Monday, December 08, 2008

Going to TN? Stay awake for this!



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.

5 comments:

Gary said...

Great system Paul - a key issue in diagnosis of OSA has been patients unwillingness to attend tests in lab settings...by screening all surgical patients who come through BIDMC you are not only creating a safer environment in the hospital, but providing the ancillary benefit of raising awareness for OSA and the associated treatments, as well as helping diagnose it in those patients who may not have otherwise received proper screening. I am the CEO of a home respiratory care company, and it is a pleasure to see hospital leadership taking a pro-active role in spreading the message about this critical disease.
Keep up the great work - love reading the blog!
Gary Sheehan, President/CEO
Cape Medical Supply

Geoffrey Gilmartin, MD-Chair, OSA Peri-Operative Workgroup, Beth Israel Deaconess Medical Center said...

Gary--Great comments--Speaking from the ground level--I think as we started the process of working to create this system within the hosptial there was a perception that it was too great an undertaking to create a system that crossed inpatient/outpaient issues as well as pulling together nursing, surgery, anesthesia, PACU sleep, respiratory therapy, primary care physicians and homecare providers. The rationale/need to do it was quite clear, however. Really setting a fixed goal of assuring that patients would move safely from the OR through to discharge home gave us an orienting focus and each discipline really took charge of their piece and we have come to a great starting point for care of these at risk patients. Thank you for the kind words and we look forward to continuing the discussion as we quanitfy the change in outcomes for our patients!

wineandsong said...

I am very impressed, and am very interested in hearing/seeing more about your perioperative protocol - our hospital needs something just like this!!! OSA is all too frequently overlooked and misunderstood, by many healthcare professionals throughout the surgical process. "Bring your CPAP machine" is what the patient gets told, but many times staff do not know how to use it or set it up, and Respiratory Staff won't touch patients' personal machines. Patients don't even know their own pressure settings! Many have old, broken, outdated machines, and don't use their machines at home, because they weren't properly educated on OSA or CPAP's importance. Where could I get more information on this wonderful protocol? Terifagan@gmail.com

John Booth said...

Thanks for the blog. I am a private practice Anesthesiologist currently writing the dpeartmental OSA policy. Tough work but your blog helps a lot. We've had in-patient issues with Biomed not approving a patients home CPAP device, meanwhile the insurance companies will not pay for another device while the first device remains at home.

In addition, we've started trialling the Boussignac disposable CPAP device. have you tried this as an alternative to regular non-disposable devices especially for those previously undiagnosed but likely OSAs screened via STOP-BANG?

Regards,

John Booth, MD

Paul Levy said...

Sorry, but I have no idea what most of those terms mean! Pls contact Eswar in our An. Dept. for more info.