Comments
yourfanat wrote: I am using another tool for Oracle developers - dbForge Studio for Oracle. This IDE has lots of usefull features, among them: oracle designer, code competion and formatter, query builder, debugger, profiler, erxport/import, reports and many others. The latest version supports Oracle 12C. More information here.
Cloud Expo on Google News
SYS-CON.TV

2008 West
DIAMOND SPONSOR:
Data Direct
SOA, WOA and Cloud Computing: The New Frontier for Data Services
PLATINUM SPONSORS:
Red Hat
The Opening of Virtualization
GOLD SPONSORS:
Appsense
User Environment Management – The Third Layer of the Desktop
Cordys
Cloud Computing for Business Agility
EMC
CMIS: A Multi-Vendor Proposal for a Service-Based Content Management Interoperability Standard
Freedom OSS
Practical SOA” Max Yankelevich
Intel
Architecting an Enterprise Service Router (ESR) – A Cost-Effective Way to Scale SOA Across the Enterprise
Sensedia
Return on Assests: Bringing Visibility to your SOA Strategy
Symantec
Managing Hybrid Endpoint Environments
VMWare
Game-Changing Technology for Enterprise Clouds and Applications
Click For 2008 West
Event Webcasts

2008 West
PLATINUM SPONSORS:
Appcelerator
Get ‘Rich’ Quick: Rapid Prototyping for RIA with ZERO Server Code
Keynote Systems
Designing for and Managing Performance in the New Frontier of Rich Internet Applications
GOLD SPONSORS:
ICEsoft
How Can AJAX Improve Homeland Security?
Isomorphic
Beyond Widgets: What a RIA Platform Should Offer
Oracle
REAs: Rich Enterprise Applications
Click For 2008 Event Webcasts
Physician-Patient Alliance for Health & Safety: CMS Proposed Quality Measure Does Not Provide Enough Protection for Patients Using PCA

CHICAGO, Jan. 16, 2013 /PRNewswire/ -- CMS is now considering a new proposed quality measure (#3040) that calls for "appropriate monitoring of patients receiving PCA [patient-controlled analgesia]."

Says Michael Wong, executive director of the Physician-Patient Alliance for Health & Safety (PPAHS), "At first glance, this seems to address a critical patient safety issue: opioid induced respiratory depression."

In its Sentinel Event Alert No. 49, "Safe Use of Opioids in Hospitals," The Joint Commission recently stated:

While opioid use is generally safe for most patients, opioid analgesics may be associated with adverse effects, the most serious effect being respiratory depression, which is generally preceded by sedation.

Monitoring patients receiving opioids by PCA is therefore essential for patient safety.

Lenore Alexander, whose daughter Leah had elective surgery for pectus carinatum, a fairly common condition where the sternum protrudes forward caused by an overgrowth of cartilage, knows of the dangers that PCA pose.

"Leah was a healthy 11-year-old girl. In the surgery," says her mother, "the doctors used an epidural anesthetic, which was left in place for post-operative pain management. I stayed with Leah that night and finally fell asleep after being up for more than 36 hours, ever since Leah checked in.  When I woke up two hours later, I found Leah dead. My screams were what alerted hospital staff that something had happened to Leah."

"Leah was not monitored, either by a pulse oximeter or capnograph," says Ms. Alexander. "Had she been monitored, perhaps she would still be alive today." For the article by Ms. Alexander on her daughter, please click here.

CMS's proposed quality measure applies to "All patient admissions with initiation of an opioid via an IV PCA device that is active for more than 2.5 continuous hours." Once PCA has been initiated, the proposed quality measure has two aspects:

  • When monitoring needs to occur.
  • What needs to be monitored.

When monitoring needs to occur

The CMS proposed quality measure provides that monitoring needs to be "documented" and the time between documentation must "not exceed 2.5 hours." This means that a nurse or other caregiver must document the patient's condition and do this in intervals of not greater than 2.5 hours.

However, recommendations by the Anesthesia Patient Safety Foundation provide that these "spot checks" are not sufficient:

Intermittent "spot checks" of oxygenation (pulse oximetry) and ventilation (nursing assessment) are not adequate for reliably recognizing clinically significant evolving drug-induced respiratory depression in the postoperative period.

Matthew Grissinger (director, error reporting programs at ISMP) explains why "spot checks" and relying on pulse oximetry as a measure of a patient's oxygenation are not effective enough:

One reason why it is not effective is that a 'periodic check' and pulse oximetry would only catch an error, not prevent the error.

Additionally, the duration of the proposed CMS quality measure is "the first 24 hours after initiation of the first IV PCA opioid administration." Surely, it would be more appropriate to monitor patients for the entire period that they are connecting to the PCA, rather than to stop monitoring after a predetermined period of time.

What needs to be monitored

The CMS proposed quality measure provides that patients using PCA be monitored for three physiological factors: "respiratory rate, sedation score and pulse oximetry." Each factor is discussed below, with associated recommendations by key healthcare organizations and health experts:

Respiratory Rate: Measuring for respiratory rate is not enough. The Pennsylvania Patient Safety Authority recommends monitoring of patients include "frequent assessment of the quality of respirations (not just a respiratory rate) ... " [emphasis added].

Sedation Score: Sedation scores measure how the patient reacts to stimuli and the patient's reaction are scaled, for example, from "no response to stimulus" to "anxious or restless." However, Mr. Grissinger explains that a patient's sedation score may not be an accurate measure, " ... current standard methods for assessing a patient's level of consciousness do not take into consideration that overly sedated patients can be aroused and respond to questions. Even though these patients can be aroused for a brief period of time and may in fact be able to speak, they immediately fall back into a state of oversedation. Accordingly, ISMP recommends observing the patient unobtrusively and noting both respiratory rate and depth of respiration in the absence of any stimulus."

Pulse Oximetry: Monitoring a patient's oxygenation by pulse oximetry is important. The Pennsylvania Patient Safety Authority recently stated, "However, while useful, pulse oximetry does not measure ventilation. Since oxygen saturation is a lagging indicator of respiration, pulse oximetry may not indicate a problem early enough for effective intervention. Pulse oximetry is even more problematic for patients who are receiving supplemental oxygen, since they may be adequately oxygenated even with dangerously depressed ventilation. Capnography, or end-tidal carbon dioxide monitoring, allows clinicians to track several indicators, but for purposes of PCA it is primarily used as a reliable monitor for respiratory rate, including apneic episodes. The Anesthesia Patient Safety Foundation (APSF) advocates monitoring both oxygenation and ventilation in all patients receiving PCA."

Dr. Frank Overdyk (executive director for research, North American Partners in Anesthesiology, and professor of anesthesiology at Hofstra North Shore-LIJ School of Medicine) explains the importance of PCA in managing pain, but also the need for continuous electronic monitoring of patients:

Spot checks of SpO2, as are commonly taken on med/surg floors, need to be eliminated from patient monitoring practice because these single measurements  may mislead a provider into thinking the the patient is fine when in fact they may be close to the precipice of unrecoverable respiratory depression.

Entering a patient room and placing a pulse oximeter on their finger stimulates their consciousness and respiration sufficiently to falsely elevate their reading, particularly when they are receive supplemental oxygen. Once the provider leaves the room, this stimulus fades and the patient may lapse back into a dangerous level of respiratory narcosis.

Although the CMS proposed quality measure touches on a critical patient safety issue, the CMS measure only pays lip service to patient safety, as it goes against the recommendations of The Joint Commission, the Anesthesia Patient Safety Foundation, ISMP, and the Pennsylvania Patient Safety Authority.

As Mr. Grissinger says, "The CMS proposed quality measure regarding patient-controlled analgesia deals with a critical patient safety issue that hospitals need to urgently address. Errors with PCA occur and, unfortunately, sometimes with tragic consequences. However, for patients to be safe, we would strongly recommend that the proposed measure to monitor patients using PCA to include continuously electronically monitoring them with oximetry for oxygenation and capnography for adequacy of ventilation. In addition, standardization of PCA procedures would greatly reduce PCA errors and adverse events."

The Physician-Patient Alliance for Health & Safety is asking that those wanting to provide to CMS on its proposed quality measure can do so by emailing measureapplications@qualityforum.org (subject line: CMS Proposed Quality Measure #3040).

SOURCE Physician-Patient Alliance for Health & Safety

About PR Newswire
Copyright © 2007 PR Newswire. All rights reserved. Republication or redistribution of PRNewswire content is expressly prohibited without the prior written consent of PRNewswire. PRNewswire shall not be liable for any errors or delays in the content, or for any actions taken in reliance thereon.

Latest AJAXWorld RIA Stories
Are you developing or hosting PHP applications? Are you doing performance sanity checks along your delivery pipeline? No? Not Yet? Then start with a quick check. It only takes 15 minutes and it really pays off. As a developer you can improve your code, and as somebody responsible...
Poorly performing websites, like Twitter’s recent fiasco with Ellen’s selfie, are a constant source of irritation for users. At first you think it’s your computer, or maybe someone on your block is downloading the entire “Game of Thrones” series. But, when nothing changes after r...
Have you seen this error message before “java.sql.Exception: ORA-00060: deadlock detected while waiting for resource”? This is caused when parallel updates require locks on either rows or tables in your database. I recently ran into this exception on an instance of an IBM eComme...
When the agile movement re-cast the roles of the SDLC they did so with small projects as the baseline of their experience. A typical minimal SDLC method includes subject matter experts (those who execute the current workflow activities), a Project Manager, a Business Analyst, a S...
Telerik Controls are great for building modern, rich clients, and web applications often seen at the enterprise level. I just worked with a company that uses these controls in their soon-to-be-released customer-facing SharePoint portal. They ran a small load test that showed that...
Subscribe to the World's Most Powerful Newsletters
Subscribe to Our Rss Feeds & Get Your SYS-CON News Live!
Click to Add our RSS Feeds to the Service of Your Choice:
Google Reader or Homepage Add to My Yahoo! Subscribe with Bloglines Subscribe in NewsGator Online
myFeedster Add to My AOL Subscribe in Rojo Add 'Hugg' to Newsburst from CNET News.com Kinja Digest View Additional SYS-CON Feeds
Publish Your Article! Please send it to editorial(at)sys-con.com!

Advertise on this site! Contact advertising(at)sys-con.com! 201 802-3021


SYS-CON Featured Whitepapers
ADS BY GOOGLE