April 14, 2014

New CMS Requirement for Monitoring of Post-Op Patients Receiving IV Opioids

The Centers for Medicare & Medicaid Services (CMS) has issued a new requirement under Conditions of Participation regarding post-op monitoring: " ‚Ķhospitals must have adequate provisions for immediate post-operative care to emphasize the need for post-operative monitoring of patients receiving IV opioid medications, regardless of where they are in the hospital."

Even when patients are attended to frequently, dangerous over-sedation can occur. A common reason for over-sedation is the titration of opioid analgesics to pain level while ignoring the effectiveness of the patient's respirations. Remember that neither respiratory rate nor oxygen saturation are sensitive enough to identify hypoventilation. Patients can have an adequate respiratory rate or O2 saturation while not effectively moving enough air to rid themselves of CO2. Capnography, the measurement of expired CO2 is the best monitoring tool.

Additionally, the use of standard sedation assessment tools like the Pasero Opioid Sedation Scale (POSS) or the Richmond Agitation Sedation Scale (RASS) can reduce the incidence of over-sedation.

And finally, planned or routine over-sedation with naloxone reversal is NOT safe and should be avoided. The half-life of naloxone is short, which can lead to a return of the over-sedation state when it wears off. Additionally, the patient may experience pain after reversal, leading to additional opioid doses, resulting in significant over-sedation once the naloxone is metabolized. If you are unsure if this is happening at your organization, look at naloxone use or naloxone stocking patterns in your procedure areas, such as the GI lab, Cardiology or Interventional Radiology.