Two of our folks, Sue Dorion and Mary Grzybinski (surrounding Dr. Eswar Sundar, the handsome guy in the middle) are presenting this week at the IHI National Forum in Nashville on an important topic, a perioperative protocol for dealing with patients with obstructive sleep apnea ("OSA"). The poster for their session is shown above. My clinical friends tell me the following:
OSA affects anywhere between 6 to 13% of the population. During hospitalizations it is associated with increased rates of complications like respiratory failure, arrhythmias and death. In 2008, the Joint Commission considered screening and managing OSA as one of their patient safety goals but did not pursue it at that time. The American Society of Anesthesiologists (ASA) recently published guidelines for its management. We at BIDMC are ahead of the curve on this as one of a handful of hospitals in the country that have developed a comprehensive screening and management program for this important public health problem. BIDMC is probably one of the safest hospitals for a OSA patient or a high risk patient to come and have surgery as a result of this comprehensive pathway.
The perioperative OSA protocol is the culmination of many hours of work and many contributions from Anesthesia, Sliverman Institute for Healthcare Quality, Sleep Medicine, Nursing, Surgery, OB/GYN, Respiratory, Case Management, Information Systems, and many many more disciplines. This is truly multidisciplinary!
Here are some details: Patients get screened in the Pre Anesthetic Testing Clinic (PAT) and at the holding area. Our Information Systems folks developed an electronic screening tool as part of our PIMS. We have screened more than 10,000 patients since May 28, 2008, when we went live. OSA status stays on the OMR and POE and gets prominently displayed. Screen positive patients get a yellow sticker, known OSA patients get a blue one on their chart. Anesthesia is alerted and intraoperative management is suitably altered.
In the PACU, all known OSA patients get either Continuous Positive Airway Pressure (CPAP) treatment or Bilevel Positive Airway Pressure (BIPAP) treatment. Patients who had screened positive undergo a indigenously developed "Sleep Trial" and those who fail the "Sleep Trial" get CPAP or BIPAP ttreatment. Newly developed POE screens greatly simplify the process of ordering CPAP or BIPAP treatment in the PACU.
Once they reach the floor, all known OSA patients and those patients who had screened "High Risk" will get continuous pulse oximetry and other enhanced monitoring/nursing. "High Risk" Patients who pass the PACU "Sleep Trial" will get standard monitoring, thus optimally utilizing our resources. All newly discovered "High Risk Patients" get a fact sheet informing them about OSA. Their PCP also gets a letter and requests them to make an appointment with the sleep clinic for further evaluation.