Purpose: To identify all inpatients at risk for having obstructive sleep apnea syndrome OSAS using t

1
Inpatient Screening for Obstructive Sleep Apnea
Syndrome Using the Adjusted Neck Circumference
Score
Christopher C. Wyckoff, MD, Anne E. ODonnell,
MD, FCCP, Eldrige Pineda, MD
MedStar-Georgetown University Hospital, Division
of Pulmonary, Critical Care, and Sleep Medicine
Georgetown University
Abstract
Results
Discussion
Purpose To identify all inpatients at risk for
having obstructive sleep apnea syndrome (OSAS)
using the adjusted neck circumference score and
evaluate whether screening inpatients for risk of
OSAS reduced in-hospital complications related to
OSAS. Methods This is an observational study
utilizing the adjusted neck circumference
screening score. In October 2006, Georgetown
University Hospital initiated a RN/RT-driven
protocol to screen adult inpatients for OSAS. If
the patients do not have a prior history of OSAS,
they are screened using the adjusted neck
circumference score neck circumference
(cmpoints), history of hypertension (4
points), history of snoring (3 points), history
of night-time choking or gasping (3 points). If
they have a preexisting history of OSAS or a
screening score 48, a purple ID band is placed
to identify them. The patient with a score48 is
then placed on a continuous pulse oximetry to
monitor for desaturation. Results To date, a
total of 491 patients with previously unknown
OSAS status have been screened for OSAS 354
(72.1) male, 137 (27.9) female, and average
score of 51 4.7. 391 (79.6) patients had a
score48. With regard to gender, male patients
had an average age of 55.1 12.9 years, and an
average score of 51.6 4.3 (85 score 48).
Female patients had an average age of 53.8
14.1, and an average score 49.4 5.3 (65.7
score48). Since this screening and banding have
been initiated, there have been no adverse events
associated with OSAS. Conclusion This
observational study shows that a high percentage
of adult inpatients are at high risk for
OSAS. Clinical Implications Given the large
number of adult inpatients at risk of OSAS,
increasing awareness and developing protocols for
who should undergo polysomnography are essential.

• MedStar-GUH has experienced 3 adverse events
  related to undiagnosed OSAS in the past 5 years
  (prior to the start of screening).
• There were no adverse events since the initiation
  of the screening.
• Most of the patients who were suspected to be at
  risk for OSAS were older and male.
• We suspect that there are more patients at risk
  for OSAS who have not been identified.
• Screening for inpatients is feasible but involves
  a multidisciplinary approach.
• The validity of ANCSS has not been evaluated.
• The validity of ANCSS as an effective screening
  tool will be evaluated with the concurrent sleep
  lab data collection.

There were 1162 patients screened from
October 2006 to August 2007. Figure 1 illustrates
the monthly OSAS screening rate. The algorithm
used to screen patient is shown in Figure 2. The
majority of screening took place in same day
surgery. Figure 3 illustrates the percentage
of patients screened with and without a prior
history of OSAS. There were 881 patients who had
no prior history of OSAS. Of these patients, 644
were males and 237 were females. The average age
for males was 56.1 13.6 and females was 54.6
14. The average ANCSS for males was 51.6 4.1,
and the average for females was 49.5 4.9. There
were 543 male patients and 147 female patients
who had a score above 48. Table 1 illustrates the
differences observed amongst all the patients
screened for OSAS.
Introduction
Figure 1 Hospital Monthly OSAS Screening rate
It is estimated that 2 of women and 4 of
men have OSAS. OSAS is defined by an
apnea-hypopnea index (AHI) 5 with associated
excessive daytime hypersomnolence. When looked
at individually, 24 of men and 9 of women, ages
30-60, have an AHI 5 and 16 of men and 22
women have daytime hypersomnolence1. Up to 26 of
adults (31 men and 21 women) are at high risk
for having OSAS2 so there needs to be an easy
screening score to identify these at risk
individuals. Flemons et al3 found that the
neck circumference, history of hypertension,
history of snoring, and history of night-time
choking or gasping were all independent
predictors of OSAS. The adjusted neck
circumference screening score (ANCSS) includes
these variables and is believed to be an
effective way of predicting the probability of an
individual having OSAS.4
Conclusions
Patient with known Sleep Apnea
Yes
No
This is an observational study. Screening is
simple, but needs a multidisciplinary approach.
Screening for OSAS can have a significant impact
on decreasing adverse events in the inpatient
setting, however, the use of the ANCSS as
screening tool for OSAS needs to be further
validated.
Conduct Screen
SMS Order for Respiratory Assessment Beeper
668-9026 Place purple Bracelet on Patient
Yes
Is Score Greater than 48 points
Possible Pulmonary med consult

Is patients home care equipment available for
use?
Does Patient utilize home care equipment?
No
Figure 3 Patients With or Without Prior History
of OSAS
Yes
Yes
No further action required
No
No
Are equipment settings known?
Place Patient into SA Protocol for
meds/monitoring. If Pulmonary consult obtained,
follow recommendations.
No
Yes
Methods
Get sleep report or pulmonary consult
References
In October 2006, an RN/RT-driven protocol was
initiated and all inpatients and same-day surgery
patients were screened using the ANCSS. The ANCSS
consists of four measures including neck
circumference (cmpoints), history of
hypertension (4 points), history of snoring (3
points), and history of night-time choking or
gasping (3 points). If the ANCSS was greater than
48, a purple band was placed on the patients and
selected patients had continuous pulse oximetry.
Data was collected through August 2007.
Equipment checked by Bio-Med. and set-up by RT.
Orders, equipment set-up by RT
Hospital equipment ordered and set-up.

• Young T et al. N Engl J Med 1993 328
  1230-1235
• Young T et al. Sleep 1997 20 705-706
• Flemons WW et al. Am J Respir Crit Care Med
  1994 150 1279-1285
• Flemons WW. N Engl J Med 2002 347 498-504

Place patient on Sleep Apnea Protocol
Figure 2 Algorithm for Screening Patients
Table 1 Differences in Patients with no Prior
Diagnosis of OSAS