 Well, thank you Mike for that kind introduction and for framing the next 40 minutes we've as he's introduced the panel We've got a great number of panelists here to talk about a topic that is near and dearer to a lot of our hearts Anybody would have to live under a rock or in a cave to not understand the pervasiveness of opioids in our society And we are going to kind of focus on the perioperative period And there certainly is linkage to what we do in the perioperative period to the opioid epidemic in the United States But first I just want to take a personal privilege here to thank Joe Mike Mike and You know for a great exceptional meeting. Thank you so much for doing this And Sam is too I can't you know forget her though the light was kind of blind in me Saw you there, but more importantly than putting on a great meeting I want to thank you for putting the patients stories at the forefront of what we do That is how we connect to real change to ignite change The heart of medicine and how much these stories hurt to hear but I can't imagine What everyone went through I hear and again that that that is how we Make change safety I think will improve only if those stories are felt every day in the systems of health care and the people that work in health care We need to be reminded that medicine goes way beyond doing things rapidly quickly Efficiently new technology not that it's not important, but it is the humanness That matters and with that we want to start off with a story from Yvonne Just to tell my story about my son, I thought the easiest way to to relate that Would be to go back to the day that ended me here I was sitting in church and my daughter leaned over and said mom look at your phone and so I pulled my phone out of my bag and I had a message for my daughter-in-law To call her so I got up and left the meeting As I did my phone ring and The only thing I remember her telling me is that he's not breathing So I went back in and I grabbed my husband and my children And we drove over to my son's house and when we arrived there the ambulance was there in the police and An EMT walked up to me and said it's too late. I'm like what? My son just had a tonsillectomy. How can it be too late? He's 21 years old perfectly healthy I was so confused and I tried to go in the house, but then the police were like, no, this is a crime scene I'm like what is going on? And so we stood it was a December morning. It was 20 degrees. We stood outside in our church clothes and Tried to process what was happening It was a few hours and they finally let me in to see my son To hug him for the last time in a body bag. They already had him in a body bag And he was still warm He They figured he'd been dead two hours by the time my daughter-in-law found him Even though they she tried to revive him initially it was of no use because he had already been gone too long, but Jump forward a few days We It took six months to get back his autopsy and we were told that he died of pneumonia You know We It was a week as a week after my son's death till I finally Checked my phone for messages and I had a message from my son's ENT and it was 11 30 at night and he had told me just call me you know, I've talked to the corner got results the initial results and So I phoned him at 11 30 at night and we had a long conversation for about an hour and He talked about a few minor things. They hadn't find any Injury from the surgery the surgery was fine. No problems there But they hadn't really come to any conclusions of what his cause of death might be So six months later Well in the meantime dr. Canton was his name he He had he was right there the whole time trying to help us through this because he couldn't understand how a Healthy 21 year old physically fit young man could go to bed at night with his wife and Not wake up the next morning So he was trying to also rectify this problem Because after my son's death, he was you know he was a football player in the on the high school team and he was Super outgoing super friendly, so he was well known and we lived in a small community and stories started pouring in of Of other incidents like this because you know, we were told well the police first off said You know, this is an overdose. I'm like No, because this child of mine this child just didn't even like taking medications So I knew that that was not the cause no matter if that's what They thought it was initially. I knew as a mother that that is not what had happened to my son and I Got a message from a friend of mine that said her neighbor's daughter that was three years old had died like my son She she'd had a tonsillectomy her mother had given her medicine put her to bed She said her daughter was up plain feeling, you know feeling fine, but the doctor told her just to stay on top of the pain and so she gave her daughter medicine put her to bed and then she woke up realizing that her daughter hadn't woke her up during the night and she went into check on her and Just found her that she'd also been gone too long to be able to be revived Three months after my son's death death we got a call from a Neighbor she actually lived only a mile from my home. I didn't know her at the time But her daughter had also been rushed to the ER They had found her she had a tonsillectomy also by the same physician and he had sent her home with a pulse oximeter but it was an older style did an alarm he had told her keep checking it just to watch your levels and When my daughter in law and I went over to visit with her she Had told us the last time, you know, she remembered seeing that she's a 15 year old girl that went to the local high school She said she she thought it said 40 and and Her mom said she'd last talked to her like at 340 I was 245 or 345 at night and then 15 minutes later her mom just woke up and notice her daughter was laying there blue unresponsive not breathing and only been 15 minutes since she'd last talked with her daughter and Her sister of course was called up. They started giving her CPR and They lost her twice. They got her back. They lost her Before the ambulance got there then they gave her seven doses of Narcan before she made it to the hospital Which was only five minutes away to help her Come out of that, but she lived she's amazing. She just got married. She's you know and I love that story because As I was researching this with my son We found five people in our small community that had died the same way as my son a three-year-old 28-year-old male he had been found after tons of ectomy just unresponsive his girlfriend came to check on him and he was dead 35-year-old woman from a nearby community whose mother lived Close to us her daughter had found her unresponsive on the couch and they called an ambulance and she was able to be saved but Through my research there were just many other people that had lost their lives for such a simple thing and when the doctor Had started sending home the pulse oximetry the pulse oximeters with his patients. He was seeing quite a bit of patients coming back with issues and He was attributing that to saving their lives because Otherwise they wouldn't have known that there was a problem brewing Before they could help get treatment But I'm just I'm just glad that this community is working to correct these problems because I didn't even know it was such an issue We had no idea that you could die, you know, not necessarily from the tonsillectomy But just from the pain medication that they gave you afterwards Well, thank you for that If that story doesn't bring tears to your eyes your your heart's not even so it's just like a gut punch Next I think Frank and George are going to kind of tag team here and give us some information on the macro system of opioids and the harm they're doing and Focus on the perioperative environment. So Yvonne Sun's Tragedy happened outside the hospital and we all know about the opioid epidemic 100,000 plus patients a year die many from opioids But we've had an opioid crisis inside our hospitals for a lot longer 35 million patients are admitted to the hospital every year in the US 50 to 60 percent of those get opioids for pain Moderate to severe pain opioids are wonderfully wonderful analgesics very effective. Mr. Keanu Attested to that yesterday, but they can also be dangerous 0.5 percent of patients who get opioids have a severe opioid adverse event including critical respiratory depression and A number of these patients have these on the med surge floors on the wards 40 percent of those respiratory arrests end up in death Now these aren't fragile Patients with lots of comorbidities. These are often young patients with few comorbidities elective admissions People sitting next to you going for an elective procedure tomorrow Who are suffering this? adverse event Why don't we have a safety culture around opioids like we have around dbt's like we have around bed sores like we have around falls The reason is because opioid deaths in the hospital remain a diagnosis of exclusion Patient was found unresponsive We don't know if there's not up see is done typically the opt the cause of death is fatal arrhythmia Or cardiac ischemia if you all stop breathing for 20 minutes, you're all gonna have a fatal arrhythmia and cardiac ischemia Laurie Lee wrote an article where she looked at the amount of time between when a patient was found in respiratory arrest on the ward and When they were last seen and the average was about 45 minutes and the modal was over an hour We have patients we find unresponsive in our hospitals Catastrophic for the patients and their families traumatic for the providers an embarrassment for our hospitals and Not all of them react like you see Irvin a lot of them call risk management So What we need is we need a safety culture around opioids like we have around some of these other issues three elements in my mind Education ask a surgeon why how they write their orders for for opioids. That's what I learned during training 20 30 years ago a lot of front time of bedside providers are Still confused on exactly how opioid induced the respiratory depression happens. You don't breathe five four three two one You often we see chaotic breathing. We see breath holding breath pausing. We see snoring I read in the chart Patient resting comfortably snoring. That's not comforting. That's a red flag in patient. Who's getting opioids a Couple of months ago. I read about a in the charts During COVID a new graduate nurse had doubled the dilated dose at 2 a.m. For an opioid naive patient It's the last drug you ever got this is still going on so Education huge Education gap that we need to fill we need quality metrics and we need the regulatory and credentialing agencies to get on this quality metrics to peel back the veil of Opioid deaths in the hospital Fortunately CMS has put a new quality metric out for 2023 relating to reversal We're making some progress, but think what happened in 2000 after the IOM report All within two years everybody had a rapid response team in hospitals across the country and In 2010 the intensivists who run those typically got together for the rapid response Symposium and they looked at the results and they said yes, we've made some progress on failure to rescue But they made another conclusion They said we have a problem in the detection side of our loop the afferent loop We are not finding people early enough and they also made a recommendation if Practical and affordable all patients in the ward should be monitored continuously If practical and affordable we can keep people from dying It speaks to the psychology of these are good docs. These are passionate people, but it's Zero tolerance is not in our vocabulary as doctors and it needs to be So That brings me to The other thing that they said so brings me to basically continuous monitoring. I'm a huge fan of continuous monitoring How can you not when you see you read the work from George and Sumagrath and Folks who've done this and they've been doing this for 15 years. I was doing the math Seven he said 17 years. We're there. We should be there right now. It's 2023 people walk into our hospitals with a watch or a Fitbit that measures respiratory rate ECG Heart rates sp02. What do we do? We take it off. We send them to a room in the back of the hallway We close the door. We give them pain pills nausea pills muscle relaxants Sleeping pills sure all this stuff is synergistic to opioids and then we say we'll stop by every four hours and Take your vital signs Every four hours Anybody know where that came from? Florence Nightingale 150 years ago She never did a randomized control trial She never showed safety and efficacy We've come a long way 2023 we now have Sue and George Basically started this 15 years ago. They were using the Model T to do this and look at the results. They have we now have Wireless wearable patches Great monitors. There's a new monitor out that you can take home the halo. That's just been approved by the FDA I the other day tested another device that's coming out soon a little Patches the mobile device and I didn't even know I had it on We are ready for prime time. The time is now. It's practical It's affordable and we got to stop having people dying behind closed doors in our hospitals George I took all your time. Yeah, well, and you took you took the key points, but it's okay You know, we've we've been working this problem for a long time, and I just want to thank Dr. Ramsey Joe The meeting this session. This is one of those topics That is ready to be solved. It's been ready to be solved when I thought about these stories under stories your son's story these are What safety is about this is the epitome of a preventable error and I had really three points I was gonna make and you've made a few of them, but One is just people don't understand the magnitude of the problem. You're absolutely right. The second is that I said it already these are not 50 percent preventable 80 percent preventable these are a hundred percent preventable It is absolutely true, and I'll prove it to you based on our data and finally And again the takeaway is that Usable practical affordable sustainable 15 years of doing this the solutions exist today, they've only gotten better And we need to get them to everybody So how big is the problem you heard it? Let me emphasize that the cdc Last year found 16,000 people died from prescription opioids So out of the hundred thousand, you know a big portion are just this kind of story The second issue is Around this hundred percent preventability. There are so many anesthesiologists here in the 80s I was a week into my residency when I learned how to recognize excess opioids pinpoint pupils depressed or stopped breathing And how to treat it Open the airways positive pressure breathing and arcane those things Detection and treatment have been around and no one should die from opioids. No one Uh in the hospital setting and in the post-operative setting at home So what are those solutions and what's our proof you heard some of this from my colleague dr. McGrath this morning Around the mid 2000s I happened to be the patient safety officer at dart myth medical center And I was aware of incidents happening in our hospital Related to opioids and and sue shared that there was a young man That had had a minor procedure And and suffered an opioid overdose death We had the opportunity to deploy an oximetry based system that had come out and was designed for use in general care You can't put you know an anesthesiologist in every room, but you can put A detector that can pick up respiratory performance On every single patient and that's what we did and that was meant to be a safety net for patients and our staff By the way in general care where this is happening Nurses are routinely having to manage five patients Now you can't be busy over here and know whether something's going on down the hall So you have to have a way to support that nurse and redirect their attention So we deployed this system We had the ability to look before and after and we saw and i'll reiterate some of what you've already heard because I think it's so important a 65 reduction in the need for rescue Because because people got the information early and and modified their behavior They didn't give the drugs as aggressively or they might have done their reversal early In addition there was a 50% Reduction in the need for transfer to the icu Now that's more than just opioids But let's talk about over 10 years what we observed. We did a look back two years ago And found that over a 10 year period 111,000 patients that we had monitored None had opioid induced respiratory depression and death None During the ramp up of adding and spreading that system to all other general care units and all other patients for the entire time They're hospitalized It took two years and during that time 15,000 patients we saw three deaths due to opioids So 110,000 none In the subsequent years in the beginning before we had gotten this system totally deployed, but we were collecting data very accurately three deaths So this is happening i've talked to dr. Ramsey and others it's happening across the country every chief quality office Sir when I was in that role that I talked to could tell stories of this I wanted to end with you know moving from Sort of this in the hospital setting And what frank said I want to reiterate the the fda granted a de novo Approval For a pulse oximetry based Opioid induced respiratory depression device That can detect that That system Can be prescribed by doctors like yours who want patients to have that or it's available over the counter It's available Now as of april and by the way the fda also approved over the counter Narcan So with a device to detect and the means to treat a nasal spray I really believe we can eliminate this problem once and for all So that's that's a great segue into our next two speakers But I want to save time for them, but if I could just interject a question that hopefully we can just spend one minute on What are the barriers To absolute continuous respiratory monitoring in people that are on opioids In hospitals and to paraphrase our last speaker If you improve quality and cost and safety Your costs will go down. So don't give me the excuse of cost. What what what are the barriers? Yeah, I I think that um, I'd love to say And this is just my opinion that Um It's it's an issue of leadership. Whatever I think we need regulatory pressure. I think it needs to be a standard of care um, I think as you know, we had a uh A congresswoman in new hampshire who took up a bill To make uh continuous monitoring of patients on opioids a new standard of care Whether it's through cms or other, you know better means and I I get the idea that maybe that's a heavy hammer But I think it just needs to be a standard Anything in 30 seconds frank to add to that evidence historically traditionally It's been no evidence which we have now have improved outcomes Costs which you took off the table ergonomics. We fixed the ergonomics. They're wearable and workflow alarm fatigue We fixed that and for those who want to listen it's there the solutions are there So let me uh move to stacy and I think we're on the brink of a Netflix moment in medicine With uh artificial intelligence machine learning And wearables and I can envision a future where patients come in a lot of things risk, etc Are supported by artificial intelligence. They go home with wearables All that data is fed into a central repository. It hits something on day three We need an intervention, etc But maybe stacy can talk a little bit about what might be going on in the post operative period both in the hospital And and at home. Yeah, thank you. And first of all, thank you to everybody for this incredible meeting and a lot of the ideas have been shared Already. Um, I also want to say sorry Excellent We uh, I think George and Frank myself Joe were in a meeting 2006 2007 talking about this problem talking about solutions and This group coming together to have science and technology working together To have all these elements that are now solved for it is time and we have to do it now the When I learned from um, George and sue and josh pike at the time About what had been done at darkmouth hitchcock and then it was possible It was possible for technology to save lives that it was not impossible For me every day in the side of the industry Part I realized that my every day had to be working towards solving these lives because we often work on implementations Like you said that from the implementation to the finished implementations lives keep getting lost So now we have wearables We had the FDA call to action To invent solutions to solve And help save lives the opiate crisis that came after president clinton here said That apathy and the opiate crisis was a real crisis. We have those steps done prior to that Sir Liam donelson had with the who Announced the medication safety global action. So it was already identified all these pieces. There was global action Global solutions and we are here with wearables. We can we can monitor. We can make the change I think For myself as a mom and for everybody else here in the room When we listen to the stories that have been shared about the complexity of the healthcare worker the family science and technology The part that I think is critical that we make the decision today on Is that that entire burden when a patient is sent home with a drug goes entirely on the family 100 on the family That entire ecosystem is put in the family The prescription is given they're supposed to understand if a drug will Be okay or could hurt them. They're supposed to stay awake. They're supposed to monitor their loved one They're supposed to alert a system and if it doesn't go well They're supposed to accept that entire burden of the outcome And as technology providers, we have the wearables. We have the systems That can now move that burden of responsibility of having to be alerted here and use technology to help us We have to think that it's absurd That in every house of all the houses we live in You would not have insurance coverage if you had a fire if you did not have a smoke alarm And you would not have insurance for a death of carbon dioxide if you didn't have a carbon dioxide alarm It's not acceptable So how could we have it be? That if i'm late for work because I didn't send an alarm that's unacceptable But as a mother Or a wife you're expected to know if your loved one isn't breathing just by your own intuition That has to be Acceptable absolutely unacceptable. There are no more excuses left The wearables like you said we don't even notice them when they're on They do their job They alert Peter's eyes spoke to quality the quality is there Every element is there. We have to decide today That the complex system of the hospital Is simple and possible in the home I can write a prescription I can issue a device That will give an alarm to make sure that that person has a chance to have their life saved that we do not Do not judge everyone for dosage, etc Errors will happen, but that alarms will happen. We know it's possible. The technology is there I think lastly we have to recognize Death to the rest of her depression is very quiet death is silent Death does not make alarms But devices do and the technology is there now. So working as a collaborative between science and technology Again, I'm sorry and we have to make the commitment today that we will work together And we'll make sure the home environment puts us into place because it's not a complex system It's a one-to-one system and we can make that change now. We have to make it happen Yeah, thank you And then now one other actionable item. I know grant has been working on Naloxone Narcan for at-home use so that A solution to that person that has been identified is having Our respiratory depression can be immediately available. Do you want to speak a little bit to that? Absolutely Dan I think this is actually wonderful because we're talking about both How do you find it and how do you fix it? And I think that actually makes us a really powerful discussion I'm going to Make my comments and and bring them towards the audience here and give everyone in this room a call to action A lot of discussion over the last day and a half has been How can we as healthcare providers? How can the hospitals do something different? But everybody in this room can actually do something about this today Quick show of hands. How many people have left over narcotics in their house after surgery? It's got to be more than this and I mean half the room's raised their hand. I guarantee it's almost everybody in this room How many people in this room have nasal Narcan? three four The FDA Allowed over-the-counter prescription or over-the-counter access to Narcan in the end of March It's going to be widely available in our pharmacies by the end of this summer The dose is four milligrams and it's actually Believed to be very safe. It's a drug that we use in the hospital all the time The dose is a little bit different, but it's something that we've used effectively to reverse the opioid overdoses and the respiratory depression from the opioids now One thing that is a barrier that keeps people from using it is number one is our just willingness to buy it and stocker first aid kits with it Our willingness to admit that it might be an issue. I've got twin daughters who are rising seniors in high school What do you think the odds are that my daughters or one of their friends might come to my house and take some of those pills? God forbid I don't want that to happen But at least if I have Narcan in my cabinet, I can do something to save their lives Now moving on the next barrier is education and I'm really proud to say that The american side of anesthesiologists and the american heart association has made online Education freely available. It's through a program called revive me and actually you can just google revive me And I believe the the web address is revive me.com And this is inspired by another fellow anesthesiologist Bonnie mylas And she tragically lost both of her sons due to The opioid crisis one of her sons became addicted as a result of Being prescribed opioids after a surgery somewhere between five and ten percent of our patients after surgery Become addicted or dependent on their opioids So this isn't just a case of Even a mistake occurring or some of metabolism issue occurring This isn't about junkies on the street and you know, there are people too and and to use Some of the language that peter promos used yesterday We need to love them too because they are our community. We are all human and we all need to be together So my charge to everybody's room is please go buy that Narcan Please go watch the revive me videos learn how to use it. Please don't be afraid And the last barrier is amnesty for people who call 911 looking for help There are too many tragedies where people call the police or call the ambulance for help And yet their actions end up being criminalized And we need to move beyond the criminalization and take care of our community and take care of people that we love So thank you Maybe in the next couple of minutes. So I've been through several waves of opiate use in the perioperative period one of them was Anybody that came through the threshold of the operating room got fentanyl period If I they did not get it. It was almost like it was malpractice The last you know, it started maybe 20 30 years ago, but it's really caught on the last 10 years Is opiate free anesthesia? Opiate sparing anesthesia Do you think any of those make a difference particularly in triggers for at-home use? Absolutely and should should patients be asking for it So we've actually the amount of opioids prescribed has gone down since around 2012-13 by surgeons The awareness of multimodal analgesia We use a lot more regional anesthesia regional blocks that has made a huge impact Continue to make an impact in bringing the overall opioid to the community down from surgical procedures Dan I think one thing I do want to point out and it's interesting in health care I think and I agree with you in my Shorter time, you know, I've seen this as well We need to also be careful about the substitutions And so we've said oh opioids are bad, but let's give people a lot of gabapentin let's give people a lot of ketamine and Lo and behold a lot of those medications are also not free And they also have their own side effects. And so I think things like regional blocks Or even just questioning why are we treating pain? What about the conversations and selling people? You know, you should be a little bit uncomfortable after surgery and that's actually healthy. That's good You know, clearly you don't want uncontrolled pain, but at the same time There's almost no such thing as painful surgery Okay, sorry about that Any other comments on that or I would say maybe in between rather than Always opioid sparing We saw a massive reductions 80 90 percent reductions and opioids prescribed When surgeons actually looked at the use While still in the hospital and used that to guide what they sent people home with Prior to that we actually had an orthopedic surgeon Who was doing carpal tunnels and giving people 30 oxycontins So I mean some of that just has to go away And and people just don't need as much Whether they get an opioid sparing technique or not This is not really based on opioid sparing. This is just Reducing what was rampant prescribing because no perceived risk Okay, and then one comment here that are all paraphrased a little bit this talks a little about health care disparities Can this organization advocate for free naloxone not everybody can afford to even buy it So i'm just putting that out there no no comments But I did want to save the last one minute and 39 seconds for yvonne If you want to give me your synthesis on this panel this entire meeting or any other comments you wanted to make Well, thank you dan Just one thing is instead of like I enjoy I have enjoyed all the discussion that we've That i've listened to the last couple of days and As far as like my situation I would like to see the implementation that they were talking about You know instead of losing another three ten twelve, you know 100 people for the opioid crisis where There are perfect solutions, you know, it would be Nice for me as a mother that was one thing that gave me solace after my son died is to hear of patients that were saved that came back in because of the monitors that Our doctor had sent them home with but he still ran into a lot of Frustration from our own hospital about wanting to implement it and he was adamant You know, he wasn't going to do surgeries without being able to send them home with the pulse oximeters and the monitors with their opioids But he just ran into so many roadblocks and so for me I would love just to see That you would consider As the other mother spoke before yeah, you don't think it's going to happen to you And you just don't want to be thrown into the situation. You don't want It to be your child but Consider how many lives that you can save by just implementing Those few little changes in your own hospitals, so Other lives can be saved Well, thank you very much to the panel. We're right on time And thank you again to the patient safety movement foundation for putting this panel on great great panel