 Welcome to our webinar today, Managing Patient Safety Across the Sedation Continuum. I am very, very excited to be joined today by Dr. Mike Ramsey, Kevin McQueen, and by Marty Moore. So just a few housekeeping items, and then we're going to ask everybody to introduce themselves. We do have credit available for this activity for nurses, pharmacists, and physicians. CE is only available to those who attend the live webinar today, so if you are viewing this on video after today, December 22nd, then I'm sorry, we are unable to provide CE for that. If you are going to get a CE, then you can anticipate receiving an email from MedStar, who's our CE provider, with an evaluation tool. It may take up to a week to receive that email from MedStar. If you complete that evaluation, then you will receive your credit. And none of our planning committee members and none of the speakers today have any financial relationships to report. Okay, so I would love for our panelists to go ahead and introduce yourselves. Let's start with Kevin. Good morning. Hi. I'm Kevin McQueen. I'm the System Director of Respiratory Care for the University of Colorado UC Health System. We encompass 12 hospitals along the front range in beautiful Colorado. I am a former risk manager and patient safety officer from Northern San Diego County, and I currently serve as the president of the Colorado Society of Respiratory Care. Thank you for joining us. Wonderful. Thank you so much, Kevin. Hi. Good morning. My name is Marty Moore, and I have been a Chief Nursing Officer for over 20 years, leading out of system level and then magnet and facility levels. Currently right now, I'm a healthcare consultant, and I consult on patient safety. And then additionally, I have been doing strategy work for COVID prevention and containment on the senior living side, working across the nation. So it's been a little busy these days. And I'm so excited to be here and for you to join us. Wonderful. Wonderful. Thank you so much, Marty. And Mike Ramsey, thank you so much for joining us, Mike. Thank you, Donna, for the invitation. I'm Mike Ramsey. I'm Chair of Anesthesia at Baylor University Medical Center in Dallas, Texas, part of the Baylor-Scotten White Healthcare System that consists of about 60 hospitals across the state of Texas. I'm also past president of the Baylor Research Institute and past president of the International Liver Transplant Society. So a lot of different types of one in the past. Now I'm concentrating on anesthesia and sedation, which has been part of my career, whole career really is safety and sedation. Wonderful. Well, then you are the right person to get us started with this. You know, I know that there are, you know, maybe some folks in our audience who aren't familiar with the term, the sedation continuum. Can you talk a bit about, you know, what that means and, you know, when did this become an ASA focus? Okay. Well, it became an ASA focus in 1999. But when I think about sedation continuum, I could give you two milligrams of Versed, which is an anxiolytic drug. And to you, it would probably do just that, just make you a little more calm and not do much else. But I could give it to somebody in poorer condition, a more frail, elderly patient, and that two milligrams could stop them breathing. And so we've got two ends of the scale, and this is the continuum. And so virtually every sedation drug, there are a few exceptions, and opioid drugs will do this. So depending on what level of sedation you want, the American Society of Anesthesiologists came up with guidelines to help keep patients safe as they receive these drugs. And you go from this, where you would go with this two milligrams of Versed from minimal sedation, just anxiolysis, but you could go right to the right side of that screen if you're frailer and more elderly and end up in general anesthesia, not breathing, and very quickly become unsafe and need resuscitation. And so that's why this continuum has been put together, because the drugs have different effects, and also the recipients of the drugs also have different effects depending on these drugs. So we want people who are going to give these drugs to know what to do if the patient moves on to the next level in this continuum of sedation. In other words, they go from anxiolysis to moderate sedation. Can you take care of them? And do you know what to do? Do you know how to monitor them? And if they go on to deep sedation, can you take care of them? Do you know how to make sure they're breathing adequately? Are you using the correct monitors? And this is the continuum, and it's trying to bring that home to everybody who administers these drugs, that they have the wherewithal, the knowledge, the technology to keep you as a patient safe, depending on what level they're targeting, and make sure they can take care of you if they overshoot and you go to the next level. So that's kind of an overview of what this continuum is. Sorry, Mike. Now I can go on, this was to talk about one of the later questions, Donna, that you're going to give me. The first one was just the continuum. But when people overshoot, you end up with the recording of a rapid response team in a hospital, and I'll talk about that on one of your later questions. Excellent. Excellent. Thank you so much, Mike. Marty, you know, very often it's the nurses who are administering all of these sedatives, and also monitoring them. What are the nursing considerations that administrators need to be aware of? I think, you know, one of the things that we have to do is we've got to move nursing out of kind of that tactic mentality. So I give a medication, I go on and I do something, and really have to look at and think about how sedation is done through, you know, the full continuum, as Dr. Ramsey was talking about. And what I've watched and what I've seen is, and, you know, in my earlier career, I was a pediatric flight nurse, and so we would do rapid intubation, and we would deliberately go to general anesthesia to, you know, to make sure that we were running the airway and the breathing. What people don't think about is, is really and truly that kind of, you know, sliding scale thought process around, what am I administering? What's the impact within, you know, the body and how it's going to be metabolized? And then additionally, understand the medications that we're giving. Understand how long they stay in the body. Don't assume that they're short window periods because many of these medications are not. And then additionally, what are the safeguards? What are the safety nets that we put in place? And, you know, I think, I think we kind of have a tendency to put safeguards in place for what we assume is a moderate sedation. But many times on general floors, medical surgical floors, we're giving medications that easily could flip somebody in as Dr. Ramsey was talking about. Do you have the safeguards, the protocols, and the monitoring in place to ensure that safety is number one? Now look at these medications as run of the mill over the counter medications. And I do think we'd normalize them. And by normalizing them, we don't understand the safety risk to them. So you've got to incorporate that. You've got to elevate knowledge transfer. So it's not just watching kind of an LMS moment and thinking nurses understand sedation and understand the drugs that they're giving or the medications they're giving. It has to be kind of a perpetual feeding in an elevation of learning so that you can create that safety net. So what organizational gaps are you seeing in your role as a consultant these days? A lot, actually. And what I've seen is in many places, you know, the things that I kind of touched upon is that giving medication is seen more as an action, it's a tactic. And that we're not necessarily stepping back and putting all the puzzles and pieces together. I've seen policies that are still reflective of the work that we had done around sedation where if you're giving a certain kind and you're utilizing oximeters, you're utilizing monitoring, what we're not understanding is simple pain medication can create, just as Dr. Ramsey talked about, can create actually a level of sedation that we don't want. And so you're seeing these events and what's really fascinating is that in some areas or within some departments of hospitals, they've done a good job, but they don't talk to the other parts of the hospital. And so you have practice and policy in one place that's not reflective in other places and so it has to be standardized. You cannot have as much variation as we do. And on the outpatient side, that is actually one of the highest risk areas. And so you've got to engage in a conversation around how do we create safety? How do we put safety nets in place? And it's just, you know, I kind of call it the Rocky Mountains because in some places there's great practice and then in other areas, you see kind of practice that is not at the same standard. Yeah. Well, thanks, Marty. Kevin, I wonder if you could, you know, talk to us from the respiratory therapy perspective. What role does a respiratory therapist play in sedation and, you know, what's that structure there in terms of their reporting structure? So like Marty had said, outside of the operating room, nurses primarily do the majority of providing sedation effect medications and pain management meds like opioids. But respiratory therapists, our training is very specialized and extensive when it comes to ventilation and oxygenation of patients. So I just believe that hospitals really have to tap into the respiratory therapy leaders and bring it together. So the nurses and therapists work together, along with the providers, to provide the safest environment for the patients. So not only looking at how are we delivering the meds, but how are we assessing the patients, how often we're assessing them and how we're monitoring them. Because I believe that if, if organizations like Marty had said, if they're not doing everything they can to protect that patient, they are putting care providers, especially nurses on acute care floors, at tremendous risk of having to deal with an adverse event because a patient has a horrible outcome that could have been avoided just by better design processes. Many states, the respiratory therapists, they're agreed and licensed similar to the nurses, but depending on the scope of practice for that state, I've worked in states where the respiratory therapist can provide the opioids and the sedation medications directly as, like if they're in a bronchoscopy procedure, other states require that a registered nurse has to give that, but the respiratory therapist can be there assisting and helping to better monitor the patients. We are also seeing a great shift in our profession where some states are starting to approve advanced practice respiratory therapist degree and licensure, which is very similar to a nurse practitioner. So moving forward in the next coming years, I believe respiratory therapists, especially at the advanced practice level, will be able to work very closely with anesthesiologists, nurses, creating much better processes to keep our patients safe. Thank you. Thank you. Mike, I wonder if you could talk about the role anesthesia plays. I mean, obviously we know the role that anesthesia plays in general anesthesia in the operating room, but across the entire sedation continuum. What organizational protocols do anesthesia oversee? Well, first of all, just let me echo and really support what Kevin just said. The respiratory therapists are the front line of our hospital now. They're out there rescuing patients when people overshoot on this continuum of sedation. It's the respiratory therapists that are keeping us out of trouble and keeping the patients in good shape. They're really our front line and we've got to thank them very much for the job they do. I can hear, I'm surprised it hasn't gone off already, an RRT call on the overhead speaker in my office here, but they really are the lifeblood of the hospital at the moment. Well said, Mike. Well said. So in terms of the role of anesthesia, we're charged by CMS and the Joint Commission to put together policies, policies on sedation. And we've had moderate sedation policies. We've had deep sedation policies. Now we have procedural sedation policies. These are policies where we're aimed to keep the patient safe, number one, number two, to make sure the proper monitoring, the proper drugs are being utilized and the proper safeguards are there. And for different levels of training, people can get credentialed to provide moderate sedation. If you want deep sedation, you've got to be able to take care of that next level, which was in that first slide that I showed, which is general anesthesia. So that means you've got to be able to know how to breathe for somebody, how to resuscitate somebody, how to support the hemodynamics. So that does require quite intensive training to be able to do that. Moderate sedation by itself if you didn't overshoot is something where you've really got to be able to maintain an airway because that's going to be the first thing that the patient loses. As they get more deeply sedated, particularly those with sleep apnea, they will obstruct. If you're not monitoring, if you can't detect that, that patient can get into trouble. And so you've got to have the basic training of airway management, hemodynamic management, and what to do when you overshoot because everybody's response to the drugs is varied, depending on their structure, their genetics, et cetera. Anzelysis is something that is on the very light end where you're just giving a small amount, usually an oral drug, to take the edge of somebody who's uptight. And that should not get somebody into trouble. But occasionally, as I said, to begin with, somebody can be very sensitive to some of these drugs where somebody else is very resistant to them. So you have to know how to take care of that next level of sedation. And so we put these policies in place. They're approved by the medical staff of the hospital. And we put through testing to make sure those credentials are understood and that the person is competent to be able to manage the different levels of sedation of the level that they're applying for the credential for. And we also oversee it. And if they're over sedation events, they come straight to my desk here to review, to look at and see what happened. Why did that patient get into trouble? And thank goodness for the RRTs that are sitting there, Kevin, who are running the corridors all the time to make sure these patients have kept safe. So thank you. Yeah. Well, and you know, that I see that there was a question that Marty had for the group regarding monitoring. And Mikey answered much of that question. And it looks like Kevin has also answered a lot of that question. Obviously, we always think about monitoring patients with, you know, cardiopulmonary, you know, monitoring while we're doing deep sedation or moderate sedation. But we don't always necessarily think about appropriate monitoring when the patient has some kind of oral sedative. So Kevin, can you talk about that? Talk about, you know, the, you know, the other end of the continuum and how opioids are associated with respiratory depression. So as we all know, you know, opioids are pretty much the main state of pain management. And there's a lot of benefit on that. But it's also a very, there's a lot of limiting factors we have to, as clinicians, think about when we're giving these meds. And often I feel really bad because we hand these meds over to nurses that may have four or five, six patients on a long drawn out hallway. And that puts, there's a lot of risk. So when we think about it, these opioids, you know, they inhibit neurons in the brainstem and that can significantly reduce the patient's respiratory-ventilatory drive. It can reduce the tidal volumes, their minute ventilation. And some people, I always say there's a fine line. We're trying to either manage pain especially with all of our CMS requirements where we really are scored on how well we manage pain. But that same time, there's a fine line between you push it too far. You're trying to manage pain and patients sometime have unrealistic expectations that they'll be pain-free. But when we're trying to give pain-free medicine, there's a risk that you will put them over the edge to where you're going to knock out enough of their respiratory drive that they're going to go into opioid-induced respiratory depression. There are many risks that when we see patients, they come with, you know, a whole list of comorbidities when they get admitted. And nurses have to deal with many and there are probably, there's seven primary risks that we talked about. Unexplained or unexpected, uncontrolled pain is one of the big ones, anxiety or agitation. Altered airway conditions are issues that say that a patient has obstructive sleep apnea. They have unusual anatomy in their airway or they were a previous history of difficult airway intubations. Increased sedation, one of my biggest preaching moments is always we have to monitor patients post-operatively at least for the first 24 hours if they're receiving what an organization determines to be a significant amount of opioids. Whether that be with a PCA pump or IV push or even patches or oral, these all, depending on like Dr. Ramsey said, depending on the patient can have much greater effect than others. Decreased ventilation is one of them when we have morbidly obese patients or they've had abdominal chest wall surgery where they're not taking deep breaths. Patients with impaired gas exchange, this could be your chronic lung patients, people that are smokers, poor cardiac function, some elderly people or people that have kidney dysfunction so they can't metabolize the meds as well. Or my, as being a patient safety and risk manager, one of the biggest ones, hospitals sometimes overlook is the ability to do patient surveillance well depending on the nursing units. In the ICU or the step down units you have a pretty close nurse to patient ratio and you have a lot of direct line of sight. When you get to the acute care settings where patients are down long hallways and may great, there may be great distance from the nurses station, we don't have direct line of sight and we don't have the ability to monitor the patients as well and that's why we need to have good solid electronic monitoring devices that are designed to alert the care providers when there's something going wrong. So that's one of the biggest areas I think I always tell people you really have to design and assess your organization's ability to properly monitor patients. I know that when I was doing a lot of research with the Hospital Quality Institute in California, I spoke to Dr. Frank Overdyke and he gave me a great piece of information no matter how many times we assess patients for high risk, there will always be patients that he's reviewing on his desk that didn't have any risk factors at all. That's why when I answered the question in the panel here, I said you have to, I just strongly feel we have to monitor everyone that's receiving these opioids post-operatively because you have the sedation effect from a general anesthesia on top of the opioids and that can be a major problem. And so Kevin, I wonder what do you think the barrier is there? Why do you think that clinicians and administrators and hospitals don't recognize that everybody needs to be monitored and how incredibly dangerous it can be? Well, back in 2017 when I was working with HQI, at that time we found out that about 50% of the hospitals across the United States do not have very detailed programs surrounding sedation and pain management that includes electronic monitoring. The monitoring can be quite costly but a single serious event can be much more costly to an organization, not only financially but reputation and throughout my career of working in this. This is one of my areas of tremendous passion. I've met parents that have lost their children or spouses that have lost their husbands or wives due to this exact thing and it could have been avoided by simply monitoring the patients. Just like Marty said, one of the things I talk to nurses when I've done risk reviews is I go to talk to the nurse and they say well I gave the medication because the doctor ordered it and because the doctor ordered it I felt I was safe. Well, it's a potpourri of medications they order and it's huge and it's click boxes nowadays with EMRs and I always tell the nurses you really have to critically think what are you giving because if you're giving concomitant meds and you're giving opioids for pain, you're giving muscle relaxants because they just had neck surgery and they don't want them to spasm, they're giving them anti-nausea meds, they're giving antihistamines. Every one of these compound each other and give a greater sedation effect and can put that patient over the edge. So and where a nurse may actually think oh the patient is finally calming down, they're resting, they may be going to sleep and going into deep sedation and potentially going to have a significant adverse event and without a monitor you may not realize that until it's too late and you can't call a rapid response and you can't bring them back. So that's why I preach over and over again you need to monitor these patients. Yes, great great. Well Mike you've had a lot of experience there. I know you've got some some other slides to show us. Donna while you're pulling up your screens there was a question about the role of pharmacist and I actually have implemented and utilized and recommend that pharmacists need to be such a key part in figuring out the individual kind of regime that you should utilize what and exactly what was Kevin was talking about and we have a tendency not to rely upon our pharmacists and they're such part of our teams in their knowledge and understanding of not only these medications and how these medications interact but but additionally the individual patient and the ability for the patient to clear it. If there's renal issues just all the kind of presentation of this patient the pharmacist can guide and assist in understanding dosage gene and what kinds of medication should be used. We don't do that because we're always so busy and Kevin described it beautifully. We use our checkbox and we implement our orders without thinking about really and truthfully this is a high-risk medication. These are high-risk medications. What safeguards do we need to do and your pharmacist is a key part of that. Yeah, yeah, agreed. Thank you Marty. Yeah and you know you know multi-disciplinary teams we're finding you know obviously are the where we really need to go. We need to you know make sure that you know that we get out of our silos and function together. So Mike tell us about you know how you reduced rapid response calls with your team. Sure and absolutely I want to echo it is teamwork. Everybody's involved here in patient safety. So how do we reduce rapid response calls and many years back we had 41 calls on one floor which in a month which was our trauma orthopedic floor where people have long bone fractures rib fractures a lot of analgesia particularly opioid energies it was used. So if you give me the next slide please Donna and this is Frank Overdike who Kevin mentioned. He and I have worked a lot on this problem of over sedation and I just want to emphasize a few of the things that Frank has published and that number one is there's an estimated 5 000 deaths a year in the United States from prescribed opioids in hospital these are medications that we physicians have prescribed given to patients to help them and we've killed them. That is totally unacceptable that is something that we have to stop we can stop we will stop and we need to use medications that are safe in the right doses for our patients and we absolutely have to monitor patients to avoid respiratory depression a side effect of these opioid drugs. So next slide please. So when we had these 42 calls in my month we decided we needed to sit down and really look at what was happening. So we put together a group that we call the breathe team because breathing is good. We had respiratory therapists physicians nurses pharmacists hospital administrators patient safety officers and even patient advocates to come together and sit down and brainstorm every one of those calls as to why that patient got over sedated and needed to be helped out. Next slide and we felt we knew who the high-risk patients were we felt these were going to be the sleep apnea patients the morbidly obese patients those receiving a lot of opioids but in fact when we went through every single patient the bottom line was it can happen to anybody absolutely the fittest healthiest patient can get into trouble with the amount of opioid that might be perfectly fine for somebody else everybody's metabolism is a little different everybody is special and we need to have that in front of us when we're prescribing opioids and we're monitoring the effects of these opioids. Next slide and so these were some of the things that we noticed right away one was that orthopedic surgeons and trauma surgeons had multiple post-op pain order sets so we honed it down to one that everybody agreed on just one set the nurses had to handle so there was not multiple order sets which most of them were actually with escalating opioid amounts because the physician didn't want to get called for a pain management in the middle of the night and so we stopped that two we stopped continuous opioid infusions into opioid naive patients in other words if this patient wasn't a chronic pain patient who we knew how they're going to respond to opioids we would not allow a continuous pca pump we stopped that we also instituted an oxygen withdrawal trial now what is that well one of our respiratory therapists mentioned that many of these calls for rrt rapid rapid response teams occurred within about 30 minutes of the patient's leaving recovery room and arriving on the floor and she said i noticed that they all had nasal oxygen on them well we kind of thought well oxygen's good oxygen's the green gas it's risk good for everybody why would she be questioning the oxygen but we sat down with the recovery nurses and asked them why all these patients are on oxygen when they leave recovery and then we found the real reason it wasn't that it'd been ordered to go back to the floor it was because it was pressure on turnover in recovery they wanted to move the patients out so that more patients could come in and the patients were not meeting the discharge criteria as far as oxygen saturation went whereas if they put them on nasal oxygen they met the criteria so we questioned why did they not meet the criteria these are patients with normal lungs no lung disease no impediment to their breathing and yet they weren't making the right level of oxygen saturation and the answer was because they had respiratory depression from the post-op drugs they were getting in recovery on top of the anesthetic drugs that have been given during the surgery so we then decided the quickest way to be able to diagnose this without doing blood tests is take the oxygen off in recovery room make sure those patients can go 15 minutes without oxygen and not desat and that was probably the biggest thing we did that had a positive effect because as soon as we did that now if the surgeon wanted oxygen on the floor that was fine but they went through this withdrawal trial which was just a poor man's trial of doing this just looking at the oximeter and if they maintain their saturation they did not have significant respiratory depression and that made a big difference the other thing we did was we put continuous electronic monitoring as we've heard people talk about so far and when you think about you get in your car if you were going to back into a brick wall the car will alarm and tell you stop if you move out of your lane the car will shudder it will let you know you're drifting out of your lane the monitoring technology has advanced tremendously and so now we have monitors that can keep patients safe and can alert the caregivers to go check on the patient if they are getting respiratory depression or are getting overdose from the pain meds that have been given next slide and so we did that and we also put in processes to avoid opioids you know morphine is good but there are other drugs you can do and use and techniques to avoid giving patients opioids and around the same time enhanced recovery techniques came in place where the idea was to try and get patients out of the hospital within 24 hours if you could and avoid the side effects of opioids and so we got back into using regional anesthesia we got back into using low dose ketamine and we'll use low dose ketamine on the floor on the ward at low doses not so that the patient will get into any problems we use drugs like dex metatomide that really don't affect your breathing and help with analgesia so we moved to these non-opioid techniques and again reduced the drugs that were causing the problem very significantly and believe it or not not only did we avoid these rapid response team calls the patients did better they improved faster they got out of bed faster they got home faster and so we put continuous monitoring in avoided opioids as far as possible and the patients did better next slide please and what to be monitored particularly oxygenation because pulse oximeters now available very readily everybody understands pulse oximeters and where we're having to use significant opioids we'll put respiratory rate monitoring continuous respiratory rate monitoring biomonitor or entitled co2 monitoring and we reduced the alarm threshold so that the nurses don't get alarm fatigue but all this put in place has reduced our rrt calls on this trauma orthopedic floor to two or three early calls a month instead of the 40 that we had and Dartmouth Hitchcock have put this in place in their post up floors and they have not had a more opioid induced mortality in something like 10 years since they've done this so this and they've also saved the cost because these patients have not had to go to ICU they can be looked after on the floor they're not getting the rrt calls so the mechanism to stop all this is there we just have to have the will to put it in place because our patients will do better so thank you tonna i did not unmute myself thank you my that is that that is uh you know it would be so wonderful if everybody could adopt those those monitoring standards you know um i i know that um you know marty a lot of hospitals have not adopted those standards what are the barriers there why why are is it so difficult to get hospitals to adopt that yeah there's challenges to it and and one of things this is just resources you know so uh one of one of my actions as a chief nursing officer is is i wanted to do universal monitoring so you develop wireless capability so that any place any time patient could be monitored and then you had it uh being built into your alarm systems and and so either your nurse call systems or your pager systems whichever you had in doing so you know it was multi-million dollars um that this initiative was uh and i was going up against uh you know things for the o r and uh facility building uh repairs and a new roof you know and so you get this tension um and you have to think about it not from the standpoint of either or it's like okay how is it that we know that there's resources associated with facilities and all the things that have to happen there's resources that are absolutely um associated with uh continued growth and in different kinds of services but but leaders have to say and then there's resources that are always committed to advancing safety that's the conversation i think that you have to have it isn't that it's an afterthought and it isn't that it's this kind of thing that happens it is truly that strategically we believe in safety and we're going to allocate the resources to that that it's always part of us advancing our patient safety um programs and our commitment to it and when team C when employees see the fact that you are continuously giving um allocation of resources to that your culture of safety starts to also do this it is a direct correlation um from it so that's the conversation that leaders have to have it is it can't be that this is a wish it can't be that it's a nicety it is not that it is not that it is truly an allocation that has to be there yeah absolutely and Mike you know you know one of the things that we want all organizations to do it is to build in some some clear tools and and uh and ways to measure the things that they're monitoring tell us a little bit about the Ramsey sedation scale that you that you developed 45 years ago why why did you uh develop that and what's been the outcome of organizations adopting it okay well let me just follow up a little bit on Marty though next slide that you have there please Donna if you can bring it up give me one sec Mike yeah and Mike Walla Donna's bringing up the slides there's uh several questions about medications that i'm thinking you're actually more inclined to answer absolutely absolutely I can give you my background on ketamine but it's been a bit since I've administrated yeah I think Mike that was really interesting information that you shared before about the ketamine I somebody had actually asked that question right before you reviewed it so and I apologize I don't know why it just keeps going out as soon as I stop sharing my screen so I have to start over for some reason I apologize for that okay this will be the last few slides once we get there so just go back to that one just go back one would you because if we have adequate monitoring failure to rescue should be a never event in the hospital we ought to know somebody's getting into trouble before the event occurs if we had monitoring you know everybody's got personal monitors it could be your watch it could be a fit bit it could be whatever and it will start to tell you when your pulse rate is changing it'll start to tell you if you're getting hypoxia it'll start to tell you if you're getting an arrhythmia the technology is out there so we should be able to go the nurse should be stimulated to go see the patient alerted to see the patient because they're getting into trouble so that we're not going into rescue we're going into intervene in what's occurring uh and next slide Donna thank you and I just want to just to really bring it home I because I talk about this quite a lot I get emails and messages and phone calls from family members who had a disaster with a family member this was from a nurse in Ohio who sent me this and her 40 year old husband had gone into hospital to have a single level laminectomy he went through the surgery in one hour successful he was one hour in recovery no problems he then went to the floor where he was put on a pca hydromorphone in pca pump and he was not checked on until nearly two hours later when the team came in to check on him he was dead they coded him for three hours trying to resuscitate him absolute disaster they weren't able to and of course the wife is very distraught about this what can she do to prevent this happening to anybody else and the sort of lame answer that I could say is you know if you're taking him home from recovery he'd be alive today he did not need to stay in the hospital but that's because that hospital wasn't safe our hospitals have to be safe our hospitals if you're going to deliver an IV continuous infusion of opioid that patient must be monitored and that patient was not monitored and uh one of the early monitors that we put in place is that everywhere you know the joint commission mandated or 20 years ago that we had to have a pain scale and that we had to monitor pain in all our patients but we put a sedation scale with the pain scale as a second monitor because level of sedation drops as you be tain as you retain carbon dioxide you become sedated and so we put the Ramsey sedation scale next to the pain scale as a safety measure to be sure that the patients weren't getting over sedated so next slide and this was the scale incredibly simple but then simple things get picked up on and people will use them and as I say I came up with that 40 years ago and it was for the ICU and next slide just go rapidly through the next few it got picked up by I think I have it in 20 different languages again because it's simple and next slide and then in 2010-11 I joined a clinical practice guideline task force for critical care medicine and came up with a new scale to really improve the management of patients in our ICUs next slide because what we wanted was an ICU where the reason I came up with the scale was back in the 70s in the 80s in the 90s even up to 2000 if you walked into an ICU and I used to run an ICU in London every patient on mechanical ventilation was in a coma and it was nearly all his a drug induced not a traumatic coma these patients had been put into coma because people were frightened of them pulling out an endotracheal tube of dislodging an IV and the only way when you walked around the ICU making rounds you knew the patient was alive was by looking at the monitors because you could see the heartbeat up there but there was no interaction with the patient and when we got a success back in the 70s and a patient would get over acute respiratory distress syndrome and there weren't many that did get over it in those days but when we did we'd say wean them off the ventilator well it would take weeks to get them awake and get them off the ventilator it would take weeks to get out of the ICU they'd spend weeks in the hospital then they'd go to rehab and then when I called the family a year later here usually it was the wife who would answer the phone I'd say how's mr so-and-so doing oh he's doing fine I said is he back to work oh no no no but he's sitting in the chair looking at the television and I thought well that's pretty good and then suddenly I realized the wording looking at the television I said what is he watching oh he's no idea would say the wife he's just looking at the television and then I realized our success was a complete disaster the family had to look after this invalid husband he never got back to anything functional he never got back to work where did we go wrong and certainly there are many things that put that patient into a coma in the ICU sepsis hypoxia hypotension etc but also the management of drugs was not controlled and part of this was drug induced so I came up with that sedation scare with the idea that instead of prescribing drugs in milligrams per kilogram that we would prescribe them to a sedation level and that's what we did it finally got picked up on with a drug called dex metatomidine and then propofol and the patients in icu's now could be up and active and you could even be walking the floors in the ICU on mechanical ventilation so this whole concept of the animated icu came through from the society critical care medicine around 2010 and patients have done so much better and so that's where that came from and I'm just so delighted that so many years later it really now what I was thinking back 40 years ago has finally come to fruition and you can walk into an icu now and patients are cognitively interacting with you even though they've got an endotracheal tube down even though they may be on ECMO if it's upper limb ECMO they can walk and the icu is a very different place it's much more vibrant than it was and the patients are doing better thank you so much my viewer absolutely right it you know getting our folks up and moving and you know being as normal as possible is so is so absolutely critical you know as Marty mentioned before there were a few other questions regarding medications um someone had asked about lirica and tramadol drugs like that you know your thoughts on on you know monitoring and sedation issues there okay um I think drugs like gabapentin have a place um acetaminophen the Australians and Europeans have used acetaminophen for years when we've been using opioids now suddenly we started using it in significant doses here in the U.S. patients are doing better less opioids I think you have to be a little careful of some of the um pro drugs that are out there drugs like codeine codeine is a pro drug for morphine and there's a few people who are rapid metabolizers of codeine if you if you've got the enzymes or the genetic makeup to rapidly metabolize codeine you'll produce high doses of morphine and there's been a number of deaths associated with that particularly in children um equally you may be a slow metabolizer and the drug doesn't work it's not that the child or the adult from a lingerie it just didn't convert to morphine and so there's a genetic side to some of these all drugs particularly the pro drugs that go to the opioids that probably uh we ought to be getting some genetic testing done if we could bring it down to a reasonable cost so that we know what's going to happen to that drug when we prescribe it so so much better if we can do better without the opioids I think they've had their place there still is a place for them but a much more controlled environment and if we can manage to go without them with drugs like acetaminophen non-steroidals without the side effects of those drugs like bleeding etc then I think patients will do better great thank you there was also a question about ketamine I thought that I apologize I thought earlier that they were asking for you know when you spoke of the low-dose ketamine but um it looks like that the person was specifically looking for information about pre-hospital administration of ketamine I know or you know in the emergency department the use of ketamine any any ideas on on the safety of those practices yes we as long as you've got a protocol in place we I'm not sure about out of hospital use of ketamine because it's an abuse drug unfortunately um and that would have to be controlled but we certainly our emergency room does use ketamine we use ketamine in low doses on the floor we've got a protocol in place and where those big long bone fractures are many of those patients are on us continuous infusion of ketamine is not stopping them breathing it's reducing the amount of pain medication opioid type medications that they need they're doing better and the low dose they don't get any dysphoria with it it seems to it has a place there's no doubt about it it has a good place so I think there are many alternatives to the opioids that we that we've got I just see one of these messages now come through from Ed Salazar an RRT I've met him God bless him he's a real tribute to the profession unfortunately he lost his son from an airway problem in a hospital and he's part of a team really trying to make our hospitals safer so God bless you Ed and that is great to see you listening into this program and we should have invited you on yes yes thank you so much Ed for your comment and you know our thoughts and prayers go out to you I wonder Kevin there's a couple of questions I wonder if you can help us address someone was talking about asking about monitoring specifically in the PACU any thoughts on the use of CPAP in the PACU or the measuring of minute ventilation to avoid safety issues in the PACU all right so one thing I want to talk about is the fact Dr. Ramsey talked about redrawing oxygen in the PACU there in Texas being that I'm up here in Colorado we're 6,000 to 8,000 feet in our hospitals so we tend to have to use a lot of oxygen and so this is something that we really try to get out to the nursing staff and other clinicians is if the patient is receiving supplemental oxygen their hemoglobin will most likely be very well saturated so even if they go into respiratory failure or even worse respiratory rest it may take minutes before the pulse oximeter catches it so that's why that's a late indicator so a lot of the talking that we say around here is don't rely on pulse oximeter alone it's a great device and in majority cases it will catch it but we use capnography because it's breath by breath we can see if the patient is starting not to ventilate well respiratory rate is a huge one it's the most common trigger that we see on our monitors up here at altitude the minute ventilation monitor that the gentleman did discuss here is I've tested that device multiple times it does a great job I like the fact that it has electrodes on the chest and not on the patient's face because some patients push back they don't want additional monitoring things on their face it really has to come down to the organization I tell everybody you need to assess the devices and figure out what works for your patient population I am very comfortable with capnography I'm comfortable with the minute ventilation monitoring but every organization they really have to you have to do an assessment very thoroughly of your organization where are you using or opioids have you looked at your closed case reviews for adverse events are you pulling reports on unplanned use of reversal agents like Narcan are you drilling deep down into your rapid response calls to say which ones are related to over sedation or decreased respiratory rate situations you have to look at where these problems are occurring so where are you using opioids where are you using PCAs are you using ib push so organizations I always say you really want to take the time to analyze where your risk occurs and like Dr. Ramsey said if you push away from using PCA pumps great you've eliminated one risk but I tell people never rest in your laurels go on what is your next level risk so keep that assessment going and dollars are limited so I tell hospitals go after your biggest risk events first you'd say you go after a monitor all postdoctoral patients that are on PCAs or get certain levels of ib push great there's your start and expand it as you can over time to allow you to have more and more monitoring to keep patients safe. Thanks Kevin. Marty I wonder if you can answer a question of you know or address the issue of you know human factors and biases in the issues that we have with sedation. Well you know we've kind of danced around it this morning and talking a little bit about you know kind of what's called human error factor and what a beautiful example was the the need set was to move the PACU to turn over the PACU and so nurses knew that there was criteria so they added the oxygen in to get to meet the criteria and then you know the patients then are transferred out and you have adverse effects. So when you think about a human error factor and you think about kind of biases and I touched on it earlier human error factor is is when we look at and think about what what potentially could cause an air and and with that how is it that we can put safeguards. So the classic examples were the PCA pumps that we put safeguards in and we put checks and balances of having two people kind of double check your dosaging that that's that's pretty classic human error factor but here's where I want people to stop and think a bit about this. We have a tendency to look at IV push medication as easy to do we do it all the time. How many times have you looked at your adverse events? How many times have you pulled through the fact that maybe there was a miscalculation or over dosaging and was there a double check? Do you have double checks that are in place? Now most hospitals say we don't have time to do that you don't have time not to do those kinds of things because I can look at something think that I'm seeing what I'm seeing and pull up the dosaging and tell myself again it's bias it's confirmation bias that what I've drawn is what I see and then I can I can give a medication error or a dosage in this two times more. So it's those kinds of things and we've worked forever and I'm going to tell you I haven't cracked the nut yet around how to keep medication administration sacred. It needs to be in a quiet place I'm not being interrupted we've normalized it and that's a bias that's a bias that has absolutely contributed not only to harm and hurt but death and we know that and yet we still are unable to change that framework because we carry these kind of visions of how we should be performing how we should be administering medication all those kinds of things and from that we then contribute to the safety issues that we're seeing and the second part of that is the fact that I don't believe and I can tell you and all the work that I've seen in my years of experience I don't believe that we truly understand these drugs that we do the in-depth education and and transfer of knowledge around what these medications mean to the people who's administering it that's nurses and so you know we will do a quick pain management kinds of education but it takes years of really thinking and understanding and so you've got to build that into your advanced learning objectives that you are perpetually moving the dial forward so that people understand how these medications perform drug-drug interactions and and then bringing in the knowledge experts the pharmacist to do that kind of transferring of knowledge perpetually that takes resources that takes commitment but again if you are looking at your culture of safety you've got to build that in. Absolutely well we've only got one minute left Kevin I know you wanted to talk about the HQI toolkit before we close all right since it's really quick in 2017 late 2017 I had the great opportunity to work with a large group of nurses, physicians, respiratory therapists patient safety and risk management managers and of course pharmacists at the hospital quality institute in California and we published this toolkit that helps organizations from literally the very beginning all the way through your entire process between orderables monitoring what devices should be used patient education everything it's a step by step easy to use no cost toolkit if you just google HQI respiratory depression you'll see the toolkit you can print out the PDF it is just very simple to help you achieve what you need. Thank you Kevin and we will be sure actually to link in the description on this video and we will send to everybody on this call the the PowerPoint slides that we saw today as well as the HQI link and a link to the ASA standards for moderate sedation so thank you so very much everybody we are at time I wish that we could continue I apologize that we weren't able to bring the patient and family voice in to this webinar you know we usually try to do that and we thought that we had a panelist who fulfilled that role and I'm so sorry that we weren't able to make it happen this time but moving forward we we will do everything we can to make sure that we also have the patient and family voice in our webinars well thank you so much Kevin Mike and Marty always a pleasure having you on our webinars thank you thank you everybody everybody have a wonderful day have a safe holiday season yes you too happy holidays everyone thank you so much