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10 Nov 2020

How to Better Detect Opioid-Induced Respiratory Depression Without Turning Every Unit Into an ICU

By Gregory Eckstein and John Zaleski

Hospitals continue to face massive financial losses in the wake of COVID-19. In January through August 2020, emergency department visits were down 16%, operating room minutes were down 14% while overall adjusted expenses per discharge have increased 17% compared to the same period in 2019, according to the most recent National Hospital Flash Report from healthcare consulting firm Kaufman Hall.

Even with CARES Act funding to lessen the impact, hospitals and health systems need to make difficult cost-cutting choices, which is especially challenging now with additional COVID-19 outbreaks looming in the fall and winter. Protecting patient safety and health is, and always will be, the top priority for hospitals. Staffing, however, is nonetheless their greatest expense.

Increasingly, the solution that balances patient need and financial pressures is for clinicians to practice more efficiently and develop workflows that eliminate the wasted time and effort. In one recent study, this and other forms of waste accounts for 25% of spending in healthcare.

A dual focus on patient safety and efficiency, however, is possible. The monitoring of patients at risk for opioid-induced respiratory depression (OIRD) is an ideal example.

Detecting OIRD A Challenge

In intensive care units (ICU) where each patient typically has at least one clinician attending him or her at all times, detecting OIRD is less challenging due to the staffing ratio, but also close physiologic monitoring facilitates rapid detection of adverse events, including respiration monitoring and capnography, which provide near real-time assessment of ventilation adequacy. In general care post-surgical units, however, staffing ratios are higher and monitoring of patient ventilation using capnography is not often the case unless by exception. Yet, in lower acuity units, pulse oximetry monitoring is more the norm. Pulse oximetry monitoring does provide an important indicator of perfusion and circulation adequacy but is not a real-time indicator of ventilation adequacy.

A limitation of heart rate and oxygen saturation monitoring is that signs of respiratory depression can be missed or delayed. For example, in a study involving 833 non-cardiac postoperative patients, 37% endured SpO2 of less than 90% (the point where supplemental oxygen is recommended) for an hour or more. However, researchers found at least 90% of these hypoxemic episodes were undetected, principally due to the lack of continuous monitoring to catch such events.

Considering vital signs may be recorded relatively infrequently in general care units, oftentimes at intervals of every four to six hours, postoperative patients could experience extended periods in which declining oxygen saturation could remain undetected, thus placing them at much greater risk for respiratory depression. Left unchecked, continuing episodes of respiratory depression can have a snowball effect, resulting in further respiratory depression leading to apnea, anoxic brain injury, cardiac arrest, and death.

Capnography Essential

Capnography monitoring is a common adjunct employed during surgery and intensive care, but less so in general post-surgical units. With nursing staff stretched thin, monitoring capnography in addition to the other vital signs and numerous other tasks, could add considerably to clinician workloads.

Capnography monitoring, however, is more effective at helping clinicians detect OIRD. In turn, it could help nurses practice more efficiently because when an alert is triggered, nurses will recognize that it is possibly an indicator of respiratory depression. By proactively responding to the decompensating patient, nurses can save themselves work, but much more importantly, save a life.

By continuously monitoring patient end-tidal carbon dioxide (EtCO2), respiratory rate (RR) and fractional inspired CO2 (FiCO2) through capnography, nurses can more accurately assess ventilation adequacy and predict the onset of changes in patients’ cardiovascular and respiratory conditions than SpO2 and heart rate alone.

Vitals Plus Enables Focus

Capsule Technologies Vitals Plus monitoring with capnography offers continuous monitoring and remote clinical surveillance of patients in units outside the ICU.  When linked with Capsule Surveillance, Vitals Plus and other medical devices can feed critical patient information, such as the measures captured through the capnography technology, to surveillance algorithms that intelligently alert caregivers to important changes in patient status.

At the bedside, a nurse’s workstation, or on a mobile device, the nurse is informed about relevant changes in the patient’s respiratory health, along with other potential critical events. They can respond when needed, whether that is immediately or in a few minutes, which reduces their daily interruptions and cognitive workload, but most importantly protects the health and safety of the patient.

About the authors

Greg Eckstein is the Director of Product Management for Patient Monitoring at Capsule Technologies. 

John Zaleski, PhD, NREMT, is the Head of Clinical Informatics at Capsule Technologies.

Learn more about Capsule’s Vitals Plus with capnography monitoring.