- Email: [email protected]
Clinical Issues—April 2016
CONTINUING EDUCATION
Clinical Issues
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MARY C. FEARON, MSN, RN, CNOR; MARY J. OGG, MS, RN, CNOR Continuing Education Contact Hours
Approvals
indicates that continuing education (CE) contact hours are available for this activity. Earn the CE contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Learner Evaluation at http:// www.aornjournal.org/content/cme. Each applicant who successfully completes this program can immediately print a certificate of completion.
This program meets criteria for CNOR and CRNFA recertification, as well as other CE requirements.
Event: #16515 Session: #0001 Fee: For current pricing, please go to: http://www.aornjournal .org/content/cme. The contact hours for this article expire April 30, 2019. Pricing is subject to change.
Purpose/Goal To provide the learner with knowledge of AORN’s guidelines related to creating a just culture, circulating while administering moderate sedation/analgesia, the monitoring RN leaving the OR during administration of moderate sedation, screening for obstructive sleep apnea before administering moderate sedation, and assessment for obstructive sleep apnea.
AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.
Conflict-of-Interest Disclosures Mary C. Fearon, MSN, RN, CNOR, and Mary J. Ogg, MS, RN, CNOR, have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article. The behavioral objectives for this program were created by Helen Starbuck Pashley, MA, BSN, CNOR, clinical editor, with consultation from Susan Bakewell, MS, RN-BC, director, Perioperative Education. Ms Starbuck Pashley and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article.
Objectives 1. Discuss practices that could jeopardize safety in the perioperative area. 2. Discuss common areas of concern that relate to perioperative best practices. 3. Describe implementation of evidence-based practice in relation to perioperative nursing care.
Sponsorship or Commercial Support No sponsorship or commercial support was received for this article.
Disclaimer Accreditation AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
AORN recognizes these activities as CE for RNs. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity. http://dx.doi.org/10.1016/j.aorn.2016.02.010 ª AORN, Inc, 2016
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CLINICAL ISSUES
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THIS MONTH Creating a just culture Key words: just culture, TeamSTEPPS, human error, briefing, huddle. Circulating while administering moderate sedation/analgesia Key words: moderate sedation/analgesia, RN circulator. Monitoring RN leaving room during administration of moderate sedation Key words: moderate sedation/analgesia, propofol. Screening for obstructive sleep apnea before administering moderate sedation Key words: moderate sedation/analgesia, obstructive sleep apnea, OSA. Assessment for obstructive sleep apnea Key words: moderate sedation/analgesia, obstructive sleep apnea, OSA, OSA questionnaires, OSA checklist.
Creating a just culture QUESTION: We had a breakdown in communication during a recent procedure; the implants listed on the preference card were in the room, but the surgeon requested a different manufacturer’s implant. The surgeon was angry, and an uncomfortable blaming conversation ensued until the needed implant arrived in the room. Are there communication
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tools available to prevent this type of ineffective communication in the future?
ANSWER: Health care personnel in an organization committed to switching from a blaming culture to a just culture can use AORN Journal j 439
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communication tools such as TeamSTEPPS, surgeon worksheets, perioperative briefings, and staff huddles to facilitate communication among team members and to decrease the potential for human error. Communication is essential in developing a just culture in which learning from errors allows team members to build trust and to develop safer operational systems. Communication also helps to problem solve and to eliminate blaming. Creating teams that can effectively communicate when they have a concern improves patient care. In a just culture, nurses, surgical technologists, surgeons, anesthesia professionals, and other health care workers accept that humans make mistakes, develop systems for reporting errors, and use the information collected to develop safer systems for providing patient care. Leaders who facilitate effective communication are important in helping to create an environment in which team members feel safe to speak up and report errors.1 Reason defined error as “the failure of a planned action to be completed as intendeddwithout the intervention of some unforeseeable event; or the use of a wrong plan to achieve an aim.”2(p9) Errors can be slips, lapses, or mistakes in memory or actions. In the scenario here, several events may have created a breakdown in communication (eg, the surgeon forgot to communicate what implant was needed, personnel did not order the implant, the person with whom the surgeon communicated did not follow through). Blaming an individual may be more immediate than taking the time required to investigate the system issue or manage the expense to fix a system issue that was the root cause. However, blaming does not help personnel understand how mistakes occur, fix a broken system, help an individual improve his or her performance, or stop unsafe acts from occurring.3 When team members communicate about incidents, it is best to remember that errors are consequences and not causes of system failures. All perioperative team members intend to do their best work. Sometimes the system inadvertently creates an environment that may impede an individual’s best response to a situation, or there are reasons why an individual may be responsible for the error. In a just culture, all team members are accountable for providing safe patient care. A just culture is a balance between personal accountability and system improvement.
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Individual counseling, coaching, or corrective action may be warranted if the individual’s conduct calls for such action. A helpful resource in assessing if accountability for the error is individual versus system related is the algorithm “Accountability in the Face of Error: A Tool to Help Manage Unsafe Acts,” which is included in the AORN Just Culture Tool Kit as the Just Culture Reason Algorithm.4 In this algorithm, the following three questions can be asked to assist team members in quickly determining if this is an individual or system error. 1. 2. 3.
Did the individual intend to cause harm? Did the individual come to work drunk or equally impaired? Did the individual knowingly and unreasonably increase risk?
If the answers to these questions are yes, then it is an individual error. If the answers are no, then team members should ask “would another similarly trained and skilled individual in the same situation act in a similar manner?” If the answer is yes, then it is a system error.5(p1694) Leaders at all levels can support a just culture by providing opportunities for individuals to practice speaking up about concerns without fear of punishment, intimidation, or shame.6 One tool that may be used to assist team members to speak up is the TeamSTEPPS method. The TeamSTEPPS program endorses the use of a tool called DESC (ie, describe, express, suggest, consequences) (Table 1) that can be used as a framework to help structure a crucial conversation.7 Using the DESC tool in the missing implant situation described in the question could decrease the blaming tone and move the conversation toward problem solving. Each person should be prepared to listen, understand, and eliminate blame. The nurse in the situation described
Table 1. The DESC Framework for Structuring a Crucial Conversation D ¼ Describe the specific situation or behavior; provide concrete data E ¼ Express how the situation makes you feel and what your concerns are S ¼ Suggest other alternatives and seek agreement C ¼ Consequences should be stated in terms of effect on established team goals and should strive for consensus
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can, at a later time, have the following conversation with the surgeon: D: “I understand we did not have the implant you requested for this procedure.” E: “I think more communication before the procedure would be helpful for all of us and help ensure that problems like this do not occur.” The nurse should pause to hear the response from the surgeon and use active listening skills. The surgeon may reply “I did call the team leader,” or “I told my office staff to order it,” or “I use this implant every time.” S: The nurse should make a suggestion about how to resolve the problem and ask the surgeon to suggest one. The nurse’s response could be “I understand that you called the team leader (or told your office to order it, or use it every time), but it appears that this message was not relayed. I talked to the team leader, and we would like to use this patient-specific worksheet. What do you think?” C: The nurse can relay the consequence as “I think this will be an improvement in the process. Using this tool provides the team with the correct information and sufficient time to obtain the correct implant before the patient is in the room.” In this conversation, mutual respect is built by understanding the limitations that led to the unintended consequence.
Clinical Issues
safety huddle allows perioperative team members to practice communicating effectively in a nonstressful situation. The frontline leader representatives (eg, charge nurse, supervisor, manager) from the surgery teams; the preadmission area; the postanesthesia care unit; and the materials management, sterile processing, environmental services, and radiology departments can conduct a daily huddle for 15 minutes. Each representative should have an opportunity to disclose a safety event that occurred in their department during the previous 24 hours. For example, the implant event described in the question could be reported at the safety huddle to determine where the system breakdown occurred. Problem solving does not occur during the quick daily huddle, but an action plan and stakeholders can be determined for further discussion and these individuals can report their findings at the next huddle. Events in the OR environment are not predictable, and each perioperative team member who interacts with the patient poses a potential risk for a variance to occur. Establishing effective communication and teamwork allows the team to work in unison and speak up when a variance may be leading toward an unsafe outcome. Effective teamwork, a systems approach, and blameless communication are the best strategies for building a just culture.
Editor’s note: TeamSTEPPS is a trademark of the Agency for Healthcare Research and Quality and the Department of Health and Human Resources, Rockville, MD.
Using preoperative briefings to confirm the availability of specific implants in the room and to review possible complications and supplies needed when emergent situations arise is an additional communication tool. The postoperative briefing also is a time to practice using the DESC tool to discuss any issues that may have occurred during the procedure. A patient-specific worksheet is another tool that can be used to decrease the potential for errors in communication. This worksheet can include items that are not frequently used for each procedure but need to be available, and it can provide a framework for the surgeon to communicate his or her plan for each patient. Items on the patient-specific worksheet can be listed in a checklist format and include the position for surgery, implants, special equipment (eg, laser, microscope), and other factors that make this patient’s procedure unique from the normal surgical plan or items on the surgeon’s preference list. A frontline leader safety huddle is a venue where issues can be identified using the DESC communication tool. The
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Mary C. Fearon, MSN, RN, CNOR, is a perioperative practice specialist in the Nursing Department at AORN, Inc, Denver, CO.
References 1. Armitage G. Human error theory: relevance to nurse management. J Nurs Manag. 2009;17(2):193-202. 2. Reason JT. Human Error. Cambridge, England: Cambridge University Press; 1990. 3. Bashaw ES, Lounsbury K. Forging a new culture: blending Magnet principles with just culture. Nurs Manag. 2012;43(10): 49-53.
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4. AORN Just Culture Tool Kit. AORN, Inc. https://www.aorn.org/ guidelines/clinical-resources/tool-kits/just-culture-tool-kit. Accessed December 17, 2015. 5. Frankel AS, Leonard MW, Denham CR. Fair and just culture, team behavior, and leadership engagement: the tools to achieve high reliability. Health Serv Res. 2006;41(4 Pt 2):1690-1709.
6. Castner J, Foltz-Ramos K, Schwartz DG, Ceravolo DJ. A leadership challenge: staff nurse perceptions after an organizational TeamSTEPPS initiative. J Nurs Adm. 2012;42(10):467-472. 7. Clark CM. Conversations to inspire and promote a more civil workplace: let’s end the silence that surrounds incivility. Am Nurs Today. 2015;10(11):18-22.
Circulating while administering moderate sedation/analgesia QUESTION: Mary J. Ogg, MS, RN,
Is it acceptable for an RN to circulate, administer medications, and monitor the patient receiving moderate sedation/analgesia?
CNOR, is a senior perioperative practice specialist in the Nursing Department at AORN, Inc, Denver, CO.
ANSWER: At a minimum, two perioperative RNs should care for a patient who is receiving moderate sedation/analgesia provided by an RN. The RN providing the moderate sedation/analgesia is responsible for monitoring the patient, administering the sedation and analgesia medications, and continuously caring for the patient throughout the procedure. The second RN is responsible for circulating duties.1 The RN assigned to care for the patient receiving moderate sedation/analgesia should have no competing responsibilities that would compromise the continuous monitoring and assessment of the patient.2-7 Through continuous monitoring and observation of the patient’s physiological and psychological status, the perioperative RN can immediately respond to an adverse event or complication, leading to earlier treatment and potentially avoiding patient complications.1 The respiratory and cardiovascular complications associated with moderate sedation/analgesia include hypoxia, hypercapnia, impaired airway reflexes, loss of airway patency, airway obstruction, respiratory depression, hypotension, and cardiac arrhythmias.8-12 When an RN is administering sedation and analgesic medications and monitoring the patient, a second RN should be assigned to the circulating role. The RN circulator helps provide safe, quality patient care in the perioperative setting.13 AORN is committed to the policy of providing a perioperative RN dedicated to the care of every surgical patient for the duration of any operative or other invasive procedure.13 In addition, 24 states have laws or regulations in place that require an RN to serve as the circulator in hospitals, and 16 states have similar language for ambulatory surgical centers.
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References 1. Guideline for care of the patient receiving moderate sedation/ analgesia. In: Guidelines for Perioperative Practice. Denver, CO: AORN; 2016:617-647. 2. American Society of PeriAnesthesia Nurses Standards and Guidelines Committee. The role of the registered nurse in the management of patients undergoing sedation for short-term therapeutic, diagnostic, or surgical procedures. In: 2015-2017 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements. Cherry Hill, NJ: American Society of PeriAnesthesia Nurses; 2015:73-79. 3. Non-anesthesia provider procedural sedation and analgesia: considerations for policy development. American Association of Nurse Anesthetists. http://www.aana.com/resources2/professionalpractice/ Documents/Non%20anesthesia%20Provider%20Procedural%20 Sedation%20and%20Analgesia.pdf. Accessed March 8, 2016. 4. Du Rand IA, Blaikley J, Booton R, et al. British Thoracic Society guideline for diagnostic flexible bronchoscopy in adults: accredited by NICE. Thorax. 2013;68(Suppl 1):i1-i44. 5. De Vito A, Carrasco Llatas M, Vanni A, et al. European position paper on drug-induced sedation endoscopy (DISE). Sleep Breath. 2014;18(3):453-465. 6. Hurford WE, Staubach KC. A hospital policy for procedural sedation in the nonintubated patient. Int Anesthesiol Clin. 2013;51(2):1-22. 7. Antonelli MT, Seaver D, Urman RD. Procedural sedation and implications for quality and risk management. J Healthc Risk Manag. 2013;33(2):3-10. 8. American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Practice guidelines for
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April 2016, Vol. 103, No. 4 sedation and analgesia by non-anesthesiologists. Anesthesiology. 2002;96(4):1004-1017. 9. Amornyotin S. Sedation-related complications in gastrointestinal endoscopy. World J Gastrointest Endosc. 2013;5(11):527-533. 10. Cabrini L, Nobile L, Cama E, et al. Non-invasive ventilation during upper endoscopies in adult patients. A systematic review. Minerva Anestesiol. 2013;79(6):683-694. 11. Hession PM, Joshi GP. Sedation: not quite that simple. Anesthesiol Clin. 2010;28(2):281-294.
Clinical Issues 12. Kauling AL, Locks Gde F, Brunharo GM, da Cunha VJ, de Almeida MC. Conscious sedation for upper digestive endoscopy performed by endoscopists. Rev Bras Anestesiol. 2010;60(6): 577-583. 13. AORN Position Statement on One Perioperative Registered Nurse Circulator Dedicated to Every Patient Undergoing an Operative or Other Invasive Procedure. AORN, Inc. 2014. https://www.aorn .org/guidelines/clinical-resources/position-statements. Accessed December 4, 2015.
Monitoring RN leaving room during administration of moderate sedation QUESTION: Is it acceptable for the RN who is monitoring the patient receiving moderate sedation/analgesia to leave the room to procure more medications from the dispensing system?
bradycardia, apnea, airway obstruction, and oxygen desaturation.6,11 When additional medications or supplies are needed that are located outside of the room, the RN circulator or other available personnel should obtain the needed items.
ANSWER:
Mary J. Ogg, MS, RN, CNOR, is a senior perioperative
The perioperative RN providing moderate sedation/analgesia should not leave the room. The RN should be in constant attendance with unrestricted immediate visual and physical access to the patient.1-3 While remaining inside the room, the perioperative RN providing moderate sedation/analgesia may perform brief, interruptible, patient-related, ancillary tasks to assist the perioperative team.1,4-7 Examples of brief, interruptible tasks are tying a sterile gown and opening supplies that are in the room when an RN circulator is unavailable. In a literature review, Hausman and Reich8 described performing biopsies and collecting specimens as tasks that do not meet the criteria of brief or interruptible. In addition to AORN, the professional organizations supporting the RN performing brief, interruptible tasks are the American Society of Anesthesiologists, the Society of American Gastrointestinal Endoscopic Surgeons, the American Society for Gastrointestinal Endoscopy, the American Academy of Pediatrics, and the Society of Gastroenterology Nurses and Associates.2,4-7 The American Association of Nurse Anesthetists and the American Society of PeriAnesthesia Nurses support the RN who is caring for a patient receiving moderate sedation having no other responsibilities during the procedure.9,10 If the patient is receiving propofol for moderate sedation/ analgesia, the RN providing the moderate sedation/analgesia should not perform brief, interruptible tasks. Propofol has a narrow therapeutic window.11 The RN should monitor the patient without interruption, continuously assessing the patient’s level of consciousness to identify early signs of hypotension,
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practice specialist in the Nursing Department at AORN, Inc, Denver, CO.
References 1. Guideline for care of the patient receiving moderate sedation/ analgesia. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2016:617-647. 2. American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology. 2002; 96(4):1004-1017. 3. Hurford WE, Staubach KC. A hospital policy for procedural sedation in the nonintubated patient. Int Anesthesiol Clin. 2013;51(2):1-22. 4. Heneghan S, Myers J, Fanelli R, Richardson W. Society of American Gastrointestinal Endoscopic Surgeons. Society of American Gastrointestinal Endoscopic Surgeons (SAGES) guidelines for office endoscopic services. Surg Endosc. 2009;23(5):1125-1129. 5. American Academy of Pediatrics, American Academy of Pediatric Dentistry, Cote CJ, Wilson S; Work Group on Sedation. Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures: an update. Clinical report. Pediatrics. 2006;118(6):2587-2602. 6. Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy, Lichtenstein DR, Jagannath S, et al. Sedation and anesthesia in GI endoscopy. Gastrointest Endosc. 2008;68(5):815-826. 7. SGNA Practice Committee. Statement on the use of sedation and analgesia in the gastrointestinal endoscopy setting. Gastroenterol Nurs. 2008;31(3):249-251. 8. Hausman LM, Reich DL. Providing safe sedation/analgesia: an anesthesiologist’s perspective. Gastrointest Endosc Clin North Am. 2008;18(4):707-716.
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April 2016, Vol. 103, No. 4 undergoing sedation for short-term therapeutic, diagnostic or surgical procedures. In: 2015-2017 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements. Cherry Hill, NJ: American Society of PeriAnesthesia Nurses; 2015: 62-65. 11. Statement on safe use of propofol. American Society of Anesthesiologists. 2014. http://www.asahq.org/Search.aspx?q¼joint þstatementþregardingþpropofol. Accessed December 4, 2015.
Screening for obstructive sleep apnea before administering moderate sedation QUESTION: Does AORN recommend that nurses screen patients for obstructive sleep apnea if they are scheduled to undergo a procedure with moderate sedation?
ANSWER: Yes, the perioperative RN administering moderate sedation/ analgesia should assess the patient’s airway preoperatively for the risk of obstructive sleep apnea (OSA).1 Obstructive sleep apnea is a sleep-related breathing disorder characterized by periodic, partial, or complete obstruction of the upper airway during sleep.2,3 The estimated incidence of OSA ranges from 2% to 26%, and it affects men more frequently than women.4 The estimated incidence of moderate to severe OSA is 82% for men and 92% for women with undiagnosed OSA.5 Surgical patients have a reported higher incidence than the general population.3 The number of patients with OSA is likely to increase as the population ages and becomes more obese.2,3 Moderate sedation medications that affect the central nervous system may interfere with the normal respiratory compensatory mechanisms of hypoxemia and hypercarbia, and depressant medications may facilitate pharyngeal collapse in patients with OSA.5 Preoperative awareness of a patient with OSA is important because these patients may experience complications during perioperative care that include cardiac dysrhythmias (eg, bradycardia, atrial fibrillation, premature ventricular contractions); myocardial infarction; severe oxygen desaturation, episodic hypoxemia, hypercapnia, respiratory arrest, airway obstruction, and hypoventilation; impaired arousal from sedation; unplanned intensive care unit admission; and sudden death.4
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The perioperative RN may need to take additional precautions when caring for a patient with OSA, such as the use of noninvasive positive pressure ventilation6 with continuous positive airway pressure3 or bilevel positive airway pressure,3 careful titration of opioids,7 nonopioid analgesia techniques,3,8 and multimodal pain management.3,7 High-risk patients (ie, severe OSA) may need a referral to a higher level of care (eg, anesthesia professional)7 or additional diagnostic testing (ie, polysomnography).4
Mary J. Ogg, MS, RN, CNOR, is a senior perioperative practice specialist in the Nursing Department at AORN, Inc, Denver, CO.
References 1. Guideline for care of the patient receiving moderate sedation/ analgesia. In: Guidelines for Perioperative Practice. Denver, CO: AORN; 2016:617-647. 2. Gross JB, Bachenberg KL, Benumof JL, et al. Practice guidelines for the perioperative management of patients with obstructive sleep apnea: a report by the American Society of Anesthesiologists Task Force on Perioperative Management of patients with obstructive sleep apnea. Anesthesiology. 2006;104(5):1081-1093. 3. Joshi GP, Ankichetty SP, Gan TJ, Chung F. Society for Ambulatory Anesthesia consensus statement on preoperative selection of adult patients with obstructive sleep apnea scheduled for ambulatory surgery. Anesth Analg. 2012;115(5):1060-1068. 4. Abrishami A, Khajehdehi A, Chung F. A systematic review of screening questionnaires for obstructive sleep apnea. Can J Anaesth. 2010;57(5):423-438. 5. Chung F, Elsaid H. Screening for obstructive sleep apnea before surgery: why is it important? Curr Opin Anesthesiol. 2009;22(3):405-411. 6. American Society of PeriAnesthesia Nurses Standards and Guidelines Committee. 2015-2017 Perianesthesia Nursing Standards, Practice
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April 2016, Vol. 103, No. 4 Recommendations and Interpretive Statements. https://www.aspan .org/Clinical-Practice/ASPAN-Standards. Accessed December 4, 2015. 7. American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Practice guidelines for sedation
Clinical Issues and analgesia by non-anesthesiologists. Anesthesiology. 2002; 96(4):1004-1017. 8. Blake DW, Yew CY, Donnan GB, Williams DL. Postoperative analgesia and respiratory events in patients with symptoms of obstructive sleep apnoea. Anaesth Intensive Care. 2009;37(5):720-725.
Assessment for obstructive sleep apnea QUESTION: How should the patient be assessed and screened for obstructive sleep apnea?
recommend the use of the STOP and STOP-Bang questionnaires to screen surgical patients for OSA.
Mary J. Ogg, MS, RN, CNOR, is a senior perioperative
ANSWER: The perioperative RN should use a screening tool to assess the patient for obstructive sleep apnea (OSA).1 Obstructive sleep apnea screening tools are useful to classify patients based on clinical symptoms and risk factors to determine high-risk patients who may need a referral to a higher level of care (eg, an anesthesia professional) or additional diagnostic testing (ie, polysomnography).2 Several screening tools are available to assess the risk of OSA. Representative questions in the screening tools include body mass index, neck size, age, sex, hypertension, loud snoring, apnea during sleep, and tiredness during the day.2 In a prospective cohort study, Lockhart et al3 screened surgical patients with four different OSA tools (ie, STOP questionnaire, STOP-Bang questionnaire, Berlin questionnaire, Flemons index). The researchers concluded that the most common characteristics of high-risk patients with OSA were male sex, older age, overweight, and comorbid conditions. Examples of OSA screening tools include the
STOP questionnaire,2-5 STOP-Bang questionnaire,2,6-17 Berlin questionnaire,2,5,18-20 Wisconsin sleep questionnaire,2 and American Society of Anesthesiologists’ checklist for the identification and assessment of OSA.2,5,21
Some screening tools are easier to administer than others, and some tools have a higher degree of sensitivity and specificity. Abrishami et al2 conducted a systematic review to identify and evaluate the available screening questionnaires for OSA. The authors concluded that the Wisconsin and Berlin questionnaires had the highest sensitivity and specificity for predicting the existence of OSA. The STOP and STOP-Bang questionnaires had the highest methodological validity, reasonable accuracy, and easy-to-use features. Based on these findings, the authors
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practice specialist in the Nursing Department at AORN, Inc, Denver, CO.
References 1. Guideline for care of the patient receiving moderate sedation/ analgesia. In: Guidelines for Perioperative Practice. Denver, CO: AORN; 2016:617-647. 2. Abrishami A, Khajehdehi A, Chung F. A systematic review of screening questionnaires for obstructive sleep apnea. Can J Anaesth. 2010;57(5):423-438. 3. Lockhart EM, Willingham MD, Abdallah AB, et al. Obstructive sleep apnea screening and postoperative mortality in a large surgical cohort. Sleep Med. 2013;14(5):407-415. 4. Chung F, Yegneswaran B, Liao P, et al. STOP questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology. 2008;108(5):812-821. 5. Chung F, Yegneswaran B, Liao P, et al. Validation of the Berlin questionnaire and American Society of Anesthesiologists checklist as screening tools for obstructive sleep apnea in surgical patients. Anesthesiology. 2008;108(5):822-830. 6. Joshi GP, Ankichetty SP, Gan TJ, Chung F. Society for Ambulatory Anesthesia consensus statement on preoperative selection of adult patients with obstructive sleep apnea scheduled for ambulatory surgery. Anesth Analg. 2012;115(5):1060-1068. 7. Chung F, Subramanyam R, Liao P, Sasaki E, Shapiro C, Sun Y. High STOP-Bang score indicates a high probability of obstructive sleep apnoea. Br J Anaesth. 2012;108(5):768-775. 8. Kulkarni GV, Horst A, Eberhardt JM, Kumar S, Sarker S. Obstructive sleep apnea in general surgery patients: is it more common than we think? Am J Surg. 2014;207(3):436-440. 9. Chung F, Yang Y, Liao P. Predictive performance of the STOPBang score for identifying obstructive sleep apnea in obese patients. Obes Surg. 2013;23(12):2050-2057. 10. Corso RM, Petrini F, Buccioli M, et al. Clinical utility of preoperative screening with STOP-Bang questionnaire in elective surgery. Minerva Anestesiol. 2014;80(8):877-884. 11. Singh M, Liao P, Kobah S, Wijeysundera DN, Shapiro C, Chung F. Proportion of surgical patients with undiagnosed obstructive sleep apnoea. Br J Anaesth. 2013;110(4):629-636.
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12. Vasu TS, Doghramji K, Cavallazzi R, et al. Obstructive sleep apnea syndrome and postoperative complications: clinical use of the STOP-BANG questionnaire. Arch Otolaryngol Head Neck Surg. 2010;136(10):1020-1024. 13. Luo J, Huang R, Zhong X, Xiao Y, Zhou J. STOP-Bang questionnaire is superior to Epworth sleepiness scales, Berlin questionnaire, and STOP questionnaire in screening obstructive sleep apnea hypopnea syndrome patients. Chin Med J (Engl). 2014;127(17):3065-3070. 14. Mehta PP, Kochhar G, Kalra S, et al. Can a validated sleep apnea scoring system predict cardiopulmonary events using propofol sedation for routine EGD or colonoscopy? A prospective cohort study. Gastrointest Endosc. 2014;79(3):436-444. 15. Ganesh BR, Kulkarni MK, Noronha MG. Screening of sleep apnoea in middle-aged hypertensive subjects using STOP-Bang Questionnairedan observational study. Indian J Physiother Occup Ther. 2014;8(2):13-16. 16. Chia P, Seet E, Macachor JD, Iyer US, Wu D. The association of pre-operative STOP-BANG scores with postoperative critical care admission. Anaesthesia. 2013;68(9):950-952.
17. Chung F, Yang Y, Brown R, Liao P. Alternative scoring models of STOPBang questionnaire improve specificity to detect undiagnosed obstructive sleep apnea. J Clin Sleep Med. 2014;10(9):951-958. 18. Boese ML, Ransom RK, Roadfuss RJ, Todd A, McGuire JM. Utility of the Berlin questionnaire to screen for obstructive sleep apnea among patients receiving intravenous sedation for colonoscopy. AANA J. 2014;82(1):38-45. 19. Khiani VS, Salah W, Maimone S, Cummings L, Chak A. Sedation during endoscopy for patients at risk of obstructive sleep apnea. Gastrointest Endosc. 2009;70(6):1116-1120. 20. Mador MJ, Nadler J, Mreyoud A, et al. Do patients at risk of sleep apnea have an increased risk of cardio-respiratory complications during endoscopy procedures? Sleep Breath. 2012;16(3): 609-615. 21. Gross JB, Bachenberg KL, Benumof JL, et al. Practice guidelines for the perioperative management of patients with obstructive sleep apnea: a report by the American Society of Anesthesiologists Task Force on Perioperative Management of patients with obstructive sleep apnea. Anesthesiology. 2006;104(5):1081-1093.
TM
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To what extent were your individual objectives met? Low 1. 2. 3. 4. 5. High
6.
Will you be able to use the information from this article in your work setting? 1. Yes 2. No
7.
Will you change your practice as a result of reading this article? (If yes, answer question #7A. If no, answer question #7B.)
7A.
How will you change your practice? (Select all that apply) 1. I will provide education to my team regarding why change is needed. 2. I will work with management to change/implement a policy and procedure. 3. I will plan an informational meeting with physicians to seek their input and acceptance of the need for change. 4. I will implement change and evaluate the effect of the change at regular intervals until the change is incorporated as best practice. 5. Other: __________________________________
7B.
If you will not change your practice as a result of reading this article, why? (Select all that apply) 1. The content of the article is not relevant to my practice. 2. I do not have enough time to teach others about the purpose of the needed change. 3. I do not have management support to make a change. 4. Other: __________________________________
8.
Our accrediting body requires that we verify the time you needed to complete the 1.2 continuing education contact hour (72-minute) program: ______________
PURPOSE/GOAL To provide the learner with knowledge of AORN’s guidelines related to creating a just culture, circulating while administering moderate sedation/analgesia, the monitoring RN leaving the OR during administration of moderate sedation, screening for obstructive sleep apnea before administering moderate sedation, and assessment for obstructive sleep apnea.
OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Discuss practices that could jeopardize safety in the perioperative area. Low 1. 2. 3. 4. 5. High 2.
Discuss common areas of concern that relate to perioperative best practices. Low 1. 2. 3. 4. 5. High
3.
Describe implementation of evidence-based practice in relation to perioperative nursing care. Low 1. 2. 3. 4. 5. High
CONTENT 4.
To what extent did this article increase your knowledge of the subject matter? Low 1. 2. 3. 4. 5. High
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MARY C. FEARON, MSN, RN, CNOR; MARY J. OGG, MS, RN, CNOR Continuing Education Contact Hours
Approvals
indicates that continuing education (CE) contact hours are available for this activity. Earn the CE contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Learner Evaluation at http:// www.aornjournal.org/content/cme. Each applicant who successfully completes this program can immediately print a certificate of completion.
This program meets criteria for CNOR and CRNFA recertification, as well as other CE requirements.
Event: #16515 Session: #0001 Fee: For current pricing, please go to: http://www.aornjournal .org/content/cme. The contact hours for this article expire April 30, 2019. Pricing is subject to change.
Purpose/Goal To provide the learner with knowledge of AORN’s guidelines related to creating a just culture, circulating while administering moderate sedation/analgesia, the monitoring RN leaving the OR during administration of moderate sedation, screening for obstructive sleep apnea before administering moderate sedation, and assessment for obstructive sleep apnea.
AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.
Conflict-of-Interest Disclosures Mary C. Fearon, MSN, RN, CNOR, and Mary J. Ogg, MS, RN, CNOR, have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article. The behavioral objectives for this program were created by Helen Starbuck Pashley, MA, BSN, CNOR, clinical editor, with consultation from Susan Bakewell, MS, RN-BC, director, Perioperative Education. Ms Starbuck Pashley and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article.
Objectives 1. Discuss practices that could jeopardize safety in the perioperative area. 2. Discuss common areas of concern that relate to perioperative best practices. 3. Describe implementation of evidence-based practice in relation to perioperative nursing care.
Sponsorship or Commercial Support No sponsorship or commercial support was received for this article.
Disclaimer Accreditation AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
AORN recognizes these activities as CE for RNs. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity. http://dx.doi.org/10.1016/j.aorn.2016.02.010 ª AORN, Inc, 2016
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THIS MONTH Creating a just culture Key words: just culture, TeamSTEPPS, human error, briefing, huddle. Circulating while administering moderate sedation/analgesia Key words: moderate sedation/analgesia, RN circulator. Monitoring RN leaving room during administration of moderate sedation Key words: moderate sedation/analgesia, propofol. Screening for obstructive sleep apnea before administering moderate sedation Key words: moderate sedation/analgesia, obstructive sleep apnea, OSA. Assessment for obstructive sleep apnea Key words: moderate sedation/analgesia, obstructive sleep apnea, OSA, OSA questionnaires, OSA checklist.
Creating a just culture QUESTION: We had a breakdown in communication during a recent procedure; the implants listed on the preference card were in the room, but the surgeon requested a different manufacturer’s implant. The surgeon was angry, and an uncomfortable blaming conversation ensued until the needed implant arrived in the room. Are there communication
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tools available to prevent this type of ineffective communication in the future?
ANSWER: Health care personnel in an organization committed to switching from a blaming culture to a just culture can use AORN Journal j 439
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communication tools such as TeamSTEPPS, surgeon worksheets, perioperative briefings, and staff huddles to facilitate communication among team members and to decrease the potential for human error. Communication is essential in developing a just culture in which learning from errors allows team members to build trust and to develop safer operational systems. Communication also helps to problem solve and to eliminate blaming. Creating teams that can effectively communicate when they have a concern improves patient care. In a just culture, nurses, surgical technologists, surgeons, anesthesia professionals, and other health care workers accept that humans make mistakes, develop systems for reporting errors, and use the information collected to develop safer systems for providing patient care. Leaders who facilitate effective communication are important in helping to create an environment in which team members feel safe to speak up and report errors.1 Reason defined error as “the failure of a planned action to be completed as intendeddwithout the intervention of some unforeseeable event; or the use of a wrong plan to achieve an aim.”2(p9) Errors can be slips, lapses, or mistakes in memory or actions. In the scenario here, several events may have created a breakdown in communication (eg, the surgeon forgot to communicate what implant was needed, personnel did not order the implant, the person with whom the surgeon communicated did not follow through). Blaming an individual may be more immediate than taking the time required to investigate the system issue or manage the expense to fix a system issue that was the root cause. However, blaming does not help personnel understand how mistakes occur, fix a broken system, help an individual improve his or her performance, or stop unsafe acts from occurring.3 When team members communicate about incidents, it is best to remember that errors are consequences and not causes of system failures. All perioperative team members intend to do their best work. Sometimes the system inadvertently creates an environment that may impede an individual’s best response to a situation, or there are reasons why an individual may be responsible for the error. In a just culture, all team members are accountable for providing safe patient care. A just culture is a balance between personal accountability and system improvement.
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Individual counseling, coaching, or corrective action may be warranted if the individual’s conduct calls for such action. A helpful resource in assessing if accountability for the error is individual versus system related is the algorithm “Accountability in the Face of Error: A Tool to Help Manage Unsafe Acts,” which is included in the AORN Just Culture Tool Kit as the Just Culture Reason Algorithm.4 In this algorithm, the following three questions can be asked to assist team members in quickly determining if this is an individual or system error. 1. 2. 3.
Did the individual intend to cause harm? Did the individual come to work drunk or equally impaired? Did the individual knowingly and unreasonably increase risk?
If the answers to these questions are yes, then it is an individual error. If the answers are no, then team members should ask “would another similarly trained and skilled individual in the same situation act in a similar manner?” If the answer is yes, then it is a system error.5(p1694) Leaders at all levels can support a just culture by providing opportunities for individuals to practice speaking up about concerns without fear of punishment, intimidation, or shame.6 One tool that may be used to assist team members to speak up is the TeamSTEPPS method. The TeamSTEPPS program endorses the use of a tool called DESC (ie, describe, express, suggest, consequences) (Table 1) that can be used as a framework to help structure a crucial conversation.7 Using the DESC tool in the missing implant situation described in the question could decrease the blaming tone and move the conversation toward problem solving. Each person should be prepared to listen, understand, and eliminate blame. The nurse in the situation described
Table 1. The DESC Framework for Structuring a Crucial Conversation D ¼ Describe the specific situation or behavior; provide concrete data E ¼ Express how the situation makes you feel and what your concerns are S ¼ Suggest other alternatives and seek agreement C ¼ Consequences should be stated in terms of effect on established team goals and should strive for consensus
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can, at a later time, have the following conversation with the surgeon: D: “I understand we did not have the implant you requested for this procedure.” E: “I think more communication before the procedure would be helpful for all of us and help ensure that problems like this do not occur.” The nurse should pause to hear the response from the surgeon and use active listening skills. The surgeon may reply “I did call the team leader,” or “I told my office staff to order it,” or “I use this implant every time.” S: The nurse should make a suggestion about how to resolve the problem and ask the surgeon to suggest one. The nurse’s response could be “I understand that you called the team leader (or told your office to order it, or use it every time), but it appears that this message was not relayed. I talked to the team leader, and we would like to use this patient-specific worksheet. What do you think?” C: The nurse can relay the consequence as “I think this will be an improvement in the process. Using this tool provides the team with the correct information and sufficient time to obtain the correct implant before the patient is in the room.” In this conversation, mutual respect is built by understanding the limitations that led to the unintended consequence.
Clinical Issues
safety huddle allows perioperative team members to practice communicating effectively in a nonstressful situation. The frontline leader representatives (eg, charge nurse, supervisor, manager) from the surgery teams; the preadmission area; the postanesthesia care unit; and the materials management, sterile processing, environmental services, and radiology departments can conduct a daily huddle for 15 minutes. Each representative should have an opportunity to disclose a safety event that occurred in their department during the previous 24 hours. For example, the implant event described in the question could be reported at the safety huddle to determine where the system breakdown occurred. Problem solving does not occur during the quick daily huddle, but an action plan and stakeholders can be determined for further discussion and these individuals can report their findings at the next huddle. Events in the OR environment are not predictable, and each perioperative team member who interacts with the patient poses a potential risk for a variance to occur. Establishing effective communication and teamwork allows the team to work in unison and speak up when a variance may be leading toward an unsafe outcome. Effective teamwork, a systems approach, and blameless communication are the best strategies for building a just culture.
Editor’s note: TeamSTEPPS is a trademark of the Agency for Healthcare Research and Quality and the Department of Health and Human Resources, Rockville, MD.
Using preoperative briefings to confirm the availability of specific implants in the room and to review possible complications and supplies needed when emergent situations arise is an additional communication tool. The postoperative briefing also is a time to practice using the DESC tool to discuss any issues that may have occurred during the procedure. A patient-specific worksheet is another tool that can be used to decrease the potential for errors in communication. This worksheet can include items that are not frequently used for each procedure but need to be available, and it can provide a framework for the surgeon to communicate his or her plan for each patient. Items on the patient-specific worksheet can be listed in a checklist format and include the position for surgery, implants, special equipment (eg, laser, microscope), and other factors that make this patient’s procedure unique from the normal surgical plan or items on the surgeon’s preference list. A frontline leader safety huddle is a venue where issues can be identified using the DESC communication tool. The
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Mary C. Fearon, MSN, RN, CNOR, is a perioperative practice specialist in the Nursing Department at AORN, Inc, Denver, CO.
References 1. Armitage G. Human error theory: relevance to nurse management. J Nurs Manag. 2009;17(2):193-202. 2. Reason JT. Human Error. Cambridge, England: Cambridge University Press; 1990. 3. Bashaw ES, Lounsbury K. Forging a new culture: blending Magnet principles with just culture. Nurs Manag. 2012;43(10): 49-53.
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4. AORN Just Culture Tool Kit. AORN, Inc. https://www.aorn.org/ guidelines/clinical-resources/tool-kits/just-culture-tool-kit. Accessed December 17, 2015. 5. Frankel AS, Leonard MW, Denham CR. Fair and just culture, team behavior, and leadership engagement: the tools to achieve high reliability. Health Serv Res. 2006;41(4 Pt 2):1690-1709.
6. Castner J, Foltz-Ramos K, Schwartz DG, Ceravolo DJ. A leadership challenge: staff nurse perceptions after an organizational TeamSTEPPS initiative. J Nurs Adm. 2012;42(10):467-472. 7. Clark CM. Conversations to inspire and promote a more civil workplace: let’s end the silence that surrounds incivility. Am Nurs Today. 2015;10(11):18-22.
Circulating while administering moderate sedation/analgesia QUESTION: Mary J. Ogg, MS, RN,
Is it acceptable for an RN to circulate, administer medications, and monitor the patient receiving moderate sedation/analgesia?
CNOR, is a senior perioperative practice specialist in the Nursing Department at AORN, Inc, Denver, CO.
ANSWER: At a minimum, two perioperative RNs should care for a patient who is receiving moderate sedation/analgesia provided by an RN. The RN providing the moderate sedation/analgesia is responsible for monitoring the patient, administering the sedation and analgesia medications, and continuously caring for the patient throughout the procedure. The second RN is responsible for circulating duties.1 The RN assigned to care for the patient receiving moderate sedation/analgesia should have no competing responsibilities that would compromise the continuous monitoring and assessment of the patient.2-7 Through continuous monitoring and observation of the patient’s physiological and psychological status, the perioperative RN can immediately respond to an adverse event or complication, leading to earlier treatment and potentially avoiding patient complications.1 The respiratory and cardiovascular complications associated with moderate sedation/analgesia include hypoxia, hypercapnia, impaired airway reflexes, loss of airway patency, airway obstruction, respiratory depression, hypotension, and cardiac arrhythmias.8-12 When an RN is administering sedation and analgesic medications and monitoring the patient, a second RN should be assigned to the circulating role. The RN circulator helps provide safe, quality patient care in the perioperative setting.13 AORN is committed to the policy of providing a perioperative RN dedicated to the care of every surgical patient for the duration of any operative or other invasive procedure.13 In addition, 24 states have laws or regulations in place that require an RN to serve as the circulator in hospitals, and 16 states have similar language for ambulatory surgical centers.
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References 1. Guideline for care of the patient receiving moderate sedation/ analgesia. In: Guidelines for Perioperative Practice. Denver, CO: AORN; 2016:617-647. 2. American Society of PeriAnesthesia Nurses Standards and Guidelines Committee. The role of the registered nurse in the management of patients undergoing sedation for short-term therapeutic, diagnostic, or surgical procedures. In: 2015-2017 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements. Cherry Hill, NJ: American Society of PeriAnesthesia Nurses; 2015:73-79. 3. Non-anesthesia provider procedural sedation and analgesia: considerations for policy development. American Association of Nurse Anesthetists. http://www.aana.com/resources2/professionalpractice/ Documents/Non%20anesthesia%20Provider%20Procedural%20 Sedation%20and%20Analgesia.pdf. Accessed March 8, 2016. 4. Du Rand IA, Blaikley J, Booton R, et al. British Thoracic Society guideline for diagnostic flexible bronchoscopy in adults: accredited by NICE. Thorax. 2013;68(Suppl 1):i1-i44. 5. De Vito A, Carrasco Llatas M, Vanni A, et al. European position paper on drug-induced sedation endoscopy (DISE). Sleep Breath. 2014;18(3):453-465. 6. Hurford WE, Staubach KC. A hospital policy for procedural sedation in the nonintubated patient. Int Anesthesiol Clin. 2013;51(2):1-22. 7. Antonelli MT, Seaver D, Urman RD. Procedural sedation and implications for quality and risk management. J Healthc Risk Manag. 2013;33(2):3-10. 8. American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Practice guidelines for
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April 2016, Vol. 103, No. 4 sedation and analgesia by non-anesthesiologists. Anesthesiology. 2002;96(4):1004-1017. 9. Amornyotin S. Sedation-related complications in gastrointestinal endoscopy. World J Gastrointest Endosc. 2013;5(11):527-533. 10. Cabrini L, Nobile L, Cama E, et al. Non-invasive ventilation during upper endoscopies in adult patients. A systematic review. Minerva Anestesiol. 2013;79(6):683-694. 11. Hession PM, Joshi GP. Sedation: not quite that simple. Anesthesiol Clin. 2010;28(2):281-294.
Clinical Issues 12. Kauling AL, Locks Gde F, Brunharo GM, da Cunha VJ, de Almeida MC. Conscious sedation for upper digestive endoscopy performed by endoscopists. Rev Bras Anestesiol. 2010;60(6): 577-583. 13. AORN Position Statement on One Perioperative Registered Nurse Circulator Dedicated to Every Patient Undergoing an Operative or Other Invasive Procedure. AORN, Inc. 2014. https://www.aorn .org/guidelines/clinical-resources/position-statements. Accessed December 4, 2015.
Monitoring RN leaving room during administration of moderate sedation QUESTION: Is it acceptable for the RN who is monitoring the patient receiving moderate sedation/analgesia to leave the room to procure more medications from the dispensing system?
bradycardia, apnea, airway obstruction, and oxygen desaturation.6,11 When additional medications or supplies are needed that are located outside of the room, the RN circulator or other available personnel should obtain the needed items.
ANSWER:
Mary J. Ogg, MS, RN, CNOR, is a senior perioperative
The perioperative RN providing moderate sedation/analgesia should not leave the room. The RN should be in constant attendance with unrestricted immediate visual and physical access to the patient.1-3 While remaining inside the room, the perioperative RN providing moderate sedation/analgesia may perform brief, interruptible, patient-related, ancillary tasks to assist the perioperative team.1,4-7 Examples of brief, interruptible tasks are tying a sterile gown and opening supplies that are in the room when an RN circulator is unavailable. In a literature review, Hausman and Reich8 described performing biopsies and collecting specimens as tasks that do not meet the criteria of brief or interruptible. In addition to AORN, the professional organizations supporting the RN performing brief, interruptible tasks are the American Society of Anesthesiologists, the Society of American Gastrointestinal Endoscopic Surgeons, the American Society for Gastrointestinal Endoscopy, the American Academy of Pediatrics, and the Society of Gastroenterology Nurses and Associates.2,4-7 The American Association of Nurse Anesthetists and the American Society of PeriAnesthesia Nurses support the RN who is caring for a patient receiving moderate sedation having no other responsibilities during the procedure.9,10 If the patient is receiving propofol for moderate sedation/ analgesia, the RN providing the moderate sedation/analgesia should not perform brief, interruptible tasks. Propofol has a narrow therapeutic window.11 The RN should monitor the patient without interruption, continuously assessing the patient’s level of consciousness to identify early signs of hypotension,
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practice specialist in the Nursing Department at AORN, Inc, Denver, CO.
References 1. Guideline for care of the patient receiving moderate sedation/ analgesia. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2016:617-647. 2. American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology. 2002; 96(4):1004-1017. 3. Hurford WE, Staubach KC. A hospital policy for procedural sedation in the nonintubated patient. Int Anesthesiol Clin. 2013;51(2):1-22. 4. Heneghan S, Myers J, Fanelli R, Richardson W. Society of American Gastrointestinal Endoscopic Surgeons. Society of American Gastrointestinal Endoscopic Surgeons (SAGES) guidelines for office endoscopic services. Surg Endosc. 2009;23(5):1125-1129. 5. American Academy of Pediatrics, American Academy of Pediatric Dentistry, Cote CJ, Wilson S; Work Group on Sedation. Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures: an update. Clinical report. Pediatrics. 2006;118(6):2587-2602. 6. Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy, Lichtenstein DR, Jagannath S, et al. Sedation and anesthesia in GI endoscopy. Gastrointest Endosc. 2008;68(5):815-826. 7. SGNA Practice Committee. Statement on the use of sedation and analgesia in the gastrointestinal endoscopy setting. Gastroenterol Nurs. 2008;31(3):249-251. 8. Hausman LM, Reich DL. Providing safe sedation/analgesia: an anesthesiologist’s perspective. Gastrointest Endosc Clin North Am. 2008;18(4):707-716.
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April 2016, Vol. 103, No. 4 undergoing sedation for short-term therapeutic, diagnostic or surgical procedures. In: 2015-2017 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements. Cherry Hill, NJ: American Society of PeriAnesthesia Nurses; 2015: 62-65. 11. Statement on safe use of propofol. American Society of Anesthesiologists. 2014. http://www.asahq.org/Search.aspx?q¼joint þstatementþregardingþpropofol. Accessed December 4, 2015.
Screening for obstructive sleep apnea before administering moderate sedation QUESTION: Does AORN recommend that nurses screen patients for obstructive sleep apnea if they are scheduled to undergo a procedure with moderate sedation?
ANSWER: Yes, the perioperative RN administering moderate sedation/ analgesia should assess the patient’s airway preoperatively for the risk of obstructive sleep apnea (OSA).1 Obstructive sleep apnea is a sleep-related breathing disorder characterized by periodic, partial, or complete obstruction of the upper airway during sleep.2,3 The estimated incidence of OSA ranges from 2% to 26%, and it affects men more frequently than women.4 The estimated incidence of moderate to severe OSA is 82% for men and 92% for women with undiagnosed OSA.5 Surgical patients have a reported higher incidence than the general population.3 The number of patients with OSA is likely to increase as the population ages and becomes more obese.2,3 Moderate sedation medications that affect the central nervous system may interfere with the normal respiratory compensatory mechanisms of hypoxemia and hypercarbia, and depressant medications may facilitate pharyngeal collapse in patients with OSA.5 Preoperative awareness of a patient with OSA is important because these patients may experience complications during perioperative care that include cardiac dysrhythmias (eg, bradycardia, atrial fibrillation, premature ventricular contractions); myocardial infarction; severe oxygen desaturation, episodic hypoxemia, hypercapnia, respiratory arrest, airway obstruction, and hypoventilation; impaired arousal from sedation; unplanned intensive care unit admission; and sudden death.4
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The perioperative RN may need to take additional precautions when caring for a patient with OSA, such as the use of noninvasive positive pressure ventilation6 with continuous positive airway pressure3 or bilevel positive airway pressure,3 careful titration of opioids,7 nonopioid analgesia techniques,3,8 and multimodal pain management.3,7 High-risk patients (ie, severe OSA) may need a referral to a higher level of care (eg, anesthesia professional)7 or additional diagnostic testing (ie, polysomnography).4
Mary J. Ogg, MS, RN, CNOR, is a senior perioperative practice specialist in the Nursing Department at AORN, Inc, Denver, CO.
References 1. Guideline for care of the patient receiving moderate sedation/ analgesia. In: Guidelines for Perioperative Practice. Denver, CO: AORN; 2016:617-647. 2. Gross JB, Bachenberg KL, Benumof JL, et al. Practice guidelines for the perioperative management of patients with obstructive sleep apnea: a report by the American Society of Anesthesiologists Task Force on Perioperative Management of patients with obstructive sleep apnea. Anesthesiology. 2006;104(5):1081-1093. 3. Joshi GP, Ankichetty SP, Gan TJ, Chung F. Society for Ambulatory Anesthesia consensus statement on preoperative selection of adult patients with obstructive sleep apnea scheduled for ambulatory surgery. Anesth Analg. 2012;115(5):1060-1068. 4. Abrishami A, Khajehdehi A, Chung F. A systematic review of screening questionnaires for obstructive sleep apnea. Can J Anaesth. 2010;57(5):423-438. 5. Chung F, Elsaid H. Screening for obstructive sleep apnea before surgery: why is it important? Curr Opin Anesthesiol. 2009;22(3):405-411. 6. American Society of PeriAnesthesia Nurses Standards and Guidelines Committee. 2015-2017 Perianesthesia Nursing Standards, Practice
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April 2016, Vol. 103, No. 4 Recommendations and Interpretive Statements. https://www.aspan .org/Clinical-Practice/ASPAN-Standards. Accessed December 4, 2015. 7. American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Practice guidelines for sedation
Clinical Issues and analgesia by non-anesthesiologists. Anesthesiology. 2002; 96(4):1004-1017. 8. Blake DW, Yew CY, Donnan GB, Williams DL. Postoperative analgesia and respiratory events in patients with symptoms of obstructive sleep apnoea. Anaesth Intensive Care. 2009;37(5):720-725.
Assessment for obstructive sleep apnea QUESTION: How should the patient be assessed and screened for obstructive sleep apnea?
recommend the use of the STOP and STOP-Bang questionnaires to screen surgical patients for OSA.
Mary J. Ogg, MS, RN, CNOR, is a senior perioperative
ANSWER: The perioperative RN should use a screening tool to assess the patient for obstructive sleep apnea (OSA).1 Obstructive sleep apnea screening tools are useful to classify patients based on clinical symptoms and risk factors to determine high-risk patients who may need a referral to a higher level of care (eg, an anesthesia professional) or additional diagnostic testing (ie, polysomnography).2 Several screening tools are available to assess the risk of OSA. Representative questions in the screening tools include body mass index, neck size, age, sex, hypertension, loud snoring, apnea during sleep, and tiredness during the day.2 In a prospective cohort study, Lockhart et al3 screened surgical patients with four different OSA tools (ie, STOP questionnaire, STOP-Bang questionnaire, Berlin questionnaire, Flemons index). The researchers concluded that the most common characteristics of high-risk patients with OSA were male sex, older age, overweight, and comorbid conditions. Examples of OSA screening tools include the
STOP questionnaire,2-5 STOP-Bang questionnaire,2,6-17 Berlin questionnaire,2,5,18-20 Wisconsin sleep questionnaire,2 and American Society of Anesthesiologists’ checklist for the identification and assessment of OSA.2,5,21
Some screening tools are easier to administer than others, and some tools have a higher degree of sensitivity and specificity. Abrishami et al2 conducted a systematic review to identify and evaluate the available screening questionnaires for OSA. The authors concluded that the Wisconsin and Berlin questionnaires had the highest sensitivity and specificity for predicting the existence of OSA. The STOP and STOP-Bang questionnaires had the highest methodological validity, reasonable accuracy, and easy-to-use features. Based on these findings, the authors
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practice specialist in the Nursing Department at AORN, Inc, Denver, CO.
References 1. Guideline for care of the patient receiving moderate sedation/ analgesia. In: Guidelines for Perioperative Practice. Denver, CO: AORN; 2016:617-647. 2. Abrishami A, Khajehdehi A, Chung F. A systematic review of screening questionnaires for obstructive sleep apnea. Can J Anaesth. 2010;57(5):423-438. 3. Lockhart EM, Willingham MD, Abdallah AB, et al. Obstructive sleep apnea screening and postoperative mortality in a large surgical cohort. Sleep Med. 2013;14(5):407-415. 4. Chung F, Yegneswaran B, Liao P, et al. STOP questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology. 2008;108(5):812-821. 5. Chung F, Yegneswaran B, Liao P, et al. Validation of the Berlin questionnaire and American Society of Anesthesiologists checklist as screening tools for obstructive sleep apnea in surgical patients. Anesthesiology. 2008;108(5):822-830. 6. Joshi GP, Ankichetty SP, Gan TJ, Chung F. Society for Ambulatory Anesthesia consensus statement on preoperative selection of adult patients with obstructive sleep apnea scheduled for ambulatory surgery. Anesth Analg. 2012;115(5):1060-1068. 7. Chung F, Subramanyam R, Liao P, Sasaki E, Shapiro C, Sun Y. High STOP-Bang score indicates a high probability of obstructive sleep apnoea. Br J Anaesth. 2012;108(5):768-775. 8. Kulkarni GV, Horst A, Eberhardt JM, Kumar S, Sarker S. Obstructive sleep apnea in general surgery patients: is it more common than we think? Am J Surg. 2014;207(3):436-440. 9. Chung F, Yang Y, Liao P. Predictive performance of the STOPBang score for identifying obstructive sleep apnea in obese patients. Obes Surg. 2013;23(12):2050-2057. 10. Corso RM, Petrini F, Buccioli M, et al. Clinical utility of preoperative screening with STOP-Bang questionnaire in elective surgery. Minerva Anestesiol. 2014;80(8):877-884. 11. Singh M, Liao P, Kobah S, Wijeysundera DN, Shapiro C, Chung F. Proportion of surgical patients with undiagnosed obstructive sleep apnoea. Br J Anaesth. 2013;110(4):629-636.
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12. Vasu TS, Doghramji K, Cavallazzi R, et al. Obstructive sleep apnea syndrome and postoperative complications: clinical use of the STOP-BANG questionnaire. Arch Otolaryngol Head Neck Surg. 2010;136(10):1020-1024. 13. Luo J, Huang R, Zhong X, Xiao Y, Zhou J. STOP-Bang questionnaire is superior to Epworth sleepiness scales, Berlin questionnaire, and STOP questionnaire in screening obstructive sleep apnea hypopnea syndrome patients. Chin Med J (Engl). 2014;127(17):3065-3070. 14. Mehta PP, Kochhar G, Kalra S, et al. Can a validated sleep apnea scoring system predict cardiopulmonary events using propofol sedation for routine EGD or colonoscopy? A prospective cohort study. Gastrointest Endosc. 2014;79(3):436-444. 15. Ganesh BR, Kulkarni MK, Noronha MG. Screening of sleep apnoea in middle-aged hypertensive subjects using STOP-Bang Questionnairedan observational study. Indian J Physiother Occup Ther. 2014;8(2):13-16. 16. Chia P, Seet E, Macachor JD, Iyer US, Wu D. The association of pre-operative STOP-BANG scores with postoperative critical care admission. Anaesthesia. 2013;68(9):950-952.
17. Chung F, Yang Y, Brown R, Liao P. Alternative scoring models of STOPBang questionnaire improve specificity to detect undiagnosed obstructive sleep apnea. J Clin Sleep Med. 2014;10(9):951-958. 18. Boese ML, Ransom RK, Roadfuss RJ, Todd A, McGuire JM. Utility of the Berlin questionnaire to screen for obstructive sleep apnea among patients receiving intravenous sedation for colonoscopy. AANA J. 2014;82(1):38-45. 19. Khiani VS, Salah W, Maimone S, Cummings L, Chak A. Sedation during endoscopy for patients at risk of obstructive sleep apnea. Gastrointest Endosc. 2009;70(6):1116-1120. 20. Mador MJ, Nadler J, Mreyoud A, et al. Do patients at risk of sleep apnea have an increased risk of cardio-respiratory complications during endoscopy procedures? Sleep Breath. 2012;16(3): 609-615. 21. Gross JB, Bachenberg KL, Benumof JL, et al. Practice guidelines for the perioperative management of patients with obstructive sleep apnea: a report by the American Society of Anesthesiologists Task Force on Perioperative Management of patients with obstructive sleep apnea. Anesthesiology. 2006;104(5):1081-1093.
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446 j AORN Journal
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LEARNER EVALUATION
Continuing Education: Clinical Issues 1.2
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T
his evaluation is used to determine the extent to which this continuing education program met your learning needs. The evaluation is printed here for your convenience. To receive continuing education credit, you must complete the online Learner Evaluation at http://www.aornjournal.org/content/cme. Rate the items as described below.
5.
To what extent were your individual objectives met? Low 1. 2. 3. 4. 5. High
6.
Will you be able to use the information from this article in your work setting? 1. Yes 2. No
7.
Will you change your practice as a result of reading this article? (If yes, answer question #7A. If no, answer question #7B.)
7A.
How will you change your practice? (Select all that apply) 1. I will provide education to my team regarding why change is needed. 2. I will work with management to change/implement a policy and procedure. 3. I will plan an informational meeting with physicians to seek their input and acceptance of the need for change. 4. I will implement change and evaluate the effect of the change at regular intervals until the change is incorporated as best practice. 5. Other: __________________________________
7B.
If you will not change your practice as a result of reading this article, why? (Select all that apply) 1. The content of the article is not relevant to my practice. 2. I do not have enough time to teach others about the purpose of the needed change. 3. I do not have management support to make a change. 4. Other: __________________________________
8.
Our accrediting body requires that we verify the time you needed to complete the 1.2 continuing education contact hour (72-minute) program: ______________
PURPOSE/GOAL To provide the learner with knowledge of AORN’s guidelines related to creating a just culture, circulating while administering moderate sedation/analgesia, the monitoring RN leaving the OR during administration of moderate sedation, screening for obstructive sleep apnea before administering moderate sedation, and assessment for obstructive sleep apnea.
OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Discuss practices that could jeopardize safety in the perioperative area. Low 1. 2. 3. 4. 5. High 2.
Discuss common areas of concern that relate to perioperative best practices. Low 1. 2. 3. 4. 5. High
3.
Describe implementation of evidence-based practice in relation to perioperative nursing care. Low 1. 2. 3. 4. 5. High
CONTENT 4.
To what extent did this article increase your knowledge of the subject matter? Low 1. 2. 3. 4. 5. High
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