2006 OPEN FORUM Abstracts
A Respiratory Care / Nursing Protocol for Monitoring and Treatment of Obstructive Sleep Apnea
Jim Hamilton RRT, William DePaso MD, Benjamin Gmelch, MD, Robert
Hase MS, RRT-NPS, Ellen Noel RN, MN, CNS, Karen Roetman, MD, Steven
Rupp, MD, Joe Streiff
RRT, Michael Westley,
MD, Virginia Mason Medical Center, Seattle, Washington.
Background: We identified a safety risk for patients predisposed to sleep-related oxygen desaturation through a combination of a literature review, data from our Medical Emergency Team (MET) calls, and several Patient Safety Alerts (PSAs-our facility's quality and safety management tool). We used our data to define a specific target population consisting of those patients who are both at risk for Obstructive Sleep Apnea (OSA) plus who are being treated with Patient-Controlled Analgesia (PCA) or Patient-Controlled Epidural Analgesia (PCEA). We then constructed a protocol for remote-monitoring of oxygen saturations that included a tiered response to address and prevent recurrent sleep-related desaturations.
Methods: Our protocol begins with the identification of those patients at risk for OSA who are also being treated with PCA/PCEA. Patients with a moderate or greater risk for sleep-related desaturations are monitored using an oximeter with remote-paging capability. Selection criteria for determining risk for OSA follow the American Society of Anesthesiologists 2005 Practice Guidelines for the Perioperative Management of Patients with Obstructive Sleep Apnea. Patients with diagnosed OSA are monitored and initially treated with CPAP or bilevel settings consistent with their home prescription; patients with OSA risk factors alone without diagnosis have monitoring alone until demonstrating sleep-related desaturations. A three-tiered response follows in escalating interventions until sleep-related desaturations are successfully prevented. Orders for all steps are combined into a single orderset within our Computerized Physician Order Entry (CPOE) which allows the bedside nurse and respiratory therapist to monitor and respond as necessary according to the protocol.
Results: The OSA protocol has defined our use of paging pulse oximetry as a safety net for patients at risk for sleep-related desaturations. We have refined our programming of the alarm paging function to remove nuisance pages by limiting paged alarms to low oxygen saturations and mechanical factors affecting the system's ability to detect SpO2. Our user-defined variables consist of a low saturation threshold of 85% with an alarm delay of 15 seconds.
Our OSA protocol has been in use for less than a year, and we are presently collecting outcome data. Our tangible and intangible goals consist of 1) eliminating MET calls instigated for sleep-related desaturations; 2) improving patient awareness of OSA by assisting affected patients to become diagnosed and treated; and 3) reinforcing treatment benefits for diagnosed but non-compliant OSA patients.