Multimodal Analgesia for Acute Pain

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We commend Jungquist and colleagues on a comprehensive review of evidence-based recommendations for monitoring hospitalized patients on opioids (“Monitoring Hospitalized Adult Patients for Opioid-Induced Sedation and Respiratory Depression,” March Supplement). But we caution readers when interpreting the expert panel recommendation to monitor patients every 2.5 hours instead of every four hours. Expert opinion is the weakest form of evidence, and the panel's opinion is, in part, derived from hospital data that showed that patients who had vital signs measured every 2.5 hours did not require naloxone.1 Close inspection of these data reveals that they were confounded by patients in ICUs receiving continuous SpO2 monitoring, and lacked statistical significance to warrant conclusions about the safety of monitoring every 2.5 hours. Nurses understand that respiratory compromise does not adhere to a timeline and that although shorter intervals may be intuitively and practically appealing, they impart a false sense of security. The fact that only 8% of hospitals were compliant in implementing monitoring every 2.5 hours further suggests it is not a pragmatic workflow compromise.
We've successfully integrated continuous respiratory monitoring into the workflow at our institutions, with acceptable false and actionable alarm rates, and in a fiscally responsible manner. The Institute for Healthcare Improvement's initiative to save 5 million patients from preventable harm had a simple slogan: “Some is not a number, soon is not a time.”2 We strongly believe that continuous vital sign monitoring is the only way to prevent some patients from being found “dead in bed,” and that now is the time to implement this technology and save lives.
Frank J. Overdyk, MD, MSEE
Charleston, SC
Susan Carol Verillo, DNP(c), RN, CRRN
Baltimore, MD
Nancee Hofmeister, MSN, RN, NE-BC
Kirkland, WA
Julie Painter, MSN, RN, OCN
Indianapolis, IN
Kim Bennion, MHS, BSRT, RRT, CHC
Salt Lake City, UT
Jeanne Zack, PhD, RN, CIC
Brentwood, MO
Authors Carla R. Jungquist and Rosemary C. Polomano respond: We wish to thank Dr. Overdyk and colleagues for acknowledging the importance of our article. Their letter stresses the importance of continuous electronic monitoring for all hospitalized patients receiving opioids to prevent patients from being found “dead in bed.” We agree that this aggressive approach to monitoring may allow for earlier detection of serious opioid-induced adverse events such as respiratory depression. At this time, however, there is a lack of rigorous evidence to substantiate such a recommendation. While hospitals may have instituted continuous monitoring without the development of alarm fatigue and increased nurse burden, it would be important to document this experience for hospitals nationwide.
We wish to also clarify the authors’ reference to our publication involving Centers for Medicare and Medicaid Services (CMS) data showing that monitoring patients on iv patient-controlled analgesia every 2.5 hours as compared to every four hours resulted in less naloxone. We never made the claim that these data were obtained from a rigorous scientific study or that our findings represented evidence; rather, these data were obtained to test a CMS core e-Measure, and it was necessary to create an optimal time frame for the frequency of monitoring. What we can say is that there is sufficient evidence that we must be assessing patients’ risk for the development of opioid-induced respiratory depression—and instituting individualized monitoring plans of care based on risk is likely to be a first step in keeping our patients safe. Additionally, there is evidence to support instituting opioid-sparing interventions that will prevent the need for continuous electronic monitoring.

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