AAMI News September 2017

Patient Danger Prompts Life-Saving Expansion of Capnography

Five years after a serious patient safety incident, Barton Health in South Lake Tahoe, CA boasts a significantly lower mortality risk from respiratory events than the national average—a reduction staff attributes to its expanded use of capnography.

A Barton team shared its experience during a recent patient safety seminar hosted by the AAMI Foundation in partnership with the National Association of Clinical Nurse Specialists.

“Unfortunately we had a pretty significant patient safety event back in 2012, and through our root cause analysis, we determined we needed to do a better job of monitoring our patients who are at risk for a respiratory event,” Dawn Evans, Barton’s director of patient safety and clinical education, explained during the seminar. “The best practices that are out there really focus on expanding capnography, and so we identified that as the need.”

Evans presented data from Barton’s capnography performance improvement project with Christine O’Farrell, director of quality management, and Mary Kay Sennings, pulmonary services manager.

After convening a multidisciplinary work group in late 2012, Barton expanded its capnography monitoring guidelines to include patients on its orthopedic floor, medical/surgical floor, intensive care unit (ICU), gastrointestinal lab, and postanesthesia care unit who:

  • Had a diagnosed or suspected sleep disorder
  • Were taking respiratory-depressing medications, such as opioids and benzodiazepines
  • Were sedated or obtunded
  • Were opioid naïve, including pediatric patients
  • Were considered to be at risk by a clinician

Prior to this expansion, Barton had 39 in-house cardiac arrests. By 2015, that number decreased to nine, representing a 77% reduction, and by June 2016, there were just three in-house cardiac arrests—a 92% reduction since 2012. The hospital also noted that ICU mortalities had dropped from 25 in 2012 to zero by June 2016.

“We believe that’s because we have the capnography program in place, which allows us to identify these patients earlier. If we can identify them earlier, we can help prevent them from developing a worse respiratory condition that might ultimately lead to a cardiac arrest or respiratory arrest,” O’Farrell said.

These results show that “early identification and response to deteriorating respiratory status saves lives and ultimately improves the overall health of our community,” according to Evans. “We believe strongly that if we were able to do it here, anybody can do it anywhere.”