Implementation Science: Incorporating Obstructive Sleep Apnea Screening and Capnography Into Everyday Practice

ORIGINAL ARTICLE

Implementation Science: Incorporating Obstructive Sleep Apnea Screening and Capnography Into Everyday Practice Kathryn R. Scully, MSN, RN, CCRN, CAPA, CPAN, Jennifer Rickerby, DNP, FNP-BC, Jessica Dunn, DNP, FNP-BC Purpose: This article describes the implementation and maintenance of obstructive sleep apnea (OSA) screening and capnography monitoring. Design: A quality improvement project. Methods: A multidisciplinary team provided staff education to three perianesthesia care units. Using the STOP-Bang screening tool, five or more positive responses indicated high risk for OSA. A postanesthesia care unit audit tool tracked STOP-Bang scores, capnography use, hypoventilation events, nursing interventions, and respiratory complications. Findings: Among 314 patients with OSA, 36% were identified as high risk. Nurses used capnography on 76% of OSA patients and were able to readily identify hypoventilation and intervene. Respiratory complications occurred in 10.8% (n 5 34) requiring a higher level of care. Postimplementation, all six postanesthesia care units employ this best practice. Conclusions: Perianesthesia nurses found OSA screening and capnography easy to incorporate into nursing practice. This process can reduce respiratory complications in the surgical patient with OSA. An EvidenceBased Practice Fellowship Program facilitated this practice change. Keywords: obstructive sleep apnea, capnography, implementation science, postoperative complications. Ó 2019 by American Society of PeriAnesthesia Nurses

Kathryn R. Scully, MSN, RN, CCRN, CAPA, CPAN, Clinical Educator Perianesthesia Care Units, Inova Fairfax Medical Campus, Falls Church, VA; Jennifer Rickerby, DNP, FNP-BC, School of Nursing, George Mason University, Fairfax, VA; and Jessica Dunn, DNP, FNP-BC, School of Nursing, George Mason University, Fairfax, VA. Conflict of interest: None to report. Funding: This quality improvement project was supported financially by 2018 Inova Health System Evidence-Based Practice Fellowship Program. Address correspondence to Kathryn R. Scully, Inova Fairfax Medical Campus, 3300 Gallows Road, Falls Church, VA 22042; e-mail address: [email protected]. Ó 2019 by American Society of PeriAnesthesia Nurses 1089-9472/$36.00 https://doi.org/10.1016/j.jopan.2019.06.004

four patients having elective surgery.1 Because of the lack of symptom awareness and routine screening for this condition, more than 80% of OSA patients are undiagnosed at the time of surgery. These vulnerable patients often have additional comorbidities associated with OSA and are at increased risk of respiratory complications when exposed to anesthesia, analgesia, and sedation associated with surgery.2 To safeguard this growing surgical population, the American Society of Perianesthesia Nurses (ASPAN) addressed this trend by recommending identification of OSA preoperatively and the use of capnography monitoring postoperatively.3 At our institution, where approximately 150 surgeries occur each day, new beside monitors capable of end-tidal CO2 (ETCO2) monitoring were installed in all six postanesthesia care units (PACUs) to improve patient

Journal of PeriAnesthesia Nursing, Vol -, No - (-), 2019: pp 1-15

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THE PATIENT WITH obstructive sleep apnea (OSA) is becoming increasingly more prevalent in the perianesthesia setting, affecting one in every

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safety and outcomes for the OSA patient after anesthesia. The purpose of this article is to share with the reader our process and observations implementing OSA screening and capnography monitoring in the PACU units. Review of Literature A subteam of our quality improvement (QI) team conducted a literature review to understand the pathophysiology of OSA and the care of patients with OSA. Examination of the literature included four online databases, including the Cumulative Index of Nursing and Allied Health Literature (CINAHL), Ovid Medline, UpToDate, and PubMed. We included articles from the United States, written in English, within the past 5 years, with the exception of three articles concerning capnography the oldest from 2008. Key word searches included adult patients, surgery, anesthesia, OSA, STOP-Bang questionnaire, capnography, and postoperative complications. This review identified evidence supporting the use of ETCO2 monitoring in the PACU as a method to reduce respiratory complications in adult, nonintubated patients with OSA. The literature illustrated the use of the STOP-Bang questionnaire in practice in discreet populations. Using the John Hopkins tools of evidence appraisal,4 the subteam evaluated 26 articles with an overall evidence level of 2B. The quality of evidence and findings were compelling; however, our PICO question was more broadly focused; therefore, we synthesized the evidence found in the literature to guide this QI project on all adult, nonintubated patients with OSA, in the PACU setting. OSA OSA is a chronic condition characterized by episodic pauses in breathing during sleep that can last 1 minute or longer and occur as many as 30 times an hour for severe cases.2 This sleep disorder causes upper airway obstruction because of reduced muscle tone in the airway, which leads to a reduction in ventilation. These patients are predisposed to comorbidities such as hypertension, obesity, coronary artery disease, arrhythmias, gastroesophageal reflux, diabetes, and sudden death.5–7 The OSA surgical patient is at risk for

postoperative respiratory complications because of increased sensitivity to anesthetics and opioids that aggravate symptoms of hypoventilation and apnea that potentiate hypoxemia.7,8 In one of the few published studies examining PACU respiratory events and OSA, Gali et al.9 found that patients at high risk for OSA and who had experienced recurrent respiratory events in the PACU were 13 times more likely to experience a postoperative complication. These complications are associated with an increase incidence of difficult intubation because of excess neck tissue, increased body mass index (BMI), and anatomical changes associated with OSA that contribute to a smaller oropharyngeal area to intubate.10 Additional PACU complications include extended PACU length of stay, unplanned intensive care unit (ICU) admissions and respiratory and cardiovascular complications during the perioperative period.7,9 Complications not only increase hospital expenses, where respiratory failure is the second most costly, but more importantly, lead to poor patient outcomes.11 OSA Screening In April 2012, ASPAN released the Practice Recommendation (#10), Obstructive Sleep Apnea in the Adult Patient ‘‘to promote perianesthesia patient safety in the care of adult patients with known or suspected OSA who have received opioids, procedural sedation, general or regional anesthesia.’’12 These evidence-based practice (EBP) measures call for OSA screening before sedation/anesthesia with the endorsed, highly validated, and easy to use STOP-Bang screening questionnaire, which has proven sensitivity and specificity in identifying the patient with moderate-to-severe OSA.13,14 This simple questionnaire consists of eight yes/no questions (Snoring, Daytime Tiredness, Observed Apnea, high blood Pressure, Body Mass Index .35 kg/m2, Age .50 years, Neck circumference $17 inches in Males, $16 inches in Females; male Gender) that relate to the clinical features of sleep apnea. Each ‘‘yes’’ answer is given a point, with a total score range from 0 to 8.15 Scores of 3 or greater have a sensitivity of 93% for moderate-to-severe OSA; whereas, the specificity of the tool is a modest 43% to detect moderate-to-severe OSA.15 Chung et al.15 went further in evaluating this tool and studied the relationship between STOP-Bang scores and predicted

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probability of OSA among surgical patients. He found that the probability of moderate-to-severe OSA increases in direct proportion to the STOPBang score. Therefore, among surgical patients, the higher the STOP-Bang score, the higher the predicted probability of having moderate-tosevere OSA.15 Patients with STOP-Bang scores (indicated by the number of positive ‘‘yes’’ responses on the questionnaire) of 5 to 8 are classified as high risk for moderate-to-severe OSA.14 ASPAN recommends this user-friendly screening tool as an excellent method for the prediction of severe OSA in the preoperative phase of care.3 Preoperative identification of high-risk patients using the STOP-Bang tool has demonstrated a reduction in postoperative respiratory complications, because of an overall increase in the safety of patient care throughout the surgical experience.16 Using the STOP-Bang tool to preoperatively categorize patients’ risk, the medical team is made aware of, and can anticipate the needs of the OSA patient. Intraoperatively, they can mitigate the effects of anesthesia and opioids; and postoperatively, use additional monitoring in the form of capnography.3 Capnography Capnography, also known as ETCO2 monitoring, is the measurement of the partial pressure of carbon dioxide (CO2) at the end of expiration. Capnography is able to detect hypercarbia and hypoxemia 2 to 3 minutes before pulse oximetry.11,17 The advantage of capnography is it provides ‘‘real time’’ observation of hypoventilation and apnea, hallmark symptoms of OSA. The continuous capnography waveform reveals rising ETCO2, slowing of respiratory rate (RR), apnea, and respiratory depression as it is happening.11 Capnography can reveal twice as many apnea periods than a standard visual, respiratory assessment.18 This enables the nurse to intervene before respiratory complications occur, promoting patient safety and outcomes.11 Capnography has shown to be beneficial for use in high-risk patients with OSA in the PACU setting. A systematic meta-analysis review from Lam et al.19 concluded that elevations in CO2 demonstrated an early warning sign of postoperative respiratory depression, with an estimated six times higher accuracy than with pulse

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oximetry alone. A QI project, which included 61 subjects in a large metropolitan hospital PACU, found that capnography was 28 times more likely than pulse oximetry to detect an impending respiratory complication.2 There is a body of evidence substantiating the importance of capnography for early identification of respiratory compromise in the OSA patient.2,6,7,11,17–19 Barriers to Implementing EBP Measures Although the STOP-Bang questionnaire and capnography have clearly been demonstrated to be beneficial in addressing surgical patients with OSA, there are barriers to incorporating this as a standard of practice. The primary barriers include lack of education, training, and resources to implement and sustain this EBP.20 Additional barriers to a practice change include unit and hospital culture, and attitudes or perception of an increased workload. Lack of nursing leadership support, along with the absence of EBP mentors available to assist providers at the bedside, further inhibit the translation of best practice to standard practice.21,22 Implementation Science Translation of research to practice can take 17 years, which then may only result in 50% of EBP becoming standard nursing practice.22,23 Patient safety and outcomes are significantly affected by this research to practice gap.22 An emerging methodology called Dissemination and Implementation Science (DIS) serves to bridge this gap by integrating proven principles that facilitate the incorporation of best clinical practices into standard nursing care.22,23 DIS is defined as ‘‘the scientific study of methods to promote the systematic uptake of research findings and other EBPs into routine practice, and hence, to improve the quality and effectiveness of health services.’’24 Dissemination refers to the communication of information about an intervention to extend the EBP, which is typically done via educational efforts; whereas, implementation science is the study of the variables that promote the incorporation of EBP interventions into daily practice. Both dissemination and implementation methods can overlap to supply the knowledge needed to generate lasting change in practices that enhance patient care.23 The strategies of DIS include dedicated nurse leaders willing to advance and

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promote the new practice; multidisciplinary teams with numerous stakeholders to benefit from the new process or intervention; mixed-method analysis via qualitative and quantitative data collection; formative evaluations that allow for feedback and alterations during the intervention; analysis and breakdown of barriers that hinder translation into practice; and the promotion of long lasting sustainability of the new practice.22,23 The goal of our QI project at our 927 bed MidAtlantic regional medical center was to improve patient safety and outcomes for the OSA patient after anesthesia. The specific aims of this project were as follows: 1. Identify the undiagnosed, high-risk patient with OSA preoperatively using the STOPBang screening questionnaire. 2. Educate the PACU nurse to recognize hypoventilation via capnography and intervene to prevent respiratory complications. 3. Implement ASPAN practice recommendation # 10 (OSA screening and ETCO2 monitoring on patients with OSA) throughout all six PACUs as a standard of practice. Impetus for the QI Project New equipment capable of ETCO2 monitoring was added to all (six) perianesthesia care units in November 2017. This upgrade was made to serve the needs of the increasingly prevalent OSA population noted in our perianesthesia environment. The clinical educator recognized the need to orient staff to this technology. Simultaneously, the health care system initiated a call for proposals to fund evidence-based, QI projects. The sponsored program required the formation of a multidisciplinary team, along with a literature review to support the QI proposal, to be considered for funding. Our proposal to implement ASPAN practice recommendation #10 as an EBP QI project was selected for funding. The System Nursing Research and EBP Coordinator provided support for our hospital QI team and met with our team biweekly to guide the development of this QI project. The institutional review board evaluated the project before its implementation and determined that the project met the requirements for a performance improvement/QI activity and as such, did not require submission to the institutional review

board for approval. Funding from the fellowship provided protected time for clinical nurses (registered nurse [RN] fellows on the QI team) to be out of staffing to work on this project. The team was held accountable and expected to accomplish goals within project timelines. The strategies of implementation science, incorporated into the infrastructure of the fellowship program, provided a template for the translation of research into practice. Table 1 discusses the implementation science strategies used with examples from this quality improvement project.

The QI Project Site The site of this project was a 927-bed, mid-Atlantic regional medical center, where approximately 150 surgeries are performed each day. Three of the six PACUs asked to take part in the initial launch of the project. There was a variety in the type of surgical procedures from ambulatory (ENT, general, orthopaedic, and urology), to inpatient (general, neurosurgery, and orthopaedic), to a combination of inpatient and outpatient (gynecology and urogynecology), based on the three participating PACU units and their specialties.

Action Plan Inspired by the availability of grant funding, we formed a multidisciplinary team of 12 members (Table 1). This group developed the practice/ PICO question: In the adult, nonintubated patient with OSA in the PACU setting, will the addition of ETCO2 monitoring result in reduced respiratory complications as measured by a PACU audit tool? As was previously mentioned, a subteam completed a literature search, review, and analysis, using the John Hopkins tools of evidence appraisal, to ensure that the interventions were based on current evidence.4 The evidence was integrated with the clinical expertise of the team, and the current practice to plan an evidencebased implementation of the ASPAN practice recommendation (#10) into our perianesthesia areas. The group met frequently to discuss staff and patient education needs. They also devised a plan for implementation of the new process and created a PACU audit tool for evaluation.

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Table 1. Implementation Science Strategies With Examples From QI Project Dedicated nurse leaders

EBP Fellowship Program:  Support from Nurse Researcher/Mentor  Accountability to nurse leaders and clinical managers  Provided format to QI project  Protected and Paid time for nursing to complete project Perianesthesia Nurse Educator:  Team leader  Committed to facilitating change in practice

Multidisciplinary team

Clinical Nurse Educator, 3 RN Fellows representing each PACU, Presurgical Services RN, 2 CRNAs, Anesthesiologist, Respiratory Therapist, 2 DNP Students, and a Patient Advisor  Many stakeholders to benefit from new practice  Aids dissemination and communication of new practice  Many ‘‘minds’’ problem solve from their perspective disciplines to overcome barriers  Patient Advisor, represented the most important stakeholder, provided valuable insights to patient teaching materials and process

Mixed method data analysis 1. Qualitative

      

2. Quantitative

Direct observation of intervention Interviews with patients and staff Chart review Education evaluation: teach back method PACU audit tool Informal survey to nursing staff Education evaluation: tests, quizzes

Formative evaluation Data fed back to team during the project to adapt and improve the process of implementation20

 PACU audit tool altered to facilitate communication between preoperative and PACU areas  Frequent reporting of data results from audit tool energized staff and promoted the process  Nurse-driven project promoted ownership and accountability of new practice among peers

Addressing and working through barriers 1. Competing demands of frontline providers

 Frequent multidisciplinary team meetings to re-evaluate process and problem solve barriers  One of the participating PACU units had a physical move during the intervention B Nurse manager committed to EBP intervention B RN Fellow on unit championed new practice among peers B Robust education committee on unit provided positive influence to maintain new practice B Ambulatory unit physical set up promoted the new intervention  PSS reported to preoperative areas number of OSA patients for next day surgeries; this information aided staffing assignments  Streamlined risk management forms required for OSA patient with home CPAP  STOP-Bang screening tool in EMR as part of preoperative checklist  Simplified and condensed OSA patient teaching and documentation in EMR

2. Time constraints with first start cases

(Continued )

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Table 1. Continued 3. Lack of knowledge, skills and resources

 Continued education provided throughout implementation  RN Fellows served as super users and resource to staff

Promotion of sustainability

 OSA screening and capnography usage audited by unit quality committees B Data report via EMR B Results provided to staff during monthly meetings  On boarding education of all new staff to the new process of OSA screening and capnography monitoring  Annual education requirement for all RNs in preoperative and PACU areas  Continued dissemination and communication to RN staff via monthly newsletters and updates in staff meetings  Successful change in practice created a ‘‘pull’’ for other preoperative and PACU areas to adopt same measures  Poster presentation to hospital system promoted participating units and gave them pride in their efforts to provide best nursing care. B Posters hung in each of the participating units

EMR, electronic medical record; EBP, evidence-based practice; QI, quality improvement; RN, registered nurse; PACU, postanesthesia care unit; CRNA, certified registered nurse anesthetist; PSS, presurgical screening; OSA, obstructive sleep apnea; CPAP, continuous positive airway pressure.

Education Development Process The clinical educator and leader of the multidisciplinary team provided staff education and dissemination of the new process in a variety of methods to enhance adult learning and retention. Table 2 discusses the staff education strategies used. Education of over 90 RNs occurred during a 3-month period before the implementation of the project. A volunteer patient advisor participated on the multidisciplinary team to review patient education Table 2. Staff Education Strategies Existing health stream modules  Care of the OSA patient  Introduction to capnography Poster presentations Staff in services Simulations Bulletin boards Instruction on CPAP machines by respiratory therapy Team huddles Bedside instruction Monitor representative in services Resource binders on all units Quizzes OSA, obstructive sleep apnea; CPAP, continuous positive airway pressure.

materials and to vet the process from a patient perspective. As a former surgical patient with a history of OSA, he reviewed the wording and phrasing of preoperative and discharge patient OSA instructions. His experience adjusting to home continuous positive airway pressure (CPAP) machine use, and corresponding benefits it provided him, were incorporated into discharge teaching for the diagnosed OSA patient. The team also developed patient education content that is now part of the PACU discharge instructions to address follow-up care for a sleep study in undiagnosed patients identified as high risk for OSA. In addition, the QI team generated instructions regarding home care for the high-risk and known OSA patient and created ‘‘smart phrases’’ for home care instruction that were incorporated into the electronic medical record. The patient advisor aided our process with insights from his lived experience as a surgical patient with OSA. For example, when asked how he would feel about wearing an additional armband and having a staff alert sign at the head of his bed, identifying him as having OSA, he said, it made him feel ‘‘safe.’’ PACU Audit Tool/Means of Evaluation The QI team created a PACU audit tool with the following goals: document the STOP-Bang score,

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PACU Audit Tool OSA pa ent and use of ETCO2 Monitoring

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PATIENT LABEL PREOP STOP-BANG SCORE: _________

Ini al PACU evalua on: a er 30 min uns mulated -

Con nued PACU evalua on: REASSESS before d/c PACU

____ETCO2 20 % rise from baseline (on PACU admission) or > 50mmHg ____Respiratory Rate < 8 ____Apnea > 10 seconds; How many episodes? _____ • Noted via capnography ____ or assessment _____ • Note which was first indicator • 2 or more apneic episodes-extend Phase 1 recovery ____SpO2 < 90% on supplemental oxygen (for > 30 seconds) ____POSS > 2 with pain scale > 5 (pain/seda on mismatch) ____ No events

____ETCO2 20 % rise from baseline (on PACU admission) OR > 50mmHg ____Respiratory Rate < 8 ____Apnea > 10 seconds; How many episodes? ____ • Noted via capnography ____ or assessment _____ • Note which was first indicator ____SpO2 < 90% on supplemental oxygen (for > 30 seconds) ____POSS > 2 with pain scale > 5 (pain/seda on mismatch) ____ No events

Ini al Nursing Interven ons:

Con nued Nursing Interven ons: ____S r up regimen: Reposi on; C&DB, Incen ve spirometry ____Jaw thrust/ Chin li ____Placement of Nasal Airway/Trumpet ____Apply CPAP ____No fica on of Anesthesia

____S r up regimen: Reposi on; C&DB, Incen ve spirometry ____Jaw thrust/ Chin li ____Placement of Nasal Airway/Trumpet ____Apply CPAP ____No fica on of Anesthesia

PACU Respiratory Complica ons/Emergencies (Safety Always Events): ______ Use of reversal agents – Narcan and/or Flumazenil ______ Bag-mask ven la on ______ Applica on of BIPAP machine ______ Re-intuba on ______ Rapid Response ______ Escala on of Care (IMC or ICU bed)

Use of ETCO2 Monitoring? Yes

Nursin

Surgery: ___________________________ Date: ___________ Time of Admission to PACU: ______________ Time of Phase 1 Discharge: _______________ Time of Phase 2 Discharge: _______________ Time of Transfer/Extended Care: ____________

**NOT PART OF MEDICAL CHART**

No

Figure 1. PACU audit tool. PACU, postanesthesia care unit; OSA, obstructive sleep apnea; ETCO2, end-tidal CO2; CPAP, continuous positive airway pressure; BIPAP, bilevel positive airway pressure; IMC, intermediate care unit; ICU, intensive care unit, SpO2, peripheral capillary oxygen saturation; POSS, Pasero Opioid-Induced Sedation Scale; C&DB, cough and deep breathe. This figure is available in color online at www.jopan.org.

record the use of capnography; measure the nurses’ recognition of hypoventilation events (with the addition of ETCO2 monitoring), document nursing response/interventions, and document-associated respiratory complications that occur in the PACU (Figure 1). The STOP-Bang screening tool supplied the basis for the audit tool, where five or more positive responses identified the patient as high risk for OSA in the moderate-to-severe category.15 This became the benchmark used to identify the undiagnosed, high-risk OSA patient. An episode of respiratory depression involves the variables of RR, apneic event, end-tidal carbon dioxide level, and oxygen saturation level.19 The exact determination of each variable remained in question for the PACU audit tool. Hutchinson and

Rodriguez18 examined the use of capnography in recognition of respiratory depression and found that the most sensitive indicator of respiratory depression was an RR , 10 as predictive of subsequent respiratory events. More recently, Lam et al.19 discussed these variables of respiratory depression in a systematic review of studies evaluating capnography in the postoperative period. Each of the studies reviewed had varying definitions of respiratory depression. In a study by Gali et al.,25 pain sedation mismatch (moderate-to-severe sedation with pain score of 5) was discussed as another important variable of respiratory depression. The anesthesia providers on our team defined respiratory depression or hypoventilation events as ETCO2 $ 50 mm Hg, or 20% rise from baseline reading determined at PACU admission; RR # 8, apnea $10 seconds, desaturation #90%, and pain-sedation mismatch where a patient reports a high pain level (.5) in the presence

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Table 3. Nursing Interventions for Hypoventilation Events Nursing Interventions Stir up regimen: reposition, cough, deep breathe, and incentive spirometry Jaw thrust/Chin lift Insertion of nasal trumpet Application of home CPAP Notification of anesthesiologist

Rationale Promotes oxygenation and ventilation Relieves airway obstruction/apnea Relieves airway obstruction/apnea Promotes ventilation/ prevents apnea Escalation of care

CPAP, continuous positive airway pressure.

of a high sedation level or Pasero Opioid-Induced Sedation Scale . 2. This is important because oversedation precedes respiratory depression.11 Nursing interventions are those actions the PACU RN carries out in response to hypoventilation based on the patient’s presentation. These nursing interventions with corresponding rationales are detailed in Table 3. PACU respiratory complications were defined as those events that would require reversal agents, bag-mask ventilation, placement on bilevel positive airway pressure machine, reintubation, rapid response, and requirement of additional monitoring and a higher level of care. The PACU audit tool was set up to be an easy checklist of symptoms observed, nursing interventions completed, and respiratory complications encountered by the nurse. The tool prompts nurses to be alert for signs and symptoms of hypoventilation with the added aid of capnography.

Method The QI team adapted the hospital policy on care of the patient with OSA into a user friendly, algorithm format addressing each phase of perioperative care, from presurgical screening (PSS) to the short stay unit. This policy served as the backbone of our process and was distributed to all involved areas. The implementation began in PSS, where the PSS RNs initiated the STOP-Bang screening question-

naire with patients via telephonic screening. Patients with five or more positive factors were identified as high risk for OSA. The PSS charge RN called the preoperative areas daily to report those patients coming in for surgery the following day, who were diagnosed OSA as well as those who were identified as high risk. This aided staffing assignments, because the OSA patient would require additional preoperative teaching. The PSS nurse instructed the known OSA patient with a home CPAP machine to bring the machine with them to the hospital on the day of surgery. In the preoperative areas, the STOP-Bang screening tool was completed by verifying the patient’s weight and BMI and measuring neck circumference (using disposable tape measures). Known OSA patients and those who screened positive for high-risk OSA received a blue ‘‘OSA’’ wrist band and an OSA alert sign placed at the patient’s head of bed. The OSA alert sign would follow the patient throughout their hospital stay. These visual cues served to identify the OSA patient to the health care team (Figure 2). The preoperative RN gave these patients additional teaching on what to expect in recovery which included close observation, use of capnography, and the potential for an increased length of stay in the PACU. The preoperative RN then initiated the PACU audit tool by documenting the STOP-Bang number on the blue papered, PACU audit tool (blue paper to indicate not for medical records) and placed the form in the paper chart. Preoperative identification of high-risk patients using the STOP-Bang tool allows the medical team to anticipate the needs of the OSA patient. Intraoperatively, they can mitigate the effects of anesthesia and opioids. Not only did the anesthesia team minimize opioid and benzodiazepines for the identified OSA patient, but also used multimodal medications preoperatively. Intraoperative measures included positioning the OSA patient differently to facilitate intubation, using regional nerve blocks when possible, and in keeping with our policy for care of the patient with OSA undergoing anesthesia, judicious use of intravenous patient-controlled analgesia and ketamine infusions for the OSA patient with chronic pain.

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OSA Alert Sign

Obstructive Sleep Apnea Precautions Please follow these precautions to decrease the risk of airway blockage:

Perform frequent respiratory assessments Positioning o no lying flat on back (unless only option) o elevate head of bed at least 30° o lie on side

Continuous pulse oximetry Multimodal / opioid sparing medication regimen Non-pharmacological comfort measures CPAP machine ON during naps and at bedtime Help us keep our patients safe!

Figure 2. OSA alert sign. OSA, obstructive sleep apnea; CPAP, continuous positive airway pressure. Reprinted with permission from Inova Health systems. This figure is available in color online at www.jopan.org.

On admission to the PACU, the known OSA patient with a home CPAP machine had CPAP applied in PACU if they were not awake. Capnography was applied to the identified OSA patients who were at high risk or those who were known OSA without their CPAP machine. The ‘‘CapnoVue’’ mask or the split tubing nasal cannula was used to provide ETCO2 monitoring. They both require a gas sampling line that attaches to the ‘‘defend’’ or water trap on the monitor. The nonintubated PACU patient has ambient air flow that naturally occurs with the use of the open face mask or nasal cannula, thus exact ETCO2 numbers cannot be obtained. The trending of ETCO2 readings and waveform analysis prove valuable in this setting, with a rising trend indicative of retained CO2 and hypoventilation, and an absent waveform revealing apnea.11 In the PACU, the OSA patient was positioned with head of bed elevated $30 or in the lateral, or semi-upright position, to promote a patent airway. Once the patient was settled (ie, after positioning, assessment, and/or medication administration), the OSA patient was observed undisturbed for 30 minutes. The PACU RN

documented on the PACU audit tool if hypoventilation or apnea occurred, and if it was first identified via capnography or assessment. Nursing interventions were then documented on the tool including PACU respiratory complications. The audit tool was completed again before discharge from PACU to capture events related to the administration of opioids in the PACU that may have augmented the symptoms of OSA. Patients with two or more apneic episodes or desaturations had extended PACU stays (Figure 1). Anticipating Needs and Potential Barriers This process was initiated over 4 weeks, in a staggered fashion, among three high volume preoperative units and PACUs. The multidisciplinary team communicated the plan and process with all disciplines. With initiation of this new practice on each unit, staff wore stickers that stated ‘‘Ask me about OSA?’’ These were used to promote a ‘‘buzz’’ among the staff, to generate interest, promote compliance among the team, and encourage awareness of OSA to the patient, the health care team, and the hospital population at large. The

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Patients with OSA n=314

Unknown 4%

High Risk 36%

OSA without CPAP 38%

OSA with CPAP 22%

Figure 3. Patients with OSA. OSA, obstructive sleep apnea; CPAP, continuous positive airway pressure. This figure is available in color online at www. jopan.org.

respiratory department purchased additional CPAP machines in anticipation of an increased demand for them.

Results Perianesthesia RNs while caring for patients collected data via a real time audit tool. As discussed earlier, this tool included STOP-Bang score, use of capnography, nurses’ recognition of hypoventilation events, nursing response/interventions, and associated respiratory complications that occurred while in the PACU. Once initiated, data collection continued for 10 weeks. Data analysis consisted of quantifying occurrences and responses listed in the audit tool with completed PACU audit tools totaling 314 patients with OSA. One hundred ninety of these patients were male and 106 female. Among these patients, 36% were identified as high risk with a STOP-Bang $ 5 (Figure 3). Nurses used ETCO2 monitoring on 76% (n 5 241/ 314) of OSA patients and were able to readily identify hypoventilation (Figure 4) and intervene as needed (Figure 5).

Respiratory complications associated with OSA occurred in 10.8% (n 5 34) and were exhibited by more than two episodes of apnea ($10 seconds in length), low RRs (, 8), and desaturations (SpO2 , 90% on nasal cannula). These events required additional monitoring, extended stay, and escalation of care. The nurse educator completed chart reviews when data indicated respiratory complications occurred in the PACU. Four patients required intermediate care unit or ICU admission for bilevel positive airway pressure machine or new application of CPAP machine, with one of the patients receiving naloxone (opioid reversal agent) in the PACU. All four of these patients were undiagnosed OSA with STOP-Bang scores of 5 to 8, had BMI of .35, and were classified American Society of Anesthesiologists (ASA) 3. The ASA physical classification system rates a patient’s physical state before anesthesia or surgical procedure. The scale, which numbers one to six, increases as the patient’s degree of illness or comorbidities worsen. A healthy patient is rated ASA 1, whereas a patient with an ASA of 6 is described preoperatively as brain-dead whose organs are being donated.26 Discussion of Results At this time, we have not found definitive studies indicating the incidence of pulmonary complications for the OSA patient in the PACU setting to compare our observations. Kelkar27 reported that postoperative pulmonary complications occur in 5% to 10% of patients undergoing nonthoracic surgery and in 22% of high-risk patients, including those with OSA. There is a wide variation in the incidence of postoperative pulmonary complications from 5% to 80% because of patient population and the lack of uniformity in the criteria to define a pulmonary complication.28 The observations of this QI project are consistent with the literature. Patients who are most at risk for postoperative respiratory complications are the undiagnosed, high-risk OSA patient with BMIs .35 kg/m2, and one or more moderate-tosevere systemic diseases, as defined as ASA class . 2.7,29 Results of this project highlight the importance of proactive, preoperative OSA screening to identify the vulnerable, high-risk OSA patient. With heightened awareness, the

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11

Hypoventilation Events Identified by Capnograpy vs. Assessment Rising ETCO2

n=124

17

Apnea

27

Resp. Rate

2

33

2

Capnography Assessment

Desaturation

Pain/Sedation

33

10

Figure 4. Hypoventilation events. ETCO2, end-tidal CO2. This figure is available in color online at www.jopan.org.

PACU RN along with interdisciplinary care team members, anticipate patient needs and work to avert adverse complications. Discussion of Implementation Implementation of this project was iterative with formative evaluations. Within the first week of putting the STOP-Bang screening into practice, it became apparent that the preoperative nurses needed to communicate the type of OSA patient to the PACU nurses, along with the corresponding plan of care. A front side to the PACU audit tool was added that provides a ‘‘check box’’ on the type of OSA patient identified preoperatively (known OSA with CPAP, known without CPAP, and high risk) and the corresponding plan of care for them in the PACU (Figure 6). This small intervention (formative evaluation) facilitated communication between preoperative and PACU and made a significant difference in the nurses’ ability to streamline PACU care. This small adjustment to the front side of the audit tool continues to be used today. Communication among the multidisciplinary team improved throughout the phases of perianesthesia care, and as the project moved ahead in its inten-

tional phased rollout. In the preoperative setting, with identification of the OSA patient, there was discussion regarding the plan of care, and an anticipation of patient needs. In the PACU phase, the certified registered nurse anesthetist facilitated the handoff process by assisting the PACU RN to establish baseline ETCO2 values and analyze the ETCO2 waveform. In addition, the short stay unit was made aware early of high-risk patients (ie, STOPBang . 6) who might need a longer length of stay. Nursing attitudes were initially reticent regarding the new process, but within the first week on each unit, preoperative nurses reported that the STOP-Bang questionnaire was easy to complete and did not increase their workload, illustrating achievement of Aim #1. Within a few weeks of experience with bedside capnography, the PACU RNs in all three units verbalized understanding of the waveforms and many ‘‘ah ha’’ moments occurred. In addition, nurses stated that they appreciated the capnography waveform to analyze the patient’s respiratory response to opioids and to see the effects of their interventions. The PACU audit tool became an educational device for the nurses, reinforcing the signs and

SCULLY, RICKERBY, AND DUNN

12

Nursing Interventions in Response to Hypoventilation Events n= 273 Jaw Thrust, 8 Nasal Trumpet 13

Apply CPAP 24

Stir Up Regimen 187 Notify Anesthesia 41

Figure 5. Nursing interventions. CPAP, continuous positive airway pressure. This figure is available in color online at www.jopan.org.

symptoms of hypoventilation and prompting nursing interventions to facilitate oxygenation and ventilation. Nurses became more familiar with the deficits of the OSA patient postanesthesia and recognized the value of the interventions included in the new process, illustrating achievement of Aim # 2. Data collection ended after 10 weeks, when this new practice of OSA screening and capnography monitoring became the standard of care. Outcomes and Change in Practice to Best Practice Over 90 nurses participated in this project and 100% of those who responded to an informal survey (n 5 38) said that it improved their perianesthesia practice and did not increase their workload. With increased confidence in capnography, PACU RNs used critical thinking and application of ETCO2 monitoring to patients beyond the OSA population. Capnography was now also used for the opioid dependent and

the opioid na€ıve, the patient extubated in PACU, and the patient on intravenous patientcontrolled analgesia. Nurses floating to PACUs without this process encouraged the use of these QI interventions on their units, and within weeks, the obstetrics PACU and cardiovascular PACU were implementing these best practice measures. Because the STOP-Bang is an adult screening tool, our pediatric PACU investigated use of the Snoring, Trouble Breathing, Un-Refreshed pediatric OSA screening tool. Capnography was also embraced in the pediatric PACU and pediatric sedation unit as a result of this QI project. At 6 months from first implementation, all six PACUs have implemented the process of OSA screening and capnography monitoring, illustrating achievement of Aim # 3. An OSA and capnography audit report generated from the electronic medical record provided information to track sustainability. This report was developed by the hospital

OSA SCREENING AND CAPNOGRAPHY MONITORING

13

PREOP: S = Do you Snore when sleeping?

B = BMI > 35

T = Do you have day me Tiredness?

A = Age > 50 years

O = Has anyone Observed you stop breathing

N = Neck Circumference: F= 16 inches

during your sleep?

M= 17 inches

P = Do you have or are you taking medica on

G = Gender/MALE

HIGH RISK OSA > 5

for high blood Pressure?

PREOP

PACU

KNOWN OSA with CPAP ---------------------------- Use CPAP if sleepy

KNOWN OSA, No CPAP ---------------------------- Use ETCO2 monitoring

High Risk OSA (> 5)

---------------------------- Use ETCO2 monitoring

Figure 6. Addition to PACU audit tool. PACU, postanesthesia care unit; BMI, body mass index; OSA, obstructive sleep apnea; CPAP, continuous positive airway pressure; ETCO2, end-tidal CO2. STOP-Bang screening tool reprinted with permission, Ó Dr Frances Chung, UHN; http://www.stopbang.ca. This figure is available in color online at www.jopan.org.

information technology support team. The data included number of surgical cases, number of STOP-Bang scores documented, number of STOP-Bang scores greater than or equal to 5, and the number of patients with capnography usage in the PACU. Six months postintervention, 74.9% of patients in the three initial PACUs had documented preoperative STOP-Bang screening scores, and ETCO2 monitoring was consistently applied to the high-risk OSA patient (Table 4).

Limitations We wanted to use this process with all surgical patients encountered within the three PACU areas. There were limitations to this QI project. Patients who were excluded are as follows: emergent cases admitted directly to the operating room, patients who were either being transported from or to the ICU, pediatric patients, and intubated patients.

Table 4. Sustained OSA Screening and Capnography Use PACU Unit

# of Surgical Cases

# of SB Scores Documented

Initial Intervention 10-Week Period (April to June, 2018): All 3 PACUs 4,039 314 (7.7%) Postintervention 4-Week Period (December 2018): All 3 PACUs 2,389 1,791 (74.9%)

# of SB scores $ 5 High-Risk OSA

Capnography Use

115

241

210

207

OSA, obstructive sleep apnea; PACU, postanesthesia care unit; SB, STOP-Bang.

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Conclusions OSA screening proves to be a simple, easy to use method to identify the vulnerable, high-risk patient for OSA. It sets in motion the process of patient awareness, education, multidisciplinary communication, and vigilant monitoring to safeguard these patients. Capnography enhances the nurses’ respiratory assessment in the PACU environment where airway and respiratory events most commonly occur. Capnography is a technology worth the investment as its uses go beyond the OSA patient to the general PACU patient at risk for respiratory compromise. In addition, its usefulness can be applied to procedural areas where moderate sedation is given as well as the postoperative floor where the nurse patient ratio can be 1:5, if not greater. These efforts have the ability to reduce respiratory complications in the OSA surgical patient. The team used strategies of implementation science throughout this QI project. Table 1 summarizes these strategies, as well as the barriers encountered, and problem-solving measures used to overcome challenges to solidify this new practice.

The format of the EBP fellowship program, which included strategies of implementation science, drove the success of our QI project. OSA screening and capnography monitoring has become standard practice throughout all the PACUs at our institution. It has been sustainable because of education, awareness, and nursing’s core belief to provide best care. Improving patients’ safety and outcomes for the OSA surgical patient is of utmost importance. The success of this QI experience has empowered nurses to implement other evidencebased, QI projects. Using concepts of implementation science to propel evidence-based, nursing measures into embedded nursing practice, bridges the research to practice gap in a timely, practical and sustainable way.

Acknowledgments The authors thank all the Perianesthesia Nurses from Inova Fairfax Medical Campus who participated in this project, along with the 2018 Inova EBP Fellowship Program sponsors for their support. They are also grateful for the contributions from Radhika Garg, MD; Patricia C. Seifert, MSN, RN, CNOR, FAAN; Mary Ann Friesen, PhD, RN, CPHQ; Joni M. Brady, DNP, RN, CAPA; and Ellen Makar, DNP, RN-BC, CCM, CPHIMS, CENP.

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