By Robyn Woidtke

In 2015, The Joint Commission drafted a quick safety advisory for obstructive sleep apnea (OSA).  In this document they cited the following concerns regarding OSA, 1) Lack of training for health care professionals to screen for and recognize OSA 2) Failure to assess patients for OSA, 3) Lack of guidelines for the care and treatment of individuals at risk for, and those diagnosed with, OSA, 4) Failure to implement appropriate monitoring of patients with risk factors associated with OSA, 5) Lack of communication among health care providers regarding patients with OSA or potential risk factors associated with OSA, 6) Lack of postoperative evaluation and treatment for OSA. These stated concerns should be cause for alarm. Further, in September of this year, the Physician-Patient Alliance for Health & Safety announced plans to evaluate hospitals on their sleep apnea preparedness.

Screening individuals for sleep apnea who are in acute care just makes good clinical and economic sense.  It is estimated that 80% of patients who have obstructive sleep apnea have not been diagnosed which has potential for adverse events in the hospital environment.  Several studies have indicated that hospital staff do not actively ask patients about sleep and further do not understand the importance of sleep (Ye, Keane, Johnson, & Dykes, 2013; Hopper, Fried, & Pisani, 2015; McIntosh & MacMillan, 2009).  Those interviewed also seem to have a lack of awareness of screening tools or questionnaires to aid in the assessment of sleep.  This is an important knowledge and clinical gap for those individuals who work in the hospital environment.  There are approximately three million nurses in the United States. A recent Medscape nursing poll found that ~ 52% work in the hospital environment. The lack of education and training in taking a sleep assessment or understanding sleep disorders can lead to adverse events for patients (Ye & Smith, 2015, Tobin &Tobin,2017, Lee, et al., 2004).

Much of the data on OSA within an in-patient setting has been in relation to the perioperative environment.  Poor post-operative outcomes which are associated with OSA include, although are not limited to: death and anoxic brain injury; hypoxemia; cardiac arrhythmias; acute respiratory failure; pulmonary embolism; unanticipated ICU admission; and increased overall healthcare costs.  Undiagnosed sleep apnea in surgical patients is a significant issue (Finkel et al., 2009)

A recent survey of Canadian anesthesiologists found that 47% of those responding did not know of an institutional policy to help guide decision making for OSA or indicated an absence of such policy. Without policies in place, the clinicians are left to make assessment and screening decisions regarding OSA on their own (Corvodoli, et al., 2016).  Without policies in place, the patients and clinicians are exposed to risk.  This is also an area of increasing concern for administrators as the numbers of OSA-related medicolegal litigations are continuing to rise.  A paper by Svider et al. (2013) found in their review of law-focused data bases, 61% of OSA-based cases were found in favor of the defendant. This is in contrast to a newer study by Fouladpour et al. (2016) where the verdict favored the plaintiff 58% of the time.  In addition, their study reviewed the years from 1991-2010 with the majority of cases appearing after the year 2000, suggesting an increase in OSA as an indication for litigation.  Although the number is increasing, the overall number of cases is quite low. Nevertheless, this should raise a red flag for health care providers.  The average award for the plaintiffs remained relatively constant at 2.5 million between the two studies. However, the financial burden may be underestimated in that many cases are settled out of court.  Defendants included physicians, nurses and hospitals.

There are other reasons for screening and identification of patients with OSA.  Sharma et al. (2016a) found that patients who had OSA were more likely to have to have a rapid response team called, versus those who were at low risk or who were being treated.  OSA is also associated with ICU delirium. ICU delirium has health consequences, increased healthcare costs and poor outcomes in patients who experience this acute state (Wang et al, 2018; Roggenbach, Klamann, von Haken, Bruckner, Karck, & Hofer, 2015)

In patients with congestive heart failure, identification of OSA while in the hospital and subsequent testing and treatment initiation improved hospital readmission rates in all patients treated, with lower hospitalization rates in those who were adherent to therapy (Sharma et al., 2018; Aurora, Patil, & Punjabi, 2018); Sharma, et al., 2018b). Trong et al. (2018) reported on a retrospective cohort study at a Veterans Affairs hospital of patients with OSA and CHF found that patients adherent to continuous positive airway pressure therapy had lower hospital readmission rates.

In summary, hospital administrations should be aware of the increasing litigation regarding OSA. Patients with OSA are at higher risk for adverse outcomes. OSA may be a modifiable risk with significant potential for reducing 30-day hospital readmission rates (Scalzitti, et al., 2018).

Barriers to change include lack of knowledge about sleep, sleep disorders and how to perform a sleep assessment in patients.  This article focused on OSA, but there are many problematic issues regarding the lack of sleep in the hospital environment.  These include noise, aperiodic lighting, waking patients up for non-urgent activities such as routine vital signs and lack of coordinating care activities to allow for uninterrupted sleep time.  In addition, hospital policies are often the basis for lack of change due to long ingrained practices (Finkel, 2009; Ye, 2013).

What can be done?  For those in sleep working in a hospital-based environment, there are many opportunities to improve patient care.  While changing behavior and initiating new programs within a hospital are challenging, more and more facilities are realizing that a quality improvement plan regarding patients with OSA is an important component of not only patient safety, but is financially sensible.  Screening patients on arrival to the hospital should be done on a routine basis.  Those who screen high should be considered for referral to a sleep specialist.  Those who are undergoing surgery should be flagged and monitored closely in the post-anesthesia recovery area as well as the general floor.  Caution should be used in patients with OSA, high BMI and other factors suggestive of sleep apnea.

The STOP-Bang questionnaire is used in variety of settings and has demonstrated consistency in identifying patients at risk for OSA (Wang, et al., 2018; Chang, et al., 2018; Nagappa, et al.,2013). The use of portable sleep testing in the hospital environment is showing promise in stroke and CHF patients (Cao, et al., 2018; Aurora, et al., 2018).  Although there is concern regarding payment for portable sleep apnea testing, it should be balanced with the potential for improved patient safety and outcomes.  Another solution which seems to be gaining ground is to hire someone as a “Sleep Navigator” who possess the skills and knowledge to screen and assess for sleep apnea (Thompson, 2018).  The role would include working with patients and clinicians alike.  Educating clinical staff will be an important component of developing a sustainable sleep apnea screening program and buy-in from administration will be essential.  The bottom line is there is much to be done to keep patients safe from harm and improve hospital-based outcomes.

References

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