Reducing Risk/Liability

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Reducing Risk/Liability

• Perioperative Program Aspects of OSA
• Reducing Risk/Liability
• While Enhancing Revenues
• Peter Allen, BS, RRT-NPS-SDS, RST, RPSGT

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Conflicts of Interest

• Philips Respironics
• ResMed Corp
• DeVilbiss
• Fisher Paykel Healthcare
• MVAP
• Natus
• Main Line Health System

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Questions for Attendees

• How many Home Care
• How many Hospital RTs
• How many Hospital owned Sleep Center
• How many Private owned Sleep Center
• How many are directly involved with a
  Perioperative OSA Mangement Program

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Goals

• Brief Overview of Perioperative Aspects
• Review my Research of the Field
• Discussion of Attendees Experiences
• Case Histories
• Solutions
• One or Two Ideas for Each Attendee

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Learning Objectives

• Identification of the At Risk Patient
• Review of Adverse Outcomes
• Tools
• Why, Who, Where, What, How
• Supporting Perioperative Management
• Raising Questions for Discussion

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Why Perioperative Management?

• At Risk Population is Growing
• More Post-Op Complications
• Respiratory Failure
• Re-Intubation
• Unexpected ICU Admissions
• Increased PACU Time
• Increased Suffering/Liability/Cost

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Raising Questions

• How often do you see respiratory emergencies in
  the hospital?
• How many could OSA have been factor?
• Unexpected Deaths in the PACU
• Unexpected Deaths 24 hrs after Surgery
• Within one week of Surgery?

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Payment for Performance

• Value-Based Purchasing
• Rewards
• Disincentives
• Quality-Payment Alignment http//www.ahrq.gov/qual
  /qpayment.htm
• Implementation Timelines http//healthreform.kff.o
  rg/timeline.aspx

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American Society of Anesthesiologists

• 2006 Commissioned a Task Force that Identified
  the Importance of Pre-Screening surgery patients
  for the presence of Obstructive Sleep Apnea
  (OSA).
• Purpose Prevent Post-Surgical Respiratory Events
• Anesthesiology 2006 1041081-93

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2008 National Patient Safety Goals

• Proposed Goal 17 from Task Force
• Reduce Risk of Post-Operative Complications for
  Patients with Obstructive Sleep Apnea
• Organization screens potential OSA patients prior
  to surgical procedures involving centrally acting
  anesthetic and/or analgesic agents.

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Epidemiology of OSA

• It is estimated that 75 to 95 of patients with
  OSA are not yet diagnosed.
• Many who are diagnosed are not being treated
  effectively.
• Body Mass Indexgt30
• Estimates are that 26 of Adults are at Risk
• 80-Bariatric/60-Diabetic/40-CHF

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Pathophysiology of OSA

• Awake Airway Patent/Neuromuscular Compensation
• Sleep Onset
• Neuromuscular compensation is lost
• Airway Collapses
• Apnea Occurs
• Hypoxia Hypercapnia ensue
• Ventilatory effort increases
• Arousal from sleep
• Pharyngeal muscle tone increases
• Patent airway restored
• Hypoxia and Hypercapnia improved by
  hyperventilation

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OSA Increasing

• Obesity is increasing at epidemic proportions
  which is only adding to the problem of increasing
  numbers of at risk patients presenting for
  surgery.
• Obesity Maps

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Associated OSA Conditions

• Obesity Hypertension
• Depression Coronary Artery Disease
• Accidents Arrhythmias
• Diabetes Left side heart enlargement
• GERD LV Dysfunction
• Stroke Congestive Heart
  Failure(CHF)

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Anesthesia Concerns with OSA

• OSA patients are more susceptible to airway
  collapse without anesthesia.
• OSA can affect all three phases of perioperative
  period.
• Anesthesiologists role in identification of the
  at risk OSA patient.
• Upper airway dilator muscles impaired.
• Effect may last for hours
• Eikermann, et. Al., AmJRespirCritCareMed 2007
  1759-15

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Anesthesia

• Impairs airway patency
• Increases difficulty of intubation
• Brain response less effective
• Narcotics decrease sensitivity to CO2
• Respiratory drive/rate depressed
• Anesthetic gases almost eliminate hypoxic drive
  in most all patients.

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Anesthesia

• Upper airway muscle tone reduced with opiates,
  sedatives and volatile agents.
• Perpheral control of O2 inhibited
• Recovery rooms
• Local and regional nerve block options
• Malampatti Scores 1-4
• Patients encouraged to bring PAP

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Anesthesia

• Unexpected Risks during Administration of
  Conscious Sedation Previously Undiagnosed
  Obstructive Sleep Apnea
• Annals of Internal Medicine, 2003139 707-708
• Pressman, et. Al.

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Case Reports 1of 6

• Male 65 years of age-Radical prostatectomy
• History showed Positive OSA Profile
• Not diagnosed/treated
• Morphine 5 mg, epidural
• 8 hours later found unresponsive
• Apneic with Cyanosis
• Patient recovered

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Case Report 2 of 6

• Male 38 years of age-Emergent mastoidectomy
• History of loud snoring
• Diagnosed with OSA, but never treated
• Upon extubation patient airway collapses
• Reintubated

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Case Report 3 of 6

• Male 41 years of age-Orthopedic surgery
• Diagnosed, but not treated
• Epidural opiods
• Post-op day 2 found unresponsive
• Irregular respiratory pattern
• Cardiac arrest lead to death

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Case Report 4 of 6

• Female 42 years of age-Laproscopic surgery
• Diagnosed with OSA, but not treated
• Post-op prolonged heart block during sleep

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Case Report 5 of 6

• Obese male, 42 years of age-Surgery
• Diagnosed with OSA, not treated
• IM Morphine
• Cardiac arrest
• Severe hypoxia followed by cerebral silence

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Case Report 6 of 6

• 101 OSA patients and 101 matched controls
• Hip knee surgery
• OSA patients diagnosis prior to or after surgery
• Controls did not get PSG-????
• Post-op complications greater in OSA patients
• Hospital reported longer stays for OSA group
• Hospital reported more ICU transfers/OSA pts.

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OSA Diagnosis

• Clinical examination(history and physicial
  examination) carries a diagnostic sensitivity and
  specificity of only 50 to 60 even when performed
  by experienced sleep physicians
• Clinics oF Chest Med 1998 191-19
• If it walks like, talks like, looks like a .
• Its OSA

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Preoperative screening for OSA

• Stop Bang Questionaire with HP
• Preoperative diagnosis
• Referral to sleep disorder center
• Preoperative treatment if possible
• PAP Treatment prior to surgery
• PAP Treatment documented prior to surgery

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Identifying the Problem
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Stop-Bang Stop-Bang Stop-Bang

• 1. Do you Snore loudly?
• 2. Do you often feel Tired during the daytime?
• 3. Has anyone Observed you stop breathing during
  your sleep?
• 4. Do you have or are you being treated for high
  blood Pressure?
  Stop
• 5. BMI more than 35 kg/m ?
• 6. Age over 50?
• 7. Neck circumference greater than 40cm?
• 8. Gender male?
  Bang
• High Risk of OSAYes to 3 or more items
• Low Risk of OSA Yes to less than 3 items

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American Society of AnesthesiologyRecommendations

• Anesthesiologists need to work with Surgeons
• Develop Protocols
• Get suspected OSA patients diagnosed and treated
  prior to surgery whenever possible
• If diagnosis of OSA is made on the day of the
  surgery, then patient and family needs to be
  informed of the potential implications of OSA on
  the perioperative course.

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ASA Recommendations Continued

• Be prepared for difficult intubation
• Choice of anesthetic technique
• Oximetry and end-tidal CO2 monitoring
• Full reversal of neuromuscular blocking agents
• Consider non-supine extubation w awake patient
• General anesthesia preferable to deep sedation
• Spinal epidural considerations vs IV
• Use of opioids vs regional anesthesia
• Discharge delay a consideration

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Perioperative Program Awareness

• Contact these areas all at the same time
• All medical staff members
• Grand Rounds Presentations
• Lunch and Learn AMA CEUs
• Community Outreach Programs
• Allied Healthcare Staff
• Home Care Companies
• Manufacturers
• Implement Outcome Tracking Protocols

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Perioperative Management of OSA, Budget

• Questions to Ask
• What is it going to cost to implement or to
  increase awareness?
• What will it cost if we do not implement or
  promote?

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Hospital Implications

• At risk patients not served
• Safety
• Hospital revenue
• Hospital reputation
• Hospital recognition
• Physician revenues
• Surgical Risk Liability and Schedules

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HME Considerations

• Perioperative program will
• Drive PAP business higher
• Drive O2 business higher
• Increase your referral base
• Improved relations with area medical and
  surgi-centers

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Sleep Disorder Centers

• Additional Revenue
• Increase Referral Base
• Reinforces the fact that to survive sleep
  disorder centers need to diversify/change their
  sales and marketing focus on more complex
  patients and new opportunities.

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Working Together

• Primary Care Physicians
• Surgeons
• Anesthesiologists
• Allied Health, Nursing, Respiratory Care
• Sleep Disorder Centers
• Home Care Companies
• Hospital Administration

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Helpful Organizations

• American Society of Anesthesiology
• ASA
• Society of Anesthesia Sleep Medicine
• SASM
• American College of Chest Physicians
• ACCP
• American Academy of Sleep Medicine
• AASM

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Summary

• Patients with OSA
• Make up a significant portion of the surgical
  population and will only increase as obesity
  trends move upward.
• Most are not identified before surgery
• Have an increased risk for perioperative
  complications
• Can be screened diagnosed and treated to manage
  perioperatively to reduce risks.
• Programs can be implemented to identify and treat
  these patients without substantial increases in
  costs, resulting in risk reduction, improved
  patient safety and better outcomes.

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Sources

• Stop Bang Questionaire, Anesthesiology, V 108, No
  5 May Chung, et al.
• Anesthesiolgy News Guide to Airway
  mangement-Obstructive Sleep Apnea Anesthesia, and
  Ambulatory Surgery, Bishop, et. al
• Perioperative Screening for and Mangement of
  Patients with Obstructive sleep Apnea-Beth Israel
  Deaconess Medical Center, Boston, MA, Sundar, et.
  al
• Avoiding adverse outcomes in patients with
  obstructive sleep apnea(OSA) development and
  implementation of a perioperative OSA protocol,
  Bolde, et. al.
• Postoperative Complications in Patients With
  Obstructive Sleep Apnea, CHEST 2012 141436-44,
  Kaw, et. Al.
• Obstructive Sleep Apnea Syndrome and
  Perioperative Complications A Systematic Review
  of the Literature, Journal of Clinical Medicine,
  Vol. 8, NO. 2 2012, Vasu, et. Al
• Postoperative Complications in Patients with
  Obstructive Sleep Apnea Syndrome Undergoing Hip
  or Knee Replacement A Case-Control Study 2001
  Mayo Foundation, Mayo Clin Proc. 200176897-905
  Gupta, et.al.

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petersleep_at_comcast.net