Improving Patient Safety and Mitigating Risks in the PACU

1. Improving Patient Safety and Mitigating Risks in the PACU Myrna Mamaril, MS, RN, CPAN, CAPA, FAAN

2. Advocacy: Call to Action! • 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

3. What do you think of when you hear the word --“Fatigue” ?

4. Let’s examine the risk factors of nurse fatigue

5. Perianesthesia Nursing Practice Culture of Postanesthesia Nursing: Worked Hours & Risk of Fatigue • 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?

6. Dissemination Strategies Educate our members on nurse fatigue, the consequences, the prevention, and the Countermeasures Publications in Breathline and JoPAN • 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 • Develop as a Position Statement Reference: ASPAN Fatigue Evaluation Checklist to be used by the membership to assess their current situation

7. 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.3Personal 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.

8. 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)

9. B.  Consider your WORK ENVIRONMENT:            My work style includes: 1. Work without breaks  (O)2. Work at a high pace. (Work paceis 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)

10. C.   Consider your SLEEP and related ISSUES:          Regarding sleep, I have: 1. Difficulty staying awake while at work.2. Fallen asleep at work3. Slept fewer than 6-7 hours before returning to work.

11. D.   Consider your PERSONAL ISSUES:  In my personal life, I have: 1. Worked while sick in the past few days2. Experienced drowsiness while driving3. Experienced recent mood changes at work4. Worked more than 1 job.

12. ASPAN Position Statement • SWT will update and strengthen position statement utilizing primary fatigue evidence • Incorporate ASPAN Fatigue Evaluation Checklist in the “2008-2010 ASPAN Standards of PeriAnesthesia Nursing Practice”

13. Employer Responsibilities Appropriate scheduling practices including sufficient rest periods between shifts, avoidance of more than 3-4 consecutive night shifts. Avoidance of early shift start times. Control over overtime and the use of extended shifts Provision of adequate break periods during the shift, and the institution of policies that allow night shift workers to sleep during their breaks Employee Responsibilities Refuse to work more than 12 consecutive hours or more than 40 Hrs. per week. Arrive at work “fit for duty,” having obtained more than at least 6-7 hours of sleep Therapeutic use of caffeine Take regular breaks, if insufficient staffing to take Dr Ann Rogers Baltimore, MD August 24, 2007 Fatigue Countermeasures

14. 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 • Duty to the patient • Breach the duty to the patient • Causation • Harm

15. What do you think of when you hear the word --“Fatigue” ?

16. Let’s examine the risk factors of alarm fatigue

17. Alarm Fatigue • 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

18. 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 • Apathy for “leads off” and “low battery” alarms • Communication breakdowns • Competing priorities • Alarm data aredifficult to obtain AACN 2013

19. 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 • AACN 2013

20. Johns Hopkins Hospital • 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

21. Peds PACU Alarm Activity • One 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

22. Unit-Based Initiative: Revamping Alarm Management • 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

23. 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

24. 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

25. “Serial sedation and respiratory assessments are recommended to evaluate patient response during opioid therapy by any route of administration.” 1 [Level 1] • Regular sedation and respiratory assessments during wakefulness and sleep 1 [Level 1] • Sedation scales with acceptable reliability & validity should be used. 1[Level 1] • 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]

26. “Serial sedation and respiratory assessments are recommended to evaluate patient response during opioid therapy by any route of administration.” 1 [Level 1] • “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] • “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]

27. “Serial sedation and respiratory assessments are recommended to evaluate patient response during opioid therapy by any route of administration.” 1 [Level 1] • 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]

28. Additive Effect of Opioids • Morphine – End metabolites • Fentanyl – 80-100 times more potent than morphine • Hydromophone (Dilaudid) 5-7 times more potent than morphine

29. Why is Handoff So Important? • PACU nurse’s duty to advocate for safe transfer or safe discharge!

30. 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

31. Why Improve Handoffs? • 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

32. Why improve postoperative hand offs? Need to use Peds examples Few examples from PACU events: • 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

33. 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

34. What did you observe? • Noisy • Overlapping conversations • Side conversations • Completely unstructured • Silos of care • Lack of Teamwork

35. Improving Perioperative Hand Offs:Johns Hopkins Baseline Study JHH Descriptive Study • Surveyed 82 nurses & physicians • Studied hand off problems • Conducted a series of focus groups to discuss potential interventions Top 5 issues: • Different communication styles • Providers not at bedside • Simultaneous tasks of technology and information transfer • Reduced opportunity to ask questions

36. Handoff Content Checklist: Surgery □ Actual Surgery Performed □ Surgical findings (anticipated & unanticipated) □ Surgical complications □ Drains/tubes — location, number, and type □ 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

37. Handoff Content Checklist: Surgery □ 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

38. Handoff Content Checklist: Nursing □ Actual surgery performed □ Isolation Type (if applicable):Contact, Airborne … □ Lines - IV , CVP, Art line , PiC Line ... □ Drains - Foley, JP, Davol, Neprostomy tube … □ 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

39. Handoff Content Checklist: Nursing □ Actual Surgery Performed □ Special needs: Wheelchair, chemo, pacemaker/shunt re-program necessary □ Psychosocial / behavioral issues □ Family Information: Spouse, children … □ Belongings and Valuables □ Events / Concerns Conclusion: “The thing that I am most concerned about in this patient is __________.” 2011 JHH PACU Studies

40. Handoff Content Checklist: Anesthesia Preop: □ History of Present Illness □ Allergies and CODE status □ Meds- specify which taken prior to surgery (esp. beta blockers, sedatives, antibiotics) □ Baseline vital signs; height; weight □ Baseline physical exam – neurologic, demeanor etc. □ Baseline labs 2011 JHH PACU Studies

41. Handoff Content Checklist: Anesthesia Intraop: □ Airway – intubation technique, abnormalities etc. □ Lines – size, location etc. □ Procedures – blocks, spinal etc. □ Fluid totals □ Paralytic status - relaxed, reversed □ Labs □ Meds: Narcotic totals, antibiotics, anticoagulant, anticonvulsant , reversal agents etc. □ 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

42. 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”.

43. 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