Monitoring Sedation in Patients Receiving Opioids for Pain Management

Nurses' Ability to Recognize and Prevent Opioid-Induced Respiratory Depression: An Evidenced-Based Practice Project

Opioids are the primary therapy for acute postoperative pain, despite being associated with opioid-induced respiratory depression (OIRD). The purpose of this study was to improve nurses' knowledge, confidence, and ability to recognize, prevent, and treat OIRD in postoperative inpatients and evaluate the feasibility of using the Pasero Opioid-Induced Sedation Scale (POSS). Registered nurses completed three tools: (1) an Opioid Knowledge Self-Assessment, which was administered pre- and post-education; (2) a Confidence Scale, which was administered pre- and post-education; and (3) a POSS Perceptions and Usability Scale that was administered post-education. Nurses were educated on the POSS and then immediately following the training practiced by undertaking a patient assessment using the instrument. They then completed the POSS Perceptions and Usability Scale to rate their perception of the feasibility of using the POSS. Between preeducation and posteducation, participant knowledge increased in the following areas: recognizing opioid-induced side effects, dose selection, risk factors for oversedation, and information to make clinical decisions. However, there was a drop in scores when asked about knowledge of who is at risk for opioid-related side effects. These findings support our conclusion that OIRD education improves nursing confidence and knowledge. There was significant agreement between the nurse and subject matter experts POSS scores, indicating that this tool is easy to use.

Opioid-Induced Sedation and Respiratory Depression: Are Sedation Scales Enough to Prevent Adverse Drug Events Postoperatively?

OBJECTIVES

Nurses who care for hospitalized patients are responsible for ensuring adequate pain management is provided in a safe manner. The clinical challenge is balancing the effective control of the patient's pain with the side effects of administering opioids. The aim of this literature review is to explore the evidence on how nurses assess for opioid-induced sedation and advancing respiratory depression and how they integrate those data in their critical thinking skills when deciding to administer opioids for pain.

DESIGN

A matrix method was used to guide the review and synthesis of the evidence. Tables with column headings (citation, purpose of study, design/measurements, outcomes, and results) were constructed to record data extracted from each study.

DATA SOURCES

Primary source research articles were examined using the MESH terms sedation, sedation scale, respiratory depression, opioid, pain, pain assessment, adverse events, naloxone and postoperative.

REVIEW/ANALYSIS METHODS

Original studies such as retrospective case-control studies and descriptive studies were included. The final studies that met the inclusion criteria and were independently reviewed by the authors. The two main areas of interest were the evidence for how nurses assess for advancing sedation and excessive respiratory depression and how nurses integrate their assessment data in their critical thinking skills when deciding to administer opioids for pain.

RESULTS

Results indicated a lack of evidence examining the relationships among sedation, respiratory depression, and adverse events and the overall impact of managing these variables on patients' pain.

CONCLUSIONS

This review revealed a lack of evidence between how nurses assess for opioid induced advancing sedation and excessive respiratory depression, and the impact, including the adverse events associate with acute pain management.

Addressing Safe Opioid Monitoring Practices Using an Interprofessional Approach

OBJECTIVE

The aims of the project are to increase knowledge related to opioids and improve adherence to evidence-based interventions for sedation monitoring and assessment in adult inpatients receiving opioids for pain through delivery of an interprofessional online program.

BACKGROUND

Preventable opioid-induced respiratory depression is a patient safety risk in hospitals. Sedation and respiratory assessment and monitoring guidelines and tools are available to improve practice.

METHODS

An interprofessional team identified organization-specific drivers of opioid-induced sedation and respiratory depression using process improvement methodology, developed interventions, and evaluated clinician opioid knowledge and documentation practice.

RESULTS

Opioid knowledge survey responses improved after the interventions. Audits showing improved appropriate documentation by RNs of the correct sedation scale were performed over 2 separate 3-month periods.

CONCLUSIONS

Clinicians demonstrated increased knowledge about newly adopted sedation and monitoring practices targeted to prevent opioid-induced respiratory depression.

Use of the Pasero Opioid-induced Sedation Scale (POSS) in Pediatric Patients

The Pasero Opioid-induced Sedation Scale (POSS) is a valid, reliable tool used to assess sedation when administering opioid medications to manage pain. The POSS is endorsed by The Joint Commission and the American Society for Pain Management Nursing to help prevent adverse opioid-related respiratory events. Although the POSS is used to assess sedation in pediatric patients at some hospitals, prior to this study, it was not formally evaluated in the pediatric population. This study used a quasi-experimental design with a convenience sample of pediatric patients admitted to a large regional medical center in southeastern North Carolina. The POSS was evaluated from three perspectives. First, the study was designed to compare the documentation of sedation when opioids were administered before (n=25) and after (n=27) implementation of the POSS to assess sedation. Second, the occurrence of respiratory adverse events before and after implementation of the POSS was compared. Third, the appropriateness of using the POSS in the pediatric population was evaluated. When the POSS was used, there was an increase in both the clarity and frequency of documentation when sedation was assessed. There was no incidence of opioid-related adverse respiratory events after implementation of the POSS. Finally, the POSS was found to be appropriate and safe to use in the pediatric population. Through a survey, the majority of registered nurses who cared for the research subjects evaluated the POSS as easy, appropriate and safe to use with pediatric patients. The nurses also noted using the POSS provided standardized communication among staff regarding patients' levels of sedation. No adverse effects, concerns, or objections were reported. Coincidentally, while it was not part of the study, frequency of documentation of assessment of pain also improved with implementation of the POSS.

One Hospital's Initiatives to Encourage Safe Opioid Use

Pain is the leading reason people seek health care. In an effort to aggressively manage pain in the hospitalized patient, we have seen an increase in the use of opioids. Unfortunately, there has been a similar increase in the number of opioid-related adverse events. As a result, The Joint Commission issued a Sentinel Event Alert in August 2012 with suggested evidenced-based actions to help avoid these adverse events. This article describes one hospital's initiatives to provide opioids safely.