Wake Forest Baptist Medical Center’s pilot program identifies at-risk patients using a questionnaire, then same-day sleep consultations allow for intervention before, during, and after surgery.

By Dillon Stickle

A pilot study suggests that screening preoperative patients for obstructive sleep apnea (OSA) in a large tertiary care facility allows for early intervention and has the potential to reduce surgical complications such as respiratory distress and mortality. The study is published in the October 2017 abstract supplement for the journal CHEST and will be presented at CHEST 2017 on November 1. Conducted at Wake Forest Baptist Medical Center, the study also reports that a large percentage of surgeons and anesthesiologists are not properly identifying at-risk and high-risk patients during preoperative evaluations.

“A lot of times [the patients] are just entering into our system through the perioperative assessment clinic,” says Daniel Forest, MD, medical director of the surgical navigation center (SNC) and perioperative assessment clinic at Wake Forest, and an author of the abstract. “The ‘SNC’ was born out of our desire for quality improvement in coordination across our entire continuum.”

Sarah Ellen Stephens, MD, sleep medicine fellow at Wake Forest and an author of the abstract, adds, “Identifying these patients who are at risk for perioperative complications early on might allow us to intervene in the surgical setting. The concept behind this pilot study was to find the best way to identify that population.”

That concept has shown positive initial results. Patients were first screened with the “DOISNORE50,” which the team described in a previous abstract as a self-administered questionnaire that identifies preoperative patients at risk for major postoperative problems and polysomnography-confirmed sleep apnea. The 9-item questionnaire was used to stratify patients into 3 groups: low risk, at risk, and high risk. All screened patients were included in a sleep registry, and importantly, at-risk patients were given an “OSA precautions” wristband to wear on surgery day while high-risk patients were referred for same-day sleep consultations before surgery and received recommendations for perioperative PAP therapy and appropriate follow-up.

“We also wanted to develop a closed-loop system where those patients are then followed on an outpatient basis and are easily identified as being at risk for complications,” says Stephens. “So every time they come to the hospital, they’ll be listed under that population, giving us the opportunity to act accordingly.”

“In our last study, we saw that a large percentage of patients with untreated OSA did have major hospital events,” Stephens adds. “We hope that by identifying these at-risk patients, we could reduce that number and help them get on a safer course following surgery.”

Andrew Namen, MD, clinical operations director of sleep at Wake Forest, says, “This is now built into our hospital system. Now, going forward, this will always be a part of the surgical experience for any patient who comes here.”

The pilot can provide an example for other institutions that want to improve quality of care for their surgical patients, Stephens says. “We have had success implementing this process—identifying patients early and getting them diagnosed and treated while they’re in the hospital,” she says. “It’s something that other institutions can absolutely implement on their own.”

Overall, this study is meant to provide beneficial information to any institution that needs answers. Forest says, “What we are seeing [in the results] is giving a lot of providers the answers to what is done next, and what interventions are being put in place for patient safety to get them through the perioperative period with reduced complications.”

Dillon Stickle is associate editor for Sleep Review.

References

1. Stephens SE, Ahmad Z, Younger K, Foard K, et al. Implementation of a Systematic Approach to Screening for OSA in a Surgical Navigation Center (SNC). CHEST Supplement. October 2017;152(4):A1073.
2. Namen AM, Forest D, Chatterjee A, Ahmad Z, et al. DO I Snore 50: A Preoperative Sleep Questionnaire Derived from Hospital Complications. Am J Resp Crit Care Med. 2016;193:A2512.