, and they actually benefited. From the respiratory therapist and nursing standpoint, once capnography is put into place and everybody is educated on its use, they will have a lot of ah-hah moments and they will recognize patients who probably would have had poor outcomes and cost the facility a lot more money than the capnograms cost.
Patient education is the key. A well-educated patient and family are key to having successful compliance with using capnography. Once the patients and the families understand that it’s being done for safety, for their safety, they’re much more compliant. They don’t have any issues wearing the cannulas.
I think that what we found after we introduced capnography, and particularly after everybody became comfortable with using it on the floors, was a significant decrease in the number of rapid response calls to the floor. Because therapists were already going to the floor once a shift and assessing the patients, if they saw changes in trends, they would get with the nurse; if clinical intervention needed to be done, it would be done at that time versus when a patient was bad and the nurse had to get a team up there to intervene with the patient. When we noted patients deteriorating, we saw a decrease in the number of times those patients had to be transferred from the floor to critical care. Because it was early on in the patient’s changes, we were able to intervene and solve the problem on the floor before the patient needed to be transferred to a higher level of care. The patients who were being moved to the ICU needed to be in the ICU. Patients who needed naloxone (Narcan) at the bedside were giving naloxone at the bedside. The problem was resolved.