© Yoav Levy/Science Faction/Corbis
As respiratory care professionals, most of us know the statistics on obstructive sleep apnea (OSA); that it is largely under-recognized and usually undiagnosed until patients start experiencing adverse health effects such as hypertension, daytime sleepiness, uncontrolled diabetes, drowsiness-related accidents, etc. If you have been in the respiratory care field for any length of time, you have probably cared for patients who have suffered the consequences of unrecognized OSA during the postoperative period. There are frequent rapid response team and code-blue calls for sleep apnea patients who have increased apneic events when given sedatives and pain medications. Often these consequences are sentinel or near-sentinel events that may prompt health care facilities to put measures in place to lower the risk to both the patient and the facility. You may have even participated in an OSA program to help screen patients and identify those at high risk for OSA prior to surgery. Such programs generally identify patients at high risk, increase patient monitoring, implement PAP during the postoperative period, provide patient education, and encourage referral to a sleep laboratory; but they often do little to diagnosis OSA and begin the patient on therapy while they are under our care. It is not that we do not want the patient’s OSA treated, it is just beyond the scope and resources of most hospital-based preoperative programs to actually diagnose and treat a problem that is not the patient’s main reason for admission.
The Obligation Is Ours
When it comes to OSA, however, I believe it is crucial to acknowledge that because this syndrome is so under-recognized and undiagnosed, we have an obligation to help identify and treat these patients while they are “captured” in our facilities. I often say, “People generally do not go to the doctor because they snore or they are tired all the time, but they will come in to have surgery to fix their knee or remove a bunion.” This then is an opportunity to begin treatment of a condition that we know has serious health consequences. I believe that we are most effective when we not only identify patients at high risk for OSA but also start those patients on treatment, and it is no different than the responsibility we would have if we identified the patient as diabetic during their stay. We would not send newly diagnosed diabetic patients home with simply a suggestion to follow up with their doctor, we would start them on treatment. If we did not, we could be considered negligent.
Developing the Program
So the question becomes, how can we improve the overall health outcomes for patients with OSA in this world of increased expectations by patients, payors, and the public, considering the obstacles we face with both decreasing reimbursement and scarce health care resources? At our facility, we have developed a simple program that not only keeps our patients safe, but also strives to have a positive impact on their future health and, therefore, improve the health of our community.
As respiratory care professionals, we are the most well equipped to design, implement, and manage an OSA program. We care for patients across the continuum of care, and our education and training uniquely prepare us to understand, assess, and treat OSA. An OSA program that our respiratory therapy department has had the opportunity to manage for the last 2 years has allowed us to identify some key components and learn some valuable lessons that may be helpful to others starting or participating in an OSA program. It is not our intent to outline our exact program, but rather offer suggestions and points to consider when developing a program designed for your facility.
Do your homework. You have to know your topic if you wish to gain credibility with your peers and your medical staff. A thorough literature search is a great place to start to familiarize yourself and your staff with the many aspects of OSA, including statistics, recognition, screening tools, strategies, and treatments. This data will build support for your program and grow your passion for minimizing the effects of OSA. It is hard to argue with well-designed, large studies. Search out best practice standards. Review the Medicare Local Coverage Determinations (LCDs) for your area and become familiar with the medical policies for the major insurers so that you can address questions and become familiar with reimbursement, coding, and billing. All of this information is easily accessible on line.
Define your goals. These will be very dependent on your facility and your department. What is the driving force for the program? Is it to keep patients safe while under your care? Build referrals for a sleep center? Diagnose and treat OSA patients to improve health outcomes? Try to align your goals for the program with the mission and vision of the hospital or hospital system. I would also encourage you to start out with a goal that is a stretch for your department and the facility. Nothing great ever came out of small thinking.
Identify champions. This includes physicians and administrative/leadership support. It is great if you have a supportive medical director, but if this is not the case, search out physicians in anesthesiology, pulmonary or sleep medicine, hospitalists, and others. Perhaps there are a few who have personally cared for a patient who experienced an adverse outcome from unrecognized OSA. This can be a powerful motivator to keep future patients safe. Administrators who have a focus on quality may be great choices to champion a program designed to improve patient safety. Nurse leaders in the PACU and postoperative areas have a vested interest in protecting patients from OSA complications and can be great allies.
Realize what is important to your stakeholders. Surgeons prefer to perform surgery when they schedule it. If your program will impact or delay a scheduled surgery, you will probably not have a lot of supportive surgeons. Have multiple pathways for your patients to enter into the program. We include patients who have a prior OSA diagnosis, patients who screen at high risk but do not complete a home sleep test (HST), and patients who do complete a home sleep test. This allows us to keep patients safe while not delaying their surgery. Anesthesiologists want to decrease their patients’ risk of complications from anesthesia and move them out of the PACU in a timely manner. An OSA program can provide them with important assessment data for OSA risk and/or home sleep testing results. This helps them manage the patient appropriately intraoperatively. Hospitalists and physicians involved with postoperative patient management want to decrease the adverse affects of OSA that can create complications and delay discharge. An OSA program, especially one with protocol-driven PAP therapy and patient management, can help them reach these goals.
Collaborate with other departments up front. A successful program happens when many different departments participate and use their expertise to plan, develop, implement, and manage the program. Involve departments such as finance or the business office for reimbursement; quality assurance for outcome measures to track; preadmit for the patient screening process; and nursing to give input on patient flow, protocols, and patient education. Bring in any department that will play a part in the patient’s OSA screening and care.
Determine financial goals. Will this program try to generate revenue for the hospital, or is the goal to avoid expense by reducing length of stay, adverse outcomes, and complications? Perhaps the goal will just to be cost neutral. How you classify patients (inpatient or outpatient) for the screening will impact your reimbursement. If you plan on doing any type of diagnostic testing (polysomnography or HST), decide how you will charge the patients for these services.
Rally the troops. The respiratory therapy staff can be the key to the success of an OSA program. Educate and inspire your staff and others who will be involved in managing OSA patients. Do not make assumptions that they know the extent of sleep apnea and its health affects. People will take ownership and do a great job identifying and managing patients if they buy into the reason for the program. Share outcome data on a regular basis, and let the staff know how the program is doing and what the patient outcomes are. Ask for their feedback on how processes are working and how things can be improved. Do not wait for them to come to you, actively seek out their opinions.
Make the process as easy as possible. New programs often create cumbersome new forms and a lot of extra work for staff who already have too much to do. Recognize this fact; and when new forms are needed, make sure they improve communication, not just add to the work. Perhaps you can simply modify something already in place or utilize the electronic medical records system to facilitate communication between caregivers. Protocol order sets can be very useful to help guide decision-making and lend consistency to patient management. A wipe-off calendar can be used inside the respiratory care department to make staff aware of OSA high-risk patients’ surgery dates and help ensure RTs follow up postoperatively. Using identification armbands on the patients that state their high-risk OSA status is an easy way for staff to identify these patients and modify their treatment when indicated.
Pilot the program. Whether you need institutional review board approval or simply the blessing of your medical staff and administration, asking to pilot the program first can be a great way to gain initial support for the program. Set a defined pilot period, and be ready to report your outcomes. This is a learning period, so expect that changes to the original program design will need to be made.
Define outcome measurements and monitor your progress. A simple Excel spreadsheet can help you track patient data and outcomes. Define up front what data are important to collect. This will depend on the goals of your program, but in my mind, this cannot be too comprehensive! There is nothing worse than getting halfway through your pilot period and figuring out you need some data you haven’t been collecting. Our program tracks patient demographics (age, gender, BMI, screening score, surgery date, etc), home sleep study results, patient APAP trials, and disposition upon discharge home (on APAP/oral appliance/sleep medicine follow-up, etc).
Use the right tools. If the program will incorporate HST, research and trial devices that will meet your needs and are easy for the patient to apply and use. We had several of our employees do HST to determine the ease of use and device reliability (and they are now on PAP therapy). Determine how patients will get the devices back to you. Remember to make it as easy as possible and consider having them mail the devices back in postage paid mailers rather than having to return to the facility.
If your program includes treating the patient postoperatively with APAP/CPAP, the devices and equipment you use can greatly impact your success rate. If a patient’s first introduction to PAP therapy is a big noninvasive ventilator with a full-face mask, you might not get the best compliance to therapy. It is best to use systems and interfaces that patients are most likely to use at home. Small, quiet APAP or CPAP devices and nasal pillows will often leave patients surprised at how easily they adapt to therapy. Remember to support and encourage patients who tolerate the PAP therapy for even a couple of hours the first few nights. That is a successful trial. Tolerance to PAP therapy should not be judged until after a good 30-day period. Letting patients know this up front will help them ease into therapy and not make a decision based on a few days’ experience. Also realize that although PAP therapy is the gold standard for OSA treatment, not all patients will go home on PAP therapy; and these patients still need treatment for their OSA. Patients who tend to have mild to moderate and positional OSA will likely be more compliant to oral appliances for their OSA treatment. Partner with a reliable and qualified provider of oral appliances that can help manage these patients after discharge.
Partner with like-minded facilities and/or companies. Depending on the goals of your program, you will need to refer patients to other health care companies for follow-up care. This may be a sleep laboratory, sleep physician, durable medical equipment company, or oral appliance provider. Shop around for facilities/companies in your area that have similar goals and are patient focused. Get agreement up front for them to provide you with outcome data on the patients you refer. Get feedback from patients on the service they provide and do not be afraid to switch companies if needed.
Keep the primary care physician in the loop. Communicate with the patient’s primary care physician through a letter or fax that the patient was identified as high risk for OSA while at your facility. Send any results from a screening tool or sleep test the patient had performed, and outline possible next steps.
Communicate with OSA patients. Often these patients and their families are aware that they snore and that it may be sleep apnea. People are busy, and offering a convenient way for them to perform a sleep test is appealing to them. We explain to patients that if we determine they are at high risk, we are going to monitor them for respiratory complications and help keep them safe during their stay with us. We follow up with them after discharge, through either a letter or phone call. They always appreciate our concern and follow-up. This builds loyalty to our facility.
Developing a great OSA program at your facility is possible if you are passionate about the safety of your patients, gain stakeholder support, plan and implement processes that are easy to follow, and instill a sense of confidence in the staff that cares for these patients.
Sharon Trongaard, BS, RRT, is manager of respiratory care at Baylor Medical Center at Frisco, Tex, and owner/CEO, Home Oximetry and Sleep Testing, Kansas City, Mo. For further information, contact [email protected].