Identify whom you can serve. There is no scientific foundation to support rejecting all sleep apnea patients from ASCs. Yet, this position commonly governs many ASCs’ practices. In reality, as with any normally distributed condition, mild sleep apnea is the dominant form in the affected population. The major risk comes from "surprises" related to 80 percent of sleep apnea patients that are undiagnosed or unmanaged. A key component in your quality program is to quantify the risk and let patients traverse the appropriate pathway, instead of barring all apnea patients from enjoying the benefits of your ASC.
The first step in a successful quality program is the ability to reliably screen patients for the risk of sleep apnea. Once fully informed, anesthesiologists can be prepared to manage many sleep apnea patients at your facility. But identification is only half of the solution.
The essential second step is to arm your center with the tools needed to safely manage the risks of sleep apnea patients as they transition to the recovery area and eventually home to the care of their family member(s) and primary healthcare provider(s). Every ASC should consider seeking professional assistance to develop a complete management program for their ASC. Peri-surgical sleep apnea management programs exist.2 Reinventing the wheel can be costly, time consuming, and potentially ineffective.
Implementing a program in your center
Screening for risk. Many ASCs use some form of screening to alert the OR team to sleep apnea risks. Examples include the Epworth Sleepiness Scale, the Berlin Questionnaire and the STOP-BANG Questionnaire. A search using your favorite Web engine will teach you more about these three instruments; each enjoys relative strengths and weaknesses. For example, the Epworth is a rapidly delivered scale that is easy to score with a long history of peer-review findings. However, it is overly sensitive, and positive scores may reflect myriad reasons other than sleep apnea (most medical residents’ schedules, for example). In contrast, the Berlin is more specific to sleep apnea; however, its complicated scoring rules can limit its deployment in many surgical screening environments. Recently, a new instrument, the STOP-BANG, has emerged: Its eight yes-or-no questions are used to determine a risk profile simply by adding the number of "yes" answers. Intuitively appealing and simple to administer, the STOP-BANG is based on limited published data at this point, but clearly worthy of strong consideration for adoption as the initial sleep apnea screening.3
Managing the at-risk patient. A key element of step two is to provide a simple pathway to: (a) convey the patient’s risk status, (b) obtain diagnostic confirmation and (c) initiate an on-going treatment plan for managing the potential risk of a sleep apnea patient. The execution of step two varies widely across surgical centers. Obtaining diagnostic confirmation cleared a substantial hurdle this year when CMS issued a revised national coverage determination that approved sleep treatment reimbursement based on results from unattended sleep tests.4 Prior practice required that diagnostic studies be performed in a sleep center. The use of at-home testing has dramatically simplified the process of peri-surgical management for sleep apnea patients. When your ASC is working with the right partner, a wide range of treatments can be rapidly deployed to manage sleep apnea patients.
Data to guide decisions. There is a need for academic institutions to provide more systematic data to govern peri-surgical decisions surrounding the management of sleep apnea risk. One such forward-thinking program is underway at the Virginia Commonwealth University Medical Center (VCUMC) under the direction of Lisa Price Stevens, MD, medical director of the pre-surgical screening clinic. VCUMC screens surgical patients via a digital tablet designed to collect patient data and simplify the clinical care process for peri-surgical sleep apnea management. The technology platform alerts the surgical team and primary healthcare providers on the patient status, while in parallel supporting diagnostic confirmation and treatment initiation services. Finally, the employed service lets Dr. Stevens monitor patient outcomes for at risk patients. The sleep apnea management service described is fully reimbursed by most carriers – it does not impose costs on the institution nor delay surgery or burden OR staff.
Planned studies by Dr. Stevens and others will soon provide systematic data to further govern the peri-surgical management of sleep apnea patients.
Dr. Burton (sburton@ionhealthcare.com) is the president and founder of Ion Healthcare and a diplomate of the American Board of Sleep Medicine. Learn more about Ion Healthcare and its sleep apnea management services for ASCs.
References:
1. Practice Guidelines for the Perioperative Management of Patients with Obstructive Sleep Apnea. Anesthesiology 2006; 104:1081–93.
2. Managing Sleep Apnea in Your Surgical Center: An Instructional Overview. ASC Annual Meeting Presentation 2008; 1:1-26.
3. Chung et al. STOP Questionnaire – A Tool to Screen Patients for Obstructive Sleep Apnea. Anesthesiology 2008; 108:812–21.
4. Coverage Decision on Continuous Positive Airway Pressure (CPAP) Therapy for Obstructive Sleep Apnea (OSA) (CAG-00093R2).
