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.