Abstract
Approximately forty million surgeries take place annually in the United States, many of them requiring overnight or lengthier post operative stays in the over five thousand hospitals that comprise our acute healthcare system. Leading up to this Century, it was common for most hospitalized patients and their families to believe that being surrounded by well-trained nurses and physicians assured their safety. That bubble burst with the Institute of Medicine’s 1999 report: To Err Is Human, followed closely by its 2001 report: Crossing the Quality Chasm. This review article discusses unexpected, potentially lethal respiratory complications known for being difficult to detect early, especially in postoperative patients recovering on hospital general care floors (GCF). We have designed our physiologic explanations and simplified cognitive framework to give our front line clinical nurses a thorough, easy-to-recall understanding of just how these events evolve, and how to detect them early when most amenable to treatment. Our review will also discuss currently available practices in general care floor monitoring that can both improve patient safety and significantly reduce monitor associated alarm fatigue.
Highlights
Evolving Clinical Cascades (RECC) are unexpected, often deadly adverse clinical events seen commonly in hospitalized patients
Current general care floor (GCF) monitoring is often limited to isolated spot checks that include physiologic parameters such as the patient’s heart rate, respiratory rate, temperature, and the brief observations that come from an array of clinical and non clinical visits, all separated by significant time spans where no monitoring occurs
A couple of appropriate questions to ask would be: Is there one best alarm threshold value (ATV) for continuous pulse oximetry monitoring on general care floors that we should be using to follow our patients, and should we be following all GCF patients simultaneously? The answers we provide in this review are simple, but the explanations that support them will be evidence based and founded on thorough physiologic understandings of the three Rapidly Evolving Clinical Cascade Patterns of Respiratory Dysfunction that frequent general care floors (GCF)
Summary
Evolving Clinical Cascades (RECC) are unexpected, often deadly adverse clinical events seen commonly in hospitalized patients. Few clinicians are able to precisely state off hand what early SPO2 oximetry changes are to be expected if sleeping patients receiving parenteral opioids are being monitored with continuous pulse oximetry and begin progressively retaining known elevations of PaCO2 from a RECC Type II process This holds especially true for patients with otherwise normal lungs who are simultaneously receiving supplemental oxygen. If patients on opioids progressively accumulate CO2 while breathing room air, the ‘substitution’ process will manifest immediately on continuous pulse oximetry monitors because the substitution and dilution of the original FIO2 entrained into the lungs by the retained CO2 translates immediately to substantial progressive reductions in PaO2 and its associated SPO2 It isn’t nearly so straightforward when supplemental oxygen is being delivered, especially when the route most commonly used to deliver it is through nasal cannulas. Its chosen ATV has served very well as a safety net for their entire patient GCF populations, but additional tools or education will be needed to optimize these advances by making the adverse events detectable in their earliest phases
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