- Email: [email protected]
Obstructive Sleep Apnea: A Standard of Care That Works
Obstructive Sleep Apnea: A Standard of Care That Works Jill Setaro, RN, MSN, CPAN Examining the care of patients with obstructive sleep apnea (OSA) is forefront in perianesthesia nursing. The issue of how to effectively manage patients with OSA emerges as the patient presents for surgery. Evaluation of current practice demonstrates a gap in the consistency of care provided to patients with OSA. The development and implementation of a nursing standard of care has proven highly effective in improving the perioperative management of patients with OSA. With the introduction of preoperative screening, we can more readily identify and facilitate communication of the presence of OSA. Staff education and an increase in postoperative monitoring time help to ensure that all patients with OSA receive safe, consistent, quality care while recovering from anesthesia. Keywords: obstructive sleep apnea, general anesthesia, PACU. Ó 2012 by American Society of PeriAnesthesia Nurses
SEVERAL QUESTIONS SURFACE while caring for patients with obstructive sleep apnea (OSA) in the surgical environment. Are patients aware that they have OSA? Are patients adequately screened for the presence of OSA before surgery? What risk does OSA pose to patients after receiving general anesthesia? Should all patients with OSA receive the same level of monitoring after anesthesia? Is the staff knowledgeable about the potential risks patients with OSA may experience after general anesthesia?
What Is Obstructive Sleep Apnea?
An exploration of answers to these questions led to an examination of the current practice trends in the care of patients with OSA presenting for surgery. As a result, a perioperative nursing standard of care was developed to improve patient safety and quality of care. A standard of care provides a framework for perianesthesia nurses to safely and consistently address the needs of patients with OSA.
The best way to identify the presence of OSA is through formal sleep studies, which can adequately document periods of apnea.2 Unfortunately, sleep studies can be uncomfortable and patients may not be willing to commit to the time required to complete the test. Because of the complexity of screening, 90% of patients with mild to moderate OSA may remain undiagnosed.3 When these patients present for surgery, the presence of OSA is not documented and often overlooked in the medical history.
Jill Setaro, RN, MSN, CPAN, is a clinician in the Post Anesthesia Care Unit at Stony Brook Medicine in Stony Brook, NY. Conflict of interest: None to report. Address correspondence to Jill Setaro, Stony Brook Medicine, PACU 04L5, 101 Nicolls Road, Stony Brook, New York 11794; e-mail address: [email protected]. Ó 2012 by American Society of PeriAnesthesia Nurses 1089-9472/$36.00 http://dx.doi.org/10.1016/j.jopan.2012.06.005
Journal of PeriAnesthesia Nursing, Vol 27, No 5 (October), 2012: pp 323-328
According to the American Society of Anesthesiologists (ASA), OSA is a respiratory illness requiring the use of continuous positive airway pressure (CPAP) in the community. Frequent periods of apnea during sleep predisposes individuals to comorbid health-related issues, such as hypertension, stroke, and cardiovascular disease. Approximately 22 million people have been diagnosed with OSA.1
Noncompliance with apnea treatments, such as the use of CPAP, is also high in those diagnosed with OSA.3 Therapy is perceived as uncomfortable and noisy, and patients find it difficult to adjust to sleeping with the device. Noncompliance increases a patient’s risk for comorbidities related to OSA.3 This factor, coupled with the anesthetics
323
324
and narcotics for surgery, increases the patient’s risk for airway complications during surgery through the postanesthesia period.4 These issues pose many challenges in caring for patients with OSA during the surgical period. Postoperatively, patients with OSA are at risk for apnea, desaturation, and cardiac dysrhythmias. Complications, including death, have occurred in patients with OSA during the postoperative period.4
Using Failure Mode Effect Analysis to Evaluate Current Practices A Failure Mode Effect Analysis (FMEA) was performed to examine the institution’s current practice in caring for patients with OSA. FMEA is an effective risk management tool that can assist with improving quality and preventing human error. The purpose of the analysis was to identify best practice and implement related changes in practice to improve safety. The Grumman Aircraft Corporation first used the FMEA process in the 1950s to improve safety in the airline industry.5 The technique has proven to be a highly effective way for engineers to establish safety hazards and analyze quality. In 2003, The Joint Commission acknowledged that the FMEA technique could also be applied to patient safety concerns and recommended that hospitals use this process to improve patient outcomes.5 The FMEA technique can facilitate the examination of practices and processes. FMEA creates an opportunity to initiate measures to reduce patient risks before harm occurs. With FMEA, prevention is the key in promoting safety. The process encourages identification of potential failure modes based on previous outcomes. ‘‘Failure modes’’ examine the processes to determine how something might fail. ‘‘Effect analysis’’ examines the consequence of the failure.6 FMEA evaluates the severity and probability of failure using a defined scoring system. Modes with the highest rank have the potential to produce catastrophic results and have a very high probability of failure. Those with lowest scores have a remote impact on safety. FMEA assists in the identification of actual and potential problems, determining the probability of impact and prioritizing events based on the
JILL SETARO
severity of outcome.7 This process highlights the greatest areas of concern, allowing the investigator to prioritize focus on the most hazardous issues first. The FMEA process conducted by our postanesthesia care unit (PACU) revealed two high priority and several moderate/low risk modes with the potential to jeopardize patient safety. The first high-risk failure mode identified was the lack of consistent preoperative screening for patients with OSA. There was no standard screening process for OSA in patients presenting for surgery. The screening and identification of patients with OSA varied greatly from practitioner to practitioner. The second high-risk failure mode noted was inconsistent postoperative airway monitoring. The FMEA indicated that the lack of consistent observation created a potential for airway complications as the patient transitioned to the next level of care. Inconsistencies in monitoring created a gap in patient care with some patients with OSA receiving longer periods of observations after anesthesia, while others did not. One moderate-scoring failure mode identified was that the perioperative nursing staff lacked knowledge and understanding of OSA and the potential for complications associated with receiving general anesthesia. To further explore this failure mode, a brief, four-question survey was distributed to assess the staff’s general knowledge of perioperative OSA management. The survey was conducted in the perioperative suite and the surgical units within the hospital. It explored the staff’s perception of the knowledge of OSA. It also explored the current use of CPAP and pulse oximetry monitoring in the institution for patients with OSA. Data collection confirmed the failure mode and the need for improving staff knowledge of the care of patients with OSA (Figure 1). Additional failure modes indicated insufficient communication and documentation of the presence of OSA as the patient transitioned through surgery. Lack of documentation of OSA in the medical history and complex electronic record forms made it almost impossible to consistently locate information regarding the presence of OSA. The FMEA
OSA STANDARD OF CARE
325
Figure 1. Obstructive sleep apnea staff knowledge survey results.
clearly established the need for standardizing the care of patients with OSA.
practice standards suggest the use of the STOP questionnaire to assess for the presence of OSA.
Current Guidelines
The STOP questionnaire, developed by anesthesiologists and sleep specialists, is a four-question screening tool that can quickly determine the presence of OSA (Figure 2). The four questions assess if the patient snores, is frequently tired, has observed apnea and has high blood pressure. With a simple yes/no response, the screening can take less than a minute to complete and is proven to be 96% effective in identifying OSA.8 The presence of OSA is presumed when the patient scores greater than two of four ‘‘yes’’ answers.
A literature review was conducted using the Cumulative Index to Nursing and Allied Health Literature and targeted Internet searches. Keywords used were OSA, PACU, and anesthesia. The search revealed no standardized practice for the perianesthesia care of patients with OSA. At the time of the search, the American Society of PeriAnesthesia Nurses did not have practice recommendations for the care of patients with OSA. In 2006, ASA developed a task force to address concerns regarding the use of general anesthesia in patients with OSA. The task force conducted an analysis of formal research and current practices in the care of patients with OSA. The group issued practice guidelines for the management of patients with OSA. These guidelines suggest ways to identify patients with OSA, recommend preoperative screening, and discuss intraoperative considerations for the anesthesia provider. In addition, the guidelines make recommendations for the postoperative care of patients with OSA, which address analgesia, positioning, monitoring, and oxygenation. The ASA recommends preoperative screening for OSA for all patients presenting for surgery. The
Since limitations with obtaining formal sleep studies exist, the ASA recommends the use of the STOP
Figure 2. STOP questionnaire.8
JILL SETARO
326
questionnaire for a rapid assessment of the presence of OSA. When combined with other clinical findings such as obesity, large neck circumference, and medical history, the anesthesia provider can make a presumptive diagnosis and manage the care of patients with OSA appropriately. Postoperative treatment of patients with OSA should be conservative, as the risk for apnea and respiratory depression lasts for several hours after receiving general anesthesia.9 The ASA recommends a minimum of 4 hours of postoperative airway and pulse oximetry monitoring in the perioperative suite for those patients who are at risk for OSA. If periods of desaturation are prolonged during recovery, it is recommended that the patient be admitted to a monitored bed.9,10 The American Sleep Apnea Association indicates that anesthesia assessment should include a consult with the Acute Pain Service to explore alternatives to general anesthesia for patients with OSA. Modifications in anesthetic administration combined with the use of epidurals and peripheral nerve blocks can reduce the need for high doses of narcotics postoperatively. Careful planning of postoperative pain management has proven cost effective and can decrease the length of stay with better patient outcomes.1,10
Working Together: Program Implementation An interdisciplinary team was involved in the decision to implement a formal, standardized perioperative nursing plan of care for patients with OSA. All stake holders agreed on the importance of standardizing care for this population to improve safety. The goal of implementing this standard was to reduce postoperative complications related to respiratory compromise in patients with OSA. The team determined that the most effective way to achieve this goal was to adapt and expand on recommendations from the ASA guidelines, creating a standardized nursing plan of care. The team’s focus was to create a plan of care that was not restrictive, and agreed that there must be room for clinical judgment in determining the course of treatment for patients with OSA. The standardized plan of care addresses the needs of the adult patient with OSA as they transition
through surgery. It does not include guidelines for medical management and treatments unrelated to a surgical event. It also does not include pediatric patients, who are assessed on an individual basis.
Preoperative Care The first step in formalizing care for those with OSA was to initiate screening for all patients presenting for surgery. The STOP questionnaire was integrated into the operating room (OR) holding area verifications process. The nurse asks each patient the four STOP questions and records the responses in the medical record. If the patient answers ‘‘yes’’ to more than two of the four questions, the attending anesthesiologist is notified before the patient is transported to the operating room. This allows the physician to then conduct a more thorough assessment of the risk for OSA. The patient can continue to be monitored by the anesthesiologist and intraoperative management of the patient can be modified accordingly. If further examination reveals the presence or suspected undiagnosed OSA, the staff will consider the patient at risk for OSA and follow the standard of care. Electronic documentation forms have been enhanced to include the STOP questionnaire. This created one central location for the perioperative staff to quickly find the OSA diagnosis in the electronic record. It also provides increased consistency in documentation of risk assessment on all patients presenting for surgery. Preoperative patient education has been implemented to provide information of the additional risk involved with receiving general anesthesia. Patients are informed that they will require additional monitoring postoperatively to monitor respiratory status. In the preadmission testing setting, evaluation of the use of CPAP equipment at home explores issues with compliance and equipment malfunction before the patient presents on the day of surgery.
Postoperative Care When a patient transfers from the operating room to the PACU, an SBAR (situation, background, assessment and recommendation) communication form is used to facilitate handoff communication. The SBAR form was modified to include OSA as a primary piece of information during report. This
OSA STANDARD OF CARE
practice has improved the communication of the risk for OSA as the patient transitions from the operating room to the PACU. Postoperative care requires patients with OSA be monitored in the perioperative suite for a minimum of 4 hours after general anesthesia. During the recovery period, sedation and narcotic analgesia can prolong anesthetic effects and increase a patient’s risk for airway compromise. A longer period of intense airway management ensures that the patient with OSA can maintain adequate ventilation. Patients experiencing effects of carbon dioxide retention may benefit from the use of CPAP in the PACU. CPAP initiated upon extubation can facilitate the elimination of anesthetics and ensure adequate ventilation during recovery. The need for continuous pulse oximetry after discharge from PACU should be based on the patient’s condition and episodes of desaturation. In addition, the amount of narcotic analgesia the patient requires, as well as the severity of the patient’s OSA should also be considered. Patients who experience airway complications require continuous pulse oximetry for 24 to 48 hours after surgery, based on the physician’s assessment of respiratory status. Ambulatory surgery patients who have been identified as high risk for OSA as a result of the STOP screening process are discharged with written guidelines. This educational material describes how to appropriately follow up on their risk for OSA with their primary care providers. It also reinforces continuing OSA management on discharge for those diagnosed with OSA. Patients with diagnosed OSA are educated on the importance of using prescribed CPAP machines at home in the weeks after surgery. Ambulatory patients who are unable to achieve acceptable oxygenation to meet discharge criteria are admitted to a monitored bed for continuous pulse oximetry.
Institutional Impact Once the institution’s regulatory committees approved the standard, the staff were educated regarding the standardization of care for patients with OSA. The staff knowledge survey was distributed again 1 month after the completion of staff education. The repeat survey confirmed an increase in staff knowledge about OSA and appropriate
327
postoperative monitoring (Figure 1). Through staff education regarding OSA risk factors and the creation of a uniform practice in delivery of care, the goal to prevent negative outcomes after anesthesia was established. Concern was raised by the PACU nursing staff about the impact of extended monitoring of the patients with OSA on throughput in the unit. PACU unit– based data reflect that PACU management of the OSA for the recommended 4-hour period had relatively little impact on unit flow. More often, the average stay in the PACU is extended because of the lack of bed availability rather than clinical indication. The availability of monitored beds in the institution also raised concerns as to how this population could be accommodated as they transition to the inpatient unit. Resources must be used appropriately to ensure patients with high risk for OSA complications transition safely to the next level of care. The need for continuous pulse oximetry after surgery should be based on the patient’s condition and acuity. To date, this standard has not had a significant impact on bed availability.
Evaluation The use of a standardized plan of care for the management of patients with OSA reaps many benefits. The STOP Questionnaire has proven to be a valuable indicator of the presence of OSA risk. Incorporating the STOP questionnaire as part of the OR holding procedure has eliminated miscommunication and omission of the presence of OSA. It creates the opportunity for quick screening before induction and can identify patients who may have OSA but have not been officially diagnosed by sleep studies. This screening also creates a forum for discussion of OSA management in those patients with a confirmed diagnosis, to explore issues with compliance. Preoperative screening helps establish and document a baseline respiratory status for those with increased risk factors for OSA. The standard has also increased the number of patients identified with high-risk factors for experiencing complications after anesthesia. The modification of electronic records to include OSA information facilitated the communication between presurgical, operating room, and postanesthesia units regarding the presence of OSA.
JILL SETARO
328
Standardized handoffs have improved interdisciplinary communication of OSA risk factors. In addition, patients with OSA now receive longer observation in the perioperative suite before transitioning to the next level of care. This has greatly impacted postoperative safety for patients with OSA. Ambulatory surgery patients are allotted more time to recover before transitioning back into the community. This ensures that patients with OSA can sustain the achievement of discharge criteria before leaving the facility. Ambulatory discharge guidelines now include patient education guidelines for appropriate OSA follow-up care. Although a longitudinal study will best reflect the positive impact this plan has on OSA patient care, an immediate improvement has been noted in the clinical setting. Data collection for 3 months after the initiation of the standard shows a 5% increase in the identification of high-risk patients.
The standard has greatly improved the safety for these patients as they recover from anesthesia. Two percent of high-risk patients identified with the new screening process required admission to the hospital for respiratory management of OSA complications. None of the patients had a documented history of OSA.
Summary A standardized nursing plan of care for the adult patient with OSA allows the perianesthesia nurse to anticipate the needs of this patient population as they recover from anesthesia. Consistency in care delivery increases the quality of care administered to these patients. Providing a nursing framework for care of the patients with OSA creates a pathway for providing safe and effective care to patients after surgery.
References 1. American Sleep Apnea Association. Sleep Apnea and Same Day Surgery. 2009. Available at: www.sleepapnea.org. Accessed June 9, 2010. 2. Lakdawala L. Creating a safer perioperative environment with an Obstructive Sleep Apnea Screening Tool. J Perianesth Nurs. 2011;26:15-22. 3. Ead H. Meeting the challenge of obstructive sleep apnea: Developing a protocol that guides perianesthesia patient care. J Perianesth Nurs. 2009;24:103-113. 4. American Society of Anesthesiologists. Practice guidelines for the perioperative management of patients with obstructive sleep apnea. Anesthesiology. 2006;104:1081. 5. Ho C, Liao C. The use of failure mode effect. Analysis to construct an effective disposal and prevention mechanism for infectious hospital waste. Waste Manag. 2011;31:26312637.
6. Smith I. The Joint Commission guide to improving staff communication. Oakbrook Terrace, IL: JC Resources, Inc, 2006:53–54. 7. American Society for Quality. FMEA. 2011. Available at: http://asq.org/learn-about-quality/process-analysis-tools/overview/ fmea.html. Accessed April 20, 2012. 8. Chung F. STOP Questionnaire, a tool to screen patients for obstructive sleep apnea. Anesthesiology. 2008;108:812-821. 9. Thorpy, M. Improving outcomes in excessive sleepiness and obstructive sleep apnea. Medscape CME. 2009;1–37. Available at: http://cme.medscape.com. Accessed June 10, 2011. 10. Pennsylvania Patient Safety Authority. Patient screening and assessment in ambulatory surgical facilities. PA-PSRS Patient Safety Advisory. 2009;6(1):3–9. Available at: http://patientsafety authority.org/PATIENTSCONSUMERS/PatientConsumerTips/Pages/ ASF_Screening_Consumer_Tips.aspx. Accessed June 10, 2011.
SEVERAL QUESTIONS SURFACE while caring for patients with obstructive sleep apnea (OSA) in the surgical environment. Are patients aware that they have OSA? Are patients adequately screened for the presence of OSA before surgery? What risk does OSA pose to patients after receiving general anesthesia? Should all patients with OSA receive the same level of monitoring after anesthesia? Is the staff knowledgeable about the potential risks patients with OSA may experience after general anesthesia?
What Is Obstructive Sleep Apnea?
An exploration of answers to these questions led to an examination of the current practice trends in the care of patients with OSA presenting for surgery. As a result, a perioperative nursing standard of care was developed to improve patient safety and quality of care. A standard of care provides a framework for perianesthesia nurses to safely and consistently address the needs of patients with OSA.
The best way to identify the presence of OSA is through formal sleep studies, which can adequately document periods of apnea.2 Unfortunately, sleep studies can be uncomfortable and patients may not be willing to commit to the time required to complete the test. Because of the complexity of screening, 90% of patients with mild to moderate OSA may remain undiagnosed.3 When these patients present for surgery, the presence of OSA is not documented and often overlooked in the medical history.
Jill Setaro, RN, MSN, CPAN, is a clinician in the Post Anesthesia Care Unit at Stony Brook Medicine in Stony Brook, NY. Conflict of interest: None to report. Address correspondence to Jill Setaro, Stony Brook Medicine, PACU 04L5, 101 Nicolls Road, Stony Brook, New York 11794; e-mail address: [email protected]. Ó 2012 by American Society of PeriAnesthesia Nurses 1089-9472/$36.00 http://dx.doi.org/10.1016/j.jopan.2012.06.005
Journal of PeriAnesthesia Nursing, Vol 27, No 5 (October), 2012: pp 323-328
According to the American Society of Anesthesiologists (ASA), OSA is a respiratory illness requiring the use of continuous positive airway pressure (CPAP) in the community. Frequent periods of apnea during sleep predisposes individuals to comorbid health-related issues, such as hypertension, stroke, and cardiovascular disease. Approximately 22 million people have been diagnosed with OSA.1
Noncompliance with apnea treatments, such as the use of CPAP, is also high in those diagnosed with OSA.3 Therapy is perceived as uncomfortable and noisy, and patients find it difficult to adjust to sleeping with the device. Noncompliance increases a patient’s risk for comorbidities related to OSA.3 This factor, coupled with the anesthetics
323
324
and narcotics for surgery, increases the patient’s risk for airway complications during surgery through the postanesthesia period.4 These issues pose many challenges in caring for patients with OSA during the surgical period. Postoperatively, patients with OSA are at risk for apnea, desaturation, and cardiac dysrhythmias. Complications, including death, have occurred in patients with OSA during the postoperative period.4
Using Failure Mode Effect Analysis to Evaluate Current Practices A Failure Mode Effect Analysis (FMEA) was performed to examine the institution’s current practice in caring for patients with OSA. FMEA is an effective risk management tool that can assist with improving quality and preventing human error. The purpose of the analysis was to identify best practice and implement related changes in practice to improve safety. The Grumman Aircraft Corporation first used the FMEA process in the 1950s to improve safety in the airline industry.5 The technique has proven to be a highly effective way for engineers to establish safety hazards and analyze quality. In 2003, The Joint Commission acknowledged that the FMEA technique could also be applied to patient safety concerns and recommended that hospitals use this process to improve patient outcomes.5 The FMEA technique can facilitate the examination of practices and processes. FMEA creates an opportunity to initiate measures to reduce patient risks before harm occurs. With FMEA, prevention is the key in promoting safety. The process encourages identification of potential failure modes based on previous outcomes. ‘‘Failure modes’’ examine the processes to determine how something might fail. ‘‘Effect analysis’’ examines the consequence of the failure.6 FMEA evaluates the severity and probability of failure using a defined scoring system. Modes with the highest rank have the potential to produce catastrophic results and have a very high probability of failure. Those with lowest scores have a remote impact on safety. FMEA assists in the identification of actual and potential problems, determining the probability of impact and prioritizing events based on the
JILL SETARO
severity of outcome.7 This process highlights the greatest areas of concern, allowing the investigator to prioritize focus on the most hazardous issues first. The FMEA process conducted by our postanesthesia care unit (PACU) revealed two high priority and several moderate/low risk modes with the potential to jeopardize patient safety. The first high-risk failure mode identified was the lack of consistent preoperative screening for patients with OSA. There was no standard screening process for OSA in patients presenting for surgery. The screening and identification of patients with OSA varied greatly from practitioner to practitioner. The second high-risk failure mode noted was inconsistent postoperative airway monitoring. The FMEA indicated that the lack of consistent observation created a potential for airway complications as the patient transitioned to the next level of care. Inconsistencies in monitoring created a gap in patient care with some patients with OSA receiving longer periods of observations after anesthesia, while others did not. One moderate-scoring failure mode identified was that the perioperative nursing staff lacked knowledge and understanding of OSA and the potential for complications associated with receiving general anesthesia. To further explore this failure mode, a brief, four-question survey was distributed to assess the staff’s general knowledge of perioperative OSA management. The survey was conducted in the perioperative suite and the surgical units within the hospital. It explored the staff’s perception of the knowledge of OSA. It also explored the current use of CPAP and pulse oximetry monitoring in the institution for patients with OSA. Data collection confirmed the failure mode and the need for improving staff knowledge of the care of patients with OSA (Figure 1). Additional failure modes indicated insufficient communication and documentation of the presence of OSA as the patient transitioned through surgery. Lack of documentation of OSA in the medical history and complex electronic record forms made it almost impossible to consistently locate information regarding the presence of OSA. The FMEA
OSA STANDARD OF CARE
325
Figure 1. Obstructive sleep apnea staff knowledge survey results.
clearly established the need for standardizing the care of patients with OSA.
practice standards suggest the use of the STOP questionnaire to assess for the presence of OSA.
Current Guidelines
The STOP questionnaire, developed by anesthesiologists and sleep specialists, is a four-question screening tool that can quickly determine the presence of OSA (Figure 2). The four questions assess if the patient snores, is frequently tired, has observed apnea and has high blood pressure. With a simple yes/no response, the screening can take less than a minute to complete and is proven to be 96% effective in identifying OSA.8 The presence of OSA is presumed when the patient scores greater than two of four ‘‘yes’’ answers.
A literature review was conducted using the Cumulative Index to Nursing and Allied Health Literature and targeted Internet searches. Keywords used were OSA, PACU, and anesthesia. The search revealed no standardized practice for the perianesthesia care of patients with OSA. At the time of the search, the American Society of PeriAnesthesia Nurses did not have practice recommendations for the care of patients with OSA. In 2006, ASA developed a task force to address concerns regarding the use of general anesthesia in patients with OSA. The task force conducted an analysis of formal research and current practices in the care of patients with OSA. The group issued practice guidelines for the management of patients with OSA. These guidelines suggest ways to identify patients with OSA, recommend preoperative screening, and discuss intraoperative considerations for the anesthesia provider. In addition, the guidelines make recommendations for the postoperative care of patients with OSA, which address analgesia, positioning, monitoring, and oxygenation. The ASA recommends preoperative screening for OSA for all patients presenting for surgery. The
Since limitations with obtaining formal sleep studies exist, the ASA recommends the use of the STOP
Figure 2. STOP questionnaire.8
JILL SETARO
326
questionnaire for a rapid assessment of the presence of OSA. When combined with other clinical findings such as obesity, large neck circumference, and medical history, the anesthesia provider can make a presumptive diagnosis and manage the care of patients with OSA appropriately. Postoperative treatment of patients with OSA should be conservative, as the risk for apnea and respiratory depression lasts for several hours after receiving general anesthesia.9 The ASA recommends a minimum of 4 hours of postoperative airway and pulse oximetry monitoring in the perioperative suite for those patients who are at risk for OSA. If periods of desaturation are prolonged during recovery, it is recommended that the patient be admitted to a monitored bed.9,10 The American Sleep Apnea Association indicates that anesthesia assessment should include a consult with the Acute Pain Service to explore alternatives to general anesthesia for patients with OSA. Modifications in anesthetic administration combined with the use of epidurals and peripheral nerve blocks can reduce the need for high doses of narcotics postoperatively. Careful planning of postoperative pain management has proven cost effective and can decrease the length of stay with better patient outcomes.1,10
Working Together: Program Implementation An interdisciplinary team was involved in the decision to implement a formal, standardized perioperative nursing plan of care for patients with OSA. All stake holders agreed on the importance of standardizing care for this population to improve safety. The goal of implementing this standard was to reduce postoperative complications related to respiratory compromise in patients with OSA. The team determined that the most effective way to achieve this goal was to adapt and expand on recommendations from the ASA guidelines, creating a standardized nursing plan of care. The team’s focus was to create a plan of care that was not restrictive, and agreed that there must be room for clinical judgment in determining the course of treatment for patients with OSA. The standardized plan of care addresses the needs of the adult patient with OSA as they transition
through surgery. It does not include guidelines for medical management and treatments unrelated to a surgical event. It also does not include pediatric patients, who are assessed on an individual basis.
Preoperative Care The first step in formalizing care for those with OSA was to initiate screening for all patients presenting for surgery. The STOP questionnaire was integrated into the operating room (OR) holding area verifications process. The nurse asks each patient the four STOP questions and records the responses in the medical record. If the patient answers ‘‘yes’’ to more than two of the four questions, the attending anesthesiologist is notified before the patient is transported to the operating room. This allows the physician to then conduct a more thorough assessment of the risk for OSA. The patient can continue to be monitored by the anesthesiologist and intraoperative management of the patient can be modified accordingly. If further examination reveals the presence or suspected undiagnosed OSA, the staff will consider the patient at risk for OSA and follow the standard of care. Electronic documentation forms have been enhanced to include the STOP questionnaire. This created one central location for the perioperative staff to quickly find the OSA diagnosis in the electronic record. It also provides increased consistency in documentation of risk assessment on all patients presenting for surgery. Preoperative patient education has been implemented to provide information of the additional risk involved with receiving general anesthesia. Patients are informed that they will require additional monitoring postoperatively to monitor respiratory status. In the preadmission testing setting, evaluation of the use of CPAP equipment at home explores issues with compliance and equipment malfunction before the patient presents on the day of surgery.
Postoperative Care When a patient transfers from the operating room to the PACU, an SBAR (situation, background, assessment and recommendation) communication form is used to facilitate handoff communication. The SBAR form was modified to include OSA as a primary piece of information during report. This
OSA STANDARD OF CARE
practice has improved the communication of the risk for OSA as the patient transitions from the operating room to the PACU. Postoperative care requires patients with OSA be monitored in the perioperative suite for a minimum of 4 hours after general anesthesia. During the recovery period, sedation and narcotic analgesia can prolong anesthetic effects and increase a patient’s risk for airway compromise. A longer period of intense airway management ensures that the patient with OSA can maintain adequate ventilation. Patients experiencing effects of carbon dioxide retention may benefit from the use of CPAP in the PACU. CPAP initiated upon extubation can facilitate the elimination of anesthetics and ensure adequate ventilation during recovery. The need for continuous pulse oximetry after discharge from PACU should be based on the patient’s condition and episodes of desaturation. In addition, the amount of narcotic analgesia the patient requires, as well as the severity of the patient’s OSA should also be considered. Patients who experience airway complications require continuous pulse oximetry for 24 to 48 hours after surgery, based on the physician’s assessment of respiratory status. Ambulatory surgery patients who have been identified as high risk for OSA as a result of the STOP screening process are discharged with written guidelines. This educational material describes how to appropriately follow up on their risk for OSA with their primary care providers. It also reinforces continuing OSA management on discharge for those diagnosed with OSA. Patients with diagnosed OSA are educated on the importance of using prescribed CPAP machines at home in the weeks after surgery. Ambulatory patients who are unable to achieve acceptable oxygenation to meet discharge criteria are admitted to a monitored bed for continuous pulse oximetry.
Institutional Impact Once the institution’s regulatory committees approved the standard, the staff were educated regarding the standardization of care for patients with OSA. The staff knowledge survey was distributed again 1 month after the completion of staff education. The repeat survey confirmed an increase in staff knowledge about OSA and appropriate
327
postoperative monitoring (Figure 1). Through staff education regarding OSA risk factors and the creation of a uniform practice in delivery of care, the goal to prevent negative outcomes after anesthesia was established. Concern was raised by the PACU nursing staff about the impact of extended monitoring of the patients with OSA on throughput in the unit. PACU unit– based data reflect that PACU management of the OSA for the recommended 4-hour period had relatively little impact on unit flow. More often, the average stay in the PACU is extended because of the lack of bed availability rather than clinical indication. The availability of monitored beds in the institution also raised concerns as to how this population could be accommodated as they transition to the inpatient unit. Resources must be used appropriately to ensure patients with high risk for OSA complications transition safely to the next level of care. The need for continuous pulse oximetry after surgery should be based on the patient’s condition and acuity. To date, this standard has not had a significant impact on bed availability.
Evaluation The use of a standardized plan of care for the management of patients with OSA reaps many benefits. The STOP Questionnaire has proven to be a valuable indicator of the presence of OSA risk. Incorporating the STOP questionnaire as part of the OR holding procedure has eliminated miscommunication and omission of the presence of OSA. It creates the opportunity for quick screening before induction and can identify patients who may have OSA but have not been officially diagnosed by sleep studies. This screening also creates a forum for discussion of OSA management in those patients with a confirmed diagnosis, to explore issues with compliance. Preoperative screening helps establish and document a baseline respiratory status for those with increased risk factors for OSA. The standard has also increased the number of patients identified with high-risk factors for experiencing complications after anesthesia. The modification of electronic records to include OSA information facilitated the communication between presurgical, operating room, and postanesthesia units regarding the presence of OSA.
JILL SETARO
328
Standardized handoffs have improved interdisciplinary communication of OSA risk factors. In addition, patients with OSA now receive longer observation in the perioperative suite before transitioning to the next level of care. This has greatly impacted postoperative safety for patients with OSA. Ambulatory surgery patients are allotted more time to recover before transitioning back into the community. This ensures that patients with OSA can sustain the achievement of discharge criteria before leaving the facility. Ambulatory discharge guidelines now include patient education guidelines for appropriate OSA follow-up care. Although a longitudinal study will best reflect the positive impact this plan has on OSA patient care, an immediate improvement has been noted in the clinical setting. Data collection for 3 months after the initiation of the standard shows a 5% increase in the identification of high-risk patients.
The standard has greatly improved the safety for these patients as they recover from anesthesia. Two percent of high-risk patients identified with the new screening process required admission to the hospital for respiratory management of OSA complications. None of the patients had a documented history of OSA.
Summary A standardized nursing plan of care for the adult patient with OSA allows the perianesthesia nurse to anticipate the needs of this patient population as they recover from anesthesia. Consistency in care delivery increases the quality of care administered to these patients. Providing a nursing framework for care of the patients with OSA creates a pathway for providing safe and effective care to patients after surgery.
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