Supports for Practice

 

Toolkit - Prevention of Respiratory Compromise Through Monitoring

What is Respiratory Compromise?

Deterioration in respiratory status with the potential for progression into respiratory failure or death in which timely specific interventions such as enhanced monitoring or therapies may prevent or lessen decompensation.

Early identification of respiratory compromise is the key to instituting appropriate interventions to avoid catastrophic events.*

*Reference: Morris TA, Gay PC, MacIntyre NR, Hess DR, Hanneman SK, Lamberti JP, Doherty DE, Chang L, Seckel MA. Respiratory Compromise as a New Paradigm for the Care of Vulnerable Hospitalized Patients. Respir Care 2017;62(4):497–512.

 

Do you know the risk factors?

Patient Factors

  • Age (vey young or elderly)
  • History of cigarette/alcohol use
  • Comorbidites*
  • Usage/administration of central nervous system (CNS) depressant drugs
  • Requires airway protection
  • Does not understand the procedure, medications, risks or recovery process

Caregiver Factors

  • Communication barriers within the healthcare team
  • Alarm fatigue
  • Improper/insufficient education or training
  • Medication errors
  • Caregiver fatigue/illness

Procedural Factors

  • Recent long or complicated procedure requiring anesthesia, sedation or pain-relieving medications
  • Transfusion was required during a surgical procedure

Institutional Factors

  • Underfunding
  • Distant location of monitoring stations or equipment relative to staff and patients
  • Environmental factors (noise, lighting, temperature)
  • Lack of protocols for medication administration and patient monitoring
  • No “buy in”/belief from attending physicians
 

* Comorbidities include cardiovascular, lung, liver, kidney or neuromuscular disease; cancer, diabetes, obesity, sepsis, organ dysfunction/failure; CNS injury or disease; chest cage dysfunction, sleep disordered breathing.

 

Implementing Change in Your Orgnaization

Do you feel your organization should decrease the incidence of respiratory compromise by implementing continuous monitoring?

You can lead high-level changes in your organization!

*adapted from the Eight Steps Process for Leading Change by Kotter International – information found at https://www.kotterinternational.com/8-steps-process-for-leading-change/

Expand each section for additional details:

1. Create a sense of urgency

If you believe the organization needs to change its systems, policies or procedures to avoid respiratory compromise in patients following surgery, help other team members see the need for change and the importance of acting – for example talk to your colleagues, meet with your supervisor, prepare case presentations to support the change, etc.

2. Build a guiding coalition

Support from other effective people, within your area of practice, will be useful to guide, coordinate and communicate the need for change. For example, once you have support from your supervisor and/or colleagues, work as a team to move the issue up the ladder to effect change.

3. Form a strategic vision

It is important to clarify and develop an evidence-based vision of how you can support the safety of patients by having systems, policies and procedures in place to mitigate the complications from respiratory compromise.

4. Enlist a volunteer army

Change can only occur when a large number of people rally around a common opportunity and championing the same goal – once you have a “guiding coalition” organized, work together to enlist volunteers to gain champions from each area of the health care system.

5. Remove barriers

There will be barriers – by working together to remove inefficient processes and cutting through silos and hierarchies, you can generate real impact that will lead to change.

6. Generate short-term wins

Each small step brings you closer to success – achieving small wins, and celebrating this success, will energize the team of champions to continue moving towards their ultimate goal of making changes.

7. Sustain acceleration

A succession of small steps forward increases your credibility and can lead to improved systems, policies and procedures. Be relentless and determined in making the strategic vision a reality.

8. Institute change

To ensure that everyone sees the value and embraces change, share your story and communicate the connection between the change and the successful implementation of new systems, policies and procedures by your organization.

Testimonials


"A number of my RT colleagues at the Health Sciences Centre (HSC) in St. John’s, Newfoundland utilize remote monitoring for surgical. In many instances there is only one RT covering all the surgical floors as well as the medical floors, and remote monitoring has proven to be a useful process for respiratory care as it allows the nurses to also act quickly as first responders when a respiratory compromise incident occurs. Remote monitoring has also decreased the demands for one on one care with by either the RT or RN and there is no need for additional staff to manage special care beds. Overall it has led to better use of health human resources and a reduction in cancelled surgery because of lack of resources."

Jessie Cox, RRT, FCSRT, CCAA
St John’s Newfoundland


"As an active ACLS instructor and Respiratory Therapist, I constantly highlight the significance of capnography in the management of cardiac arrests’. Capnography’s inclusion has completely changed the way we view and manage cardiac arrest scenarios."

Marco Zaccagnini, RRT. BHSc. MSc (c)
Department of Anesthesia & Critical Care
McGill University Health Centre
Montréal, Quebec


"Where we have seen great successful with continuous monitoring is in our spinal cord population. Attempting to liberate these patients from the ventilator is a process which requires constant monitoring of their respiratory status. Although, we use saturations, work of breathing and Respiratory Rate, along with patient subjective responses to weaning trials, Endtidal CO2 monitoring is an objective tool to help us determine fatigue and respiratory compromise during weaning attempts. We use the upwards trending of endtidal CO2 to indicate respiratory muscle fatigue and we often see the increase in CO2 well before a decrease in SpO2. This helps us to appropriately assess the strength and condition of the patient’s respiratory muscles while ensuring the patient has adequate rest between weaning attempts. It also reduces the number of ABGs that are needed in patients while weaning from the ventilator."

Andrea Wnuk, RRT
Vancouver Coastal Health
Vancouver, B.C.


"I believe that continuous monitoring will allow respiratory therapists to catch some near-misses after patients have been liberated from the ventilator and transferred from ICU to the wards. In this environment, there are fewer staff per patient and often a lesser degree of surveillance. A good example would be a patient with a lower C-spine injury that is successfully weaned from the ventilator and does well for days or weeks on the ward, only to end up back in ICU a few days or weeks later in respiratory failure. When this happens, it’s often because they are slowly and insidiously derecruiting and thus hypoventilating due to their injury, which is not detectable by even the most thorough respiratory assessments. Continuous CO2 monitoring could potentially tease out patients who are slowly failing, and we would know early to try methods such as nocturnal Bipap for rest and recruitment, sparing them an ICU visit."

Ingrid Hakanson, RRT
Vancouver, B.C.