The investigation found it’s not happening during surgery or in the recovery room, but instead, in hospital rooms and floors where complications and risks are judged the absolute lowest.
Within hospitals it’s routinely referred to as “Dead in Bed” — a tragic but preventable consequence of the impact of opioids widely used to relieve patient pain following surgery where patients’ breathing slows to critical levels.
But outside the medical field, it’s a deadly phenomenon rarely discussed or shared with patients, families or healthcare consumers. And new pain management standards implemented by hospitals 15 years ago may be contributing to risk factors.
In an effort to better manage patient pain, there’s concern that hospitals may be providing too much pain medication.
The investigation also found that hospitals actually profit when patients are kept pain-free. That’s because patients grade hospitals on how well their pain is managed – higher scores can mean millions in federal cash.
Opioids have recently created an addiction epidemic in neighborhoods across the country, but there is another “opioid crisis” within hospitals themselves.
The American Hospital Association (AHA) has even raised concerns that the hospital survey, known as a Hospital Consumer Assessment of Healthcare Providers and Services (HCAHPS), “may be inadvertently contributing to the opioid epidemic.”
An April 2016 AHA letter to the Centers for Medicare & Medicaid Services (CMS) raisied serious concerns about “linking the pain control questions to payment,” adding, “we want to ensure the questions do not create pressure to prescribe opioids...or punish providers who, in their best judgment, choose not to prescribe them.”
The HCAHPS survey has also come under scrutiny by 60 prominent physicians and healthcare professionals across the country, who are demanding CMS change its patient survey.
Another April 2016 letter, also signed by 60 healthcare professionals, to the Acting Director for the Centers for Medicare & Medicaid Services underscoring concerns that “hospitals are being financially incentivized by CMS to obtain scores on HCAHPS survey questions.”
The letter was sent by Physicians for Responsible Opioid Prescribing, an advocacy group calling for the reduction of opioid-related deaths. It warned that “aggressive pain management” should “not be equated with quality healthcare” and “can result in unhelpful and unsafe treatment.”
Both the AHA and CMS declined to respond to questions raised in our investigation.
“Certainly it does not bode well for the reputation, from a marketing standpoint in a competitive healthcare environment to have unexplained deaths,” said Dr. Frank Overdyk, a nationally recognized anesthesiologist at Roper St. Francis Hospital in Charleston, S.C.
“This sort of collateral damage as it were – or cost of doing business — is totally unacceptable in our healthcare system,” he added.
Dr. Overdyk is just one of scores of respected medical authorities who have been urging hospitals for years to take steps to prevent these “avoidable” deaths.
Perhaps most revealing, the basic technology to save lives, generally referred to as pulse oximetry, has been in existence for years and is similar in concept to a $25 device sold in drugs stores that measures oxygen levels in the blood stream.
Yet, a review of hospital deaths across the country found as many as 50,000 who underwent “successful” surgeries and were recovering on “low risk” hospital floors, have died or sustained serious brain injuries over the last decade.
Patients who have been found “dead in bed” include a 17-year-old girl being treated for strep throat.
Amanda Abbiehl’s mother had left her daughter’s hospital room for the night but soon received a chilling phone call.
“She was dead in bed,” Cindy Abbiehl recalled, who choked back tears describing how she and her husband learned their daughter had died. “Half my heart died when she died.”
This is especially alarming because these are patients who are recovering so well. They are back in their own rooms — on a general floor — but dying within hours of visiting with family and friends, and surrounded by ‘get well’ cards and flowers.
Marty Schmidt’s wife was recovering from surgery when she went into respiratory depression and later died.
“They told me they found Jean not breathing,” Schmidt said.
So was Bill Neckerman, whose daughter described nurses finding her father “cyanotic and his heart eventually stopped.”
And 14 years ago, Lenore Alexander’s 11-year-old daughter was recovering from an elective surgery when she was found “dead in bed.”
An investigation found a range of contributing factors leading to what is medically described as “respiratory depression” — a condition leading to critically low levels of oxygen in the blood stream that can trigger cardiac arrest or brain damage.
Among the factors we found within hospitals contributing to patients being found “dead in bed” as a result of respiratory depression:
- • Lack of knowledge about potency differences among opioids
- • Improper prescribing of multiple opioids
- • Inadequate monitoring of surgical patients
- • Hospitals increasing the use of opioid pain medications
- • Millions of undiagnosed sleep apnea patients with respiratory systems already depressed and signaled by chronic snoring
Opioids such as morphine, fentanyl and dilaudid are among the most commonly used pain killers given to patients for pain.
One of the earliest voices calling for an end to these preventable deaths was Dr. Robert Stoelting, who served as president of the Anesthesia Patient Safety Foundation (APSF).
“In retrospect,” Stoelting said, “too much pain medication.”
As far back as 2006, Dr. Stoelting and the APSF first raised concerns over brain damage and death linked to opioids used by hospitals to treat patients’ pain.
In 2011, the APSF called on hospitals to provide “continuous monitoring of all patients” through “pulse oximetry” that monitors oxygen levels in the bloodstream and declared “no patient shall be harmed by opioid induced respiratory depression.”
Even so, hospitals across the country have ignored warning and fail to provide continuous monitoring of all surgical patients.
In Ohio, only University Hospitals Geneva Medical Center provides all surgical patients with a hospital wide wireless monitoring system that can alert doctors and nurses when a patient is experiencing life threatening respiratory depression.
University Hospitals says it's continuing to evaluate when continuous monitoring will be employed throughout its entire system but says there is screening for other patients.
The Cleveland Clinic reports “it truly depends on the case” whether a patient is afforded continuous monitoring.
While the Cleveland Clinic is among thousands of other hospitals nationwide that have failed to implement continuous monitoring involving pulse oximetry or other forms for all surgical patients with exception, Cleveland Clinic Director of Outcomes Research Dr. Daniel Sessler has said “While it’s likely many catastrophic respiratory events could be prevented by continuous…monitoring, however major trials are need to determine what should be monitored and how."
“The ordering of pulse oximetry depends upon the level of care and patient condition,” a Cleveland Clinic spokesperson said.
At best, some hospitals screen patients at risk for sleep apnea, including the MetroHealth System that operates one of the most respected sleep apnea screening programs in the nation.
Additional Medical Experts
Dr. Norman Bolden is a MetroHealth anesthesiologist who also helped create a “Dead in Bed” Registry as chairman of the Society of Anesthesia and Sleep Medicine’s committee on sleep apnea deaths and “near misses.”
A MetroHealth spokesperson reports “for patients with sleep apnea, we have special beds on the post-op surgical floor that have continuous monitors for pulse oximetry. Others undergo specialized screening for symptoms of sleep apnea.”
Even so, MetroHealth Medical Center does not routinely provide continuous monitoring for the remainder of surgical patients who have not been screened for sleep apnea.
But as recently as this past January, Bolden warned in a professional article published in Anesthesiology News that “most hospitals have not complied” with establishing protocols to manage sleep apnea patients.
Bolden also warned that “critical cases continue to occur” with “high financial penalties” with medical malpractice lawsuits.
Bolden found that nationwide malpractice lawsuits are increasing with the average payout totaling $1.5 million and more than $4 million involving serious brain injury.
Concerns of litigation and publicity are chief reasons why hospitals are slow to report to the “Dead in Bed” Registry, launched in May 2014 at the University of Washington.
Meanwhile, there are other prominent voices raising serious concerns including the Joint Commission—the top accrediting agency that also helps create patient safety standards for hospitals nationwide.
In a 2012 alert on the safe use of opioids in hospitals, the Joint Commission found “the most serious effect being respiratory depression."
It also found more than 1 in 4 opioid related adverse events, including death, are related to improper monitoring.
“This is something that is entirely preventable, and it’s something that we need to stop,” insisted Dr. Michael Ramsay, president of the Baylor Research Institute in Dallas.
“People are denying that it’s happening,” Ramsay said. “Yet in every hospital I’ve given a talk in about the risk of opioids, they’ve come up to me and said, ‘Yes, we had a patient just a month ago that we found dead in bed from respiratory depression.’”
Ramsay also serves on the Board of Directors for the Patient Safety Movement—an advocacy group whose goal is to eliminate preventable deaths by the year 2020.
The Patient Safety Movement has issued a challenge to hospitals who are “failing to rescue” patients who experience opioid induced respiratory depression.
It also has created “Ten Things Patients Should Know” about post-operative pain management.
Healthcare technology advocates are also concerned over the reluctance among hospitals nationwide to fully participate in continuous monitoring of all patients.
The Association for the Advancement of Medical Instrumentation (AAMI) Foundation is one of the nation’s leading groups advocating for patient safety and the advancement of healthcare technology.
AAMI Foundation President and CEO Mary Logan is among those who fears not enough is being done to save lives — including the Joint Commission that accredits hospitals.
“I think there is more the Joint Commission can do because the healthcare community listens when the Joint Commission speaks,” Logan said.
In November 2014, AAMI brought together healthcare professionals, patient advocates, professional societies and regulators to launch a national coalition dedicated to raising awareness about the need for continuous electronic monitoring of patients.
Overdyk was among those speaking and served as Chair of the National Coalition as well as AAMI board member.
“Let’s stop spending money on the treatment of in-hospital arrests and start preventing them instead,” said Overdyk, referencing the millions of dollars hospitals spend on treating patients who suffered cardiac arrests and require expensive treatment in intensive care units and prolonged hospital stays.
The expense associated with implementing continuous monitoring for all surgical patients is one reason often cited by hospitals for failing to act more quickly.
Yet the conference cited the success achieved at Dartmouth-Hitchcock Medical Center in Lebanon, N.H. that suggests hospitals can actually save money over the long term.
A study by Dartmouth researchers found hospitals can save millions.
For example, the study found a cost saving of $3.2 to $9 million with increased monitoring. Plus patients have “significantly fewer rescues and transfers to intensive care units.”
AAMI executive director Maryilyn Neder Flack says hospitals need to realize that continuous monitoring can save hospitals millions over time.
So how can patients judge how effectively hospitals are performing when it comes to reducing preventable deaths?
One way is by reviewing hospital safety scores released by the Leapfrog Group that assigns letter grades to hospitals based on their record of “patient safety, helping consumers protect themselves and their families from errors, injuries, accidents and infections.”
Its analysis found that “selecting the right hospital can reduce your risk of avoidable death by 50 percent.”
Yet, in its most recent 2016 survey of more than 2,600 hospitals nationwide, almost half, 1,131, were graded C and below and where patients have more than a 35 percent higher risk of avoidable death.
According to the survey, 177 were graded D or F, where patients have a 50 percent higher risk.
In total, the analysis found an estimated 206,021 avoidable deaths occur in U.S. hospitals every year from a wide range of causes beyond opioid related respiratory depression.
But after more than a decade of serious discussion within the medical field, patients continue to be found “dead in bed,” and hospitals nationwide continue to ignore solutions that can save lives.
The Lone Survivor
Perhaps no better victim is the story of Matt Whitman, a former Michigan state trooper, who literally was found “dead in bed” and lived to tell about it.
Whitman was back in his hospital room, a general floor following successful surgery.
And like most surgical patients, Whitman was not being monitored.
Only luck saved his life.
A hospital nurse was simply passing by his room and heard the sounds of Whitman fighting for his life.
“Something made me stick my head in your room,” she confided to him later. “I heard you take your last breath.”
After a close brush with death, Wittman is an outspoken advocate for continuous monitoring.
“I truly think it’s criminal that this isn’t used in every single hospital—because it’s out there.”
National Coalition to Promote Continuous Monitoring of Patients on Opioids
Cleveland-area hospital policies:
University Hospitals Geneva Medical Center
University Hospitals Cleveland Medical Center