Transcript Surveillance, Prevention, Control of Infection

Improving Patient Safety
and
Mitigating Risks in the PACU
Myrna Mamaril, MS, RN, CPAN, CAPA, FAAN
Advocacy: Call to Action!
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2002 Institute of Medicine (IOM) Report: To Err is
Human: Building a Safer Health System
Nurses are the largest group of healthcare
providers
Play a significant advocacy role
2003 IOM Report: Keeping Patients Safe:
Transforming the Work Environment of Nurses
Examined the work environment of nurses and
patient outcomes
Since 2005, mores than 200 patients have died
from Alarm Fatigue
What do you think of when
you hear the word -“Fatigue” ?
Let’s examine the risk factors
of nurse fatigue
Perianesthesia Nursing Practice
Culture of Postanesthesia Nursing:
Worked Hours & Risk of Fatigue
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Duty to provide care – focus is on the patient first.
Flow of patients out of the Operating Room
Unpredictability of the OR schedule – cases go later than
expected
Emergencies – unpredictable and require staff to provide
care.
Overflow issues – when there are no inpatient surgical
beds the surgical patient needs to board in the PACU
On call – does hospital management understand that
many times the same nurses that are working during the
day also take call on nights, weekends and holidays?
Dissemination Strategies
Educate our members on nurse fatigue, the consequences,
the prevention, and the Countermeasures
Publications in Breathline and JoPAN
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Clinical Clips Column
JOPAN, Oct 07
“Keeping our nurses and patients safe”
Ellen Sullivan
Pathophysiology Column
JOPAN, Dec 07
“Fatigue: When the “Little Engine That Could” Just Can’t Anymore
Kim Noble
Safety Column
JoPAN, Feb 08
“Fatigue: Do you understand the Safety Risks?”
Jackie Ross
 Poster Session
Celebrate Successful Practices
ASPAN National Conference
May 2008
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Develop as a Position Statement Reference: ASPAN Fatigue Evaluation
Checklist to be used by the membership to assess their current situation
ASPAN FATIGUE CHECKLIST
ASPAN recognizes fatigue among nurses as a potentially dangerous factor that can impact safe nursing
practice and patient safety. Evidence reports personal and professional contributors to nurse fatigue that can
affect patient outcomes, as well as the nurse’s health and job performance. Nationally-known nurse researchers
in fatigue, Dr. Trinkoff and Dr. Rogers, presented evidence on fatigue to an ASPAN strategic work team in August
2007. From this review, a list of factors related to nurse fatigue, as well as its consequences, was comprised and
includes:
Professional (scheduling) factors: on-call hours 6,7, required (mandatory) overtime,1,2,3,6, few or no
breaks during shift 1,2,6, high number of total hours worked in a week,2,3,6,7 shift length >12.5 hours,1,2,3,6,7
number of weekends worked per month1,7 working non-day shifts,1,5,7 worked when scheduled off, 1,2
inadequate numbers of staff.3
Personal factors: Working more than one job6, voluntary overtime,1,2,3,6 working while sick1, inadequate
rest.1,4,6,
Job performance: struggle to remain awake,2,5,,fell asleep at work,2 and some effects on decision-making
and critical-thinking: decreased vigilance,2 increased risk of errors,2,3 lapses of attention,5 delayed reaction
time.2
Nurse health:
Musculoskeletal injury (MSD),1,6 injury by needlestick,6,7 psychological strain,4 sleep
impairment/deprivation,4,5 “spillover” of work strain into non-work time,4 “unhealthful” behaviors (excessive caffeine or alcohol, smoking,
inadequate diet, no exercise),6 drowsy driving.9
Purpose: Inquiry into the topic of nurse fatigue and patient outcomes continues.
The Nursing Organization Alliance (NOA) recommended
that every specialty nursing organization educate their members about nurse fatigue and its effects on nursing practice. The American Nurses
Association (ANA) developed a position statement which recommends every nurse, as an ethical responsibility, should “carefully consider”
her/his fatigue level and has the duty to evaluate personal “readiness to provide competent care.”11 Selected evidence was reviewed with
intention to educate ASPAN members on nurse fatigue and its factors, and the implications of fatigue on the safety of the perianesthesia patient
and nurse.
Assessment:
Factors linked with nurse fatigue were compiled into the following
checklist to educate about fatigue risks. ASPAN
offers this evidence-based resource to healthcare providers for purposes of personal education and self-assessment. All of the factors listed
below can be used in your self-assessment. Some of these fatigue factors can also be assessed by peers and managers and are objective in
nature. Those factors are indicated with an (O). Research has shown that a person can recover from sleep deprivation after two consecutive
nights of adequate sleep (6-8 hours), even after several days of working 12-hour shifts.10 Consider that evidence as you complete the following
checklist.
To assess fatigue risks and consequences, recall your most
recent work experience, then circle each factor that applies to
your current situation:
A. Consider your SCHEDULE
I worked the following:
1. more than 12.5 concurrent hours in a 24 hour period. (O)
2. more than my scheduled hours in the past 48-72 hours. (O)
(Overtime is defined as a worked shift/actual hours worked as
exceeding scheduled hours, whether voluntary or mandated).
3. more than 40 hours in the week. (O)
on-call” hours during which I returned to work for patient care.
(On-call hours are an addition to regularly scheduled hours
and may result in overtime, evening or night shift work,
weekend hours, and significantly increase the total number of
hours worked each week). (0)
5. an evening or night shift. (O)
6. returned to work after fewer than 10 hours off since my last
shift. (O)
B. Consider your WORK ENVIRONMENT:
My work style includes:
1. Work without breaks (O)
2. Work at a high pace. (Work pace is the speed at which
decisions and nursing assessments are made and actions
are planned).
3. Experience of psychological strain while at
work. (Psychological strain includes emotional demands of
work, mental effort, and relationships with peers and/or
supervisors).
4. Work when I was scheduled OFF. (O)
C. Consider your SLEEP and related ISSUES:
Regarding sleep, I have:
1. Difficulty staying awake while at work.
2. Fallen asleep at work
3. Slept fewer than 6-7 hours before returning to
work.
D. Consider your PERSONAL ISSUES:
In my personal life, I have:
1. Worked while sick in the past few days
2. Experienced drowsiness while driving
3. Experienced recent mood changes at
work
4. Worked more than 1 job.
ASPAN Position Statement
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SWT will update and strengthen position statement
utilizing primary fatigue evidence
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Incorporate ASPAN Fatigue Evaluation Checklist
in the
“2008-2010 ASPAN Standards of
PeriAnesthesia Nursing Practice”
Fatigue Countermeasures
Employer Responsibilities
Employee Responsibilities
Appropriate scheduling practices
including sufficient rest periods
between shifts, avoidance of more than
3-4 consecutive night shifts.
Refuse to work more than 12
consecutive hours or more than 40
Hrs. per week.
Avoidance of early shift start times.
Arrive at work “fit for duty,” having
obtained more than at least 6-7
hours of sleep
Control over overtime and the use of
extended shifts
Therapeutic use of caffeine
Provision of adequate break periods
during the shift, and the institution of
policies that allow night shift workers
to sleep during their breaks
Take regular breaks, if insufficient
staffing to take
Dr Ann Rogers
Baltimore, MD
August 24, 2007
PACU Nurse’s Ethical
Responsibility
 Ensure
work practices are healthy and fit
for duty to make cognitive decisions in the
best interest of the patient
 Elements of Negligence
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Duty to the patient
Breach the duty to the patient
Causation
Harm
What do you think of when
you hear the word -“Fatigue” ?
Let’s examine the risk factors
of alarm fatigue
Alarm Fatigue
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The Joint Commission proposal: 2014 National
Patient Safety Goal on Alarm Management
 Results from “alarm” sounding so constant that
health care providers become desensitized,
either not noticing them or ignoring them
altogether
 Peds PACU explored alarm data from the 32
physiologic monitors and discover:
 3463 times the oxygen saturation alarm was
activated in one day
ACCN
Alarm fatigue is a complex issue:
 Unique set of circumstances and vulnerabilities
Hospital and organizational culture
— Nuisances specific to patient unit
 Many variations of common problems
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Apathy for “leads off” and “low battery” alarms
— Communication breakdowns
— Competing priorities
Alarm data are difficult to obtain
AACN 2013
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AACN
Alarm Integration Model
 Clinical device alarms are transmitted to a
central system.
 System communicates with caregiver via
devices such as a pager or telephone.
 System has potential to:
— Relay alarms only
— Attempt to filter out nuisance alarms
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AACN 2013
Johns Hopkins Hospital
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Demonstrated that the number of non-actionable alarms can be
reduced:
Thereby decreasing caregivers’ alarm burden without
compromising patient safety by making modest default parameter
changes;
Standardizing care policies and equipment; and
Providing reliable secondary alarm notification.
The organization invested the time to understand the problem.
Studied and tested various solutions
Shared knowledge among various staff and departments
The project was a collaborative effort, involving contributions from
nurses, physicians, clinical engineers, and IT personnel, as well
as the cooperation of the hospital’s monitor vendor
Peds PACU Alarm Activity
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24 hr. Day Surveillance
70-80 Pediatric Patients/Day
1032 SPO2 Probe Alarms
957 Lead Fail Alarms
695 HR LO Alarms
478 SPO2 LO Alarms
341 Respiratory Rate Alarms 401 Alarms
311 HR HI Alarms
60 Apnea Alarms
Unit-Based Initiative: Revamping
Alarm Management
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Peds PACU Staff analyzed alarm parameters & alarm
levels to determine if they are appropriately set & avoid
duplication.
Alarm parameters should be set to actionable levels to
decrease the number of false or “nuisance” alarms
occurring and increase the likelihood of the alarm being
an actionable alarm so it will not be ignored.
Nurses must be trained to individualize alarm parameters
& levels so alarms that occur are meaningful and
actionable
Institutions would do well to establish an institution wide
standard for management of physiologic monitor alarms
Case Studies on Alarm Fatigue
53 year old male admitted to the PACU
with OSA
 2 year old female undergoing a
circumcision
 38 year old female undergoing an
abdominal hysterectomy
 5 year old male undergoing T&A
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Unwanted Sedation
 Postanesthesia
care nurses should always
be vigilant in assessing the potential for
postoperative opioid-induced respiratory
depression.
1. Inadequate gas exchange
2. Demand for oxygen exceeds supply
3. Failure of lungs to remove carbon
dioxide
“Serial sedation and respiratory assessments are
recommended to evaluate patient response during opioid
therapy by any route of administration.” 1 [Level 1]
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Regular sedation and respiratory assessments during wakefulness
and sleep 1 [Level 1]
Sedation scales with acceptable reliability & validity should be used.
1 [Level 1]
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Unwanted or advancing sedation from opioids is often a sign that the
patient may be at higher risk for respiratory depression, suggesting
the need for increased frequency of assessment of sedation levels
and respiratory status. 1 [Level 1]
“Respirations should be counted for a full minute and qualified
according to rhythm and depth of chest excursion while the patient
is in a restful/sleep state in a quiet unstimulated environment.” 1 [Level
1]
“Serial sedation and respiratory assessments are
recommended to evaluate patient response during opioid
therapy by any route of administration.” 1 [Level 1]
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“Patients should not be transferred between levels of care near peak
effect of medication.” 1, 10 [Level 1, Level 2]
D. Patients found to have signs of respiratory depression, evidence
of advancing sedation, poor respiratory effort or quality, snoring or
other noisy respiration of desaturation should be aroused
immediately and instructed to take deep breaths. 1, 8 [Level 1; Level 3-c]
E. “Technology-supported monitoring (i.e., continuous pulse
oxymetry and capnography) can be effective for patients at high risk
for unwanted advancing sedation and respiratory depression.” 1 [Level
1]
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“Technology monitoring systems that integrate with medication
delivery features, such as modular ETCO2 devices, may interfere
with individualizing analgesia therapy or effective analgesia.” 1 [Level 1]
“Serial sedation and respiratory assessments are
recommended to evaluate patient response during opioid
therapy by any route of administration.” 1 [Level 1]
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F. More vigilant monitoring of sedation and respiratory status should be
performed when patients may be a greatest risk for adverse events:
i. Peak of medication effect 1 [Level 1]
ii. During the first 24 hours after surgery 1, 8 [Level 1; Level 3-c]
iii. After an increase in the dose of an opioid 1 [Level 1]
iv. Coinciding with aggressive titration of opioids 1 [Level 1]
v. Recent or rapid change in end-organ function
(specifically hepatic, renal, and/or pulmonary) 1 [Level 1]
vi. When moving from one opioid to another or one route of
administration to another 1 [Level 1]
vii. Within the first 6 hours after anesthesia 8 [Level 3-c]
viii. During the hours of midnight to 6AM 8 [Level 3-c]
Additive Effect of Opioids
Morphine – End metabolites
 Fentanyl – 80-100 times more potent than
morphine
 Hydromophone (Dilaudid) 5-7 times more
potent than morphine
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Why is Handoff So Important?
 PACU
nurse’s duty to advocate
for safe transfer or safe
discharge!
Improving Perioperative Handoffs
Inside:
- Why improve hand offs?
- Video clip of a poor hand off
- Highlights of baseline study
- New hand off protocol
- New hand off content checklists
Why Improve Handoffs?
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High risk periods for miscommunication
 Associated with increased risk for patient
adverse events.
 In a recent analysis of 240 malpractice cases
involving medical errors, >66% involved
teamwork breakdowns
 errors due to hand offs were twice as
prevalent among physician trainees.
Weinberger,S.E. 2006; Laine,C. 1993; Petersen,L.A. 1994;
Sinha,M., 2007; Orwitz,L.I. 2006
Why improve postoperative hand
Need to
offs?
use Peds
examples
Few examples from PACU events:
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Isolation status not reported to PACU so isolation
precautions were not observed and other PACU
patients were put at risk (multiple instances)
 Multiple reports of missing information issues prior
to patient arrival, and after admission to unit.
 Missing information issues regarding future care
plan
Improving Perioperative Hand offs
Inside:
- Why improve hand offs?
- Video clip of a poor hand off
- Highlights of baseline study
- New hand off protocol
- New hand off content checklists
What did you observe?
 Noisy
 Overlapping
conversations
 Side conversations
 Completely unstructured
 Silos of care
 Lack of Teamwork
Improving Perioperative Hand Offs:
Johns Hopkins Baseline Study
JHH Descriptive Study
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Surveyed 82 nurses &
physicians
Studied hand off
problems
Conducted a series of
focus groups to discuss
potential interventions
Top 5 issues:
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Different communication
styles
Providers not at bedside
Simultaneous tasks of
technology and
information transfer
Reduced opportunity to
ask questions
Handoff Content Checklist: Surgery
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Actual Surgery Performed
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Surgical findings (anticipated & unanticipated)
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Surgical complications
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Drains/tubes — location, number, and type
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Special instructions
e.g. “chest tubes to suction for 12 hrs”
“remove NGT in 6 hours”
“nasal cannula sutured in naris” etc.
2011 JHH PACU Studies
Handoff Content Checklist: Surgery
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Actual Surgery Performed
□ Patient Disposition (home, floor, IMC/ICU) and if to
be discharged provide discharge instructions
□ Responsible 1° service (medicine, ortho etc.)
□ Who to Page
Conclusion: “The thing that I am most concerned
about in this patient is __________.”
2011 JHH PACU Studies
Handoff Content Checklist: Nursing
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Actual surgery performed
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Isolation Type (if applicable): Contact, Airborne …
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Lines - IV , CVP, Art line , PiC Line ...
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Drains - Foley, JP, Davol, Neprostomy tube …
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Skin Inspection e.g. alteration of skin integrity,
pressure points, location,…
Packing: rectal, vaginal, nasal...
Special Equipment/ Others: Iceman, Vac machine,
SCD Sleeves /TED …
2011 JHH PACU Studies
Handoff Content Checklist: Nursing
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Actual Surgery Performed
Special needs: Wheelchair, chemo,
pacemaker/shunt re-program necessary
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Psychosocial / behavioral issues
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Family Information: Spouse, children …
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Belongings and Valuables
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Events / Concerns
Conclusion: “The thing that I am most concerned
about in this patient is __________.”
2011 JHH PACU Studies
Handoff Content Checklist: Anesthesia
Preop:
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History of Present Illness
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Allergies and CODE status
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Meds- specify which taken prior to surgery
(esp. beta blockers, sedatives, antibiotics)
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Baseline vital signs; height; weight
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Baseline physical exam –
neurologic, demeanor etc.
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Baseline labs
2011 JHH PACU Studies
Handoff Content Checklist: Anesthesia
Intraop:
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Airway – intubation technique, abnormalities etc.
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Lines – size, location etc.
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Procedures – blocks, spinal etc.
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Fluid totals
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Paralytic status - relaxed, reversed
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Labs
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Meds: Narcotic totals, antibiotics, anticoagulant,
anticonvulsant , reversal agents etc.
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Key events - e.g. unexpected episode of
SVT/hypotension/hypoxia etc.
Conclusion: “The thing that I am most concerned about
in this patient is __________.”
2011 JHH PACU Studies
Handoff of Care
“The thing that I am most concerned about in
this patient is: this patient received 500 mcg and
40mg Morphine in the OR. Please note the
patient needed to be reversed twice – one in the
OR and 1 hour ago in the PACU.
 The patient had an anterior cervical fusion
 Be sure to watch for snoring as that is a sign of
partial airway obstruction”.
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Advocacy:
“From Silence to Voice”
“Today’s nurses have a critical opportunity to affect the
future of nursing….
Nurses can have a profound impact on healthcare if, and
only if, they will work together and speak out.”
Dorothy Novella