Predicting opioid-induced oversedation in hospitalised patients: a multicentre observational study.

OBJECTIVES: Opioid-induced respiratory depression (OIRD) and oversedation are rare but potentially devastating adverse events in hospitalised patients. We investigated which features predict an individual patient's risk of OIRD or oversedation; and developed a risk stratification tool that can be used to aid point-of-care clinical decision-making. DESIGN: Retrospective observational study. SETTING: Twelve acute care hospitals in a large not-for-profit integrated delivery system. PARTICIPANTS: All inpatients ≥18 years admitted between 1 July 2016 and 30 June 2018 who received an opioid during their stay (163 190 unique hospitalisations). MAIN OUTCOME MEASURES: The primary outcome was occurrence of sedation or respiratory depression severe enough that emergent reversal with naloxone was required, as determined from medical record review; if naloxone reversal was unsuccessful or if there was no evidence of hypoxic encephalopathy or death due to oversedation, it was not considered an oversedation event. RESULTS: Age, sex, body mass index, chronic obstructive pulmonary disease, concurrent sedating medication, renal insufficiency, liver insufficiency, opioid naïvety, sleep apnoea and surgery were significantly associated with risk of oversedation. The strongest predictor was concurrent administration of another sedating medication (adjusted HR, 95% CI=3.88, 2.48 to 6.06); the most common such medications were benzodiazepines (29%), antidepressants (22%) and gamma-aminobutyric acid analogue (14.7%). The c-statistic for the final model was 0.755. The 24-point Oversedation Risk Criteria (ORC) score developed from the model stratifies patients as high (>20%, ≥21 points), moderate (11%-20%, 10-20 points) and low risk (≤10%, <10 points). CONCLUSIONS: The ORC risk score identifies patients at high risk for OIRD or oversedation from routinely collected data, enabling targeted monitoring for early detection and intervention. It can also be applied to preventive strategies-for example, clinical decision support offered when concurrent prescriptions for opioids and other sedating medications are entered that shows how the chosen combination impacts the patient's risk.

Timing of Oversedation Events Following Opiate Administration in Hospitalized Patients.

BACKGROUND: Unintended overdoses of opiate medications are potentially lethal events. Monitoring patients for oversedation is fundamental to ensuring safe use of opiates, and the timing of this evaluation is guided by the onset of action, time to max effect and duration of action of the opiate. The study's aim was to describe the timing of oversedation in relation to the predicted duration of action of the administered opiate. METHODS: This study was conducted as a retrospective review of all opiate-related oversedation events during a 2-year period involving patients admitted to an urban teaching hospital. RESULTS: Of the 53 opiate-related oversedation events evaluated, 47% occurred after the predicted maximal duration of action of the administered opiate. CONCLUSION: Opiate-induced oversedation routinely occurs after predicted based upon duration of action. The study findings have profound implications upon nursing practice regarding duration of time required to monitor for opiate-induced oversedation.

Utilizing a Human Factors Nursing Worksystem Improvement Framework to Increase Nurses' Time at the Bedside and Enhance Safety.

OBJECTIVE: The aim of this study is to increase nurses' time for direct patient care and improve safety via a novel human factors framework for nursing worksystem improvement. BACKGROUND: Time available for direct patient care influences outcomes, yet worksystem barriers prevent nurses adequate time at the bedside. METHODS: A novel human factors framework was developed for worksystem improvement in 3 units at 2 facilities. Objectives included improving nurse efficiency as measured by time-and-motion studies, reducing missing medications and subsequent trips to medication rooms and improving medication safety. RESULTS: Worksystem improvement resulted in time savings of 16% to 32% per nurse per 12-hour shift. Requests for missing medications dropped from 3.2 to 1.3 per day. Nurse medication room trips were reduced by 30% and nurse-reported medication errors fell from a range of 1.2 to 0.8 and 6.3 to 4.0 per month. CONCLUSIONS: An innovative human factors framework for nursing worksystem improvement provided practical and high priority targets for interventions that significantly improved the nursing worksystem.

Implementing SBAR across a large multihospital health system.

BACKGROUND: Communication problems among health care personnel during critical clinical situations can jeopardize patient safety. SBAR, a structured-communication technique, has been adapted from aviation and the military as a strategy for clear communication based on a statement of the situation, background, assessment, and recommendations related to a critical issue. Nurses' use of SBAR and physician perception of communication quality after SBAR implementation was assessed at a 13-hospital health care system. METHODS: Baylor Health Care System initiated a campaign to implement SBAR and train staff in SBAR techniques across its hospitals. Nurse surveys and physician audits were conducted. FINDINGS: Of 156 nurses interviewed, 152 (97.4%) had been educated about SBAR, and 91 (58.3%) used SBAR for critical communication. Of 84 nurses whose proficiency with SBAR was assessed, 72.6% demonstrated good or high proficiency. Of the 155 physicians who responded to the physician survey, 121 (78.1%) said that the last report they received was adequate to make clinical decisions. Of the 27 who indicated that the last report was not adequate to make clinical decisions, 25 (92.6%) had not received the report in SBAR format. CONCLUSIONS: SBAR was generally well understood. Challenges included inconsistent uptake across facilities, lack of physician education about SBAR, and a tendency to view SBAR as a document rather than a verbal technique. Future research will address the need for refresher education with nurses after initial SBAR education, the need for formal physician education about SBAR use, and the possibility of conducting annual competency validation of the utilization of SBAR. Research should also examine the effect of SBAR on quality of care and patient outcomes in controlled trials.