Creating a Safer Perioperative Environment With an Obstructive Sleep Apnea Screening Tool

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1 Creating a Safer Perioperative Environment With an Obstructive Sleep Apnea Screening Tool Linda Lakdawala, DNP, RN, CPAN Obstructive sleep apnea (OSA) is a common condition that increases the risk of complications for patients undergoing sedation and/or general anesthesia. The purpose of this quality improvement project was to promote evidence-based practice for nurses to screen patients with OSA in the perioperative setting. A step-by-step team process was implemented using the Iowa Model of Evidence-Based Practice in a shared leadership environment at an acute care facility to educate staff and evaluate the practice change. A pilot project reviewed patient data pre- and postimplementation of an OSA screening tool, which revealed evidence of safer patient care. As a result of incorporating an OSA assessment, patient advocacy and a safer perioperative environment was created. Keywords: obstructive sleep apnea, screening tool, perioperative, evidence-based practice, shared leadership, best practice. Ó 2011 by American Society of PeriAnesthesia Nurses OBSTRUCTIVE SLEEP APNEA (OSA) is a syndrome that increases the risk of complications to patients requiring general anesthesia, sedation, or intravenous (IV) analgesia/opioids. To create a safer perioperative environment for the OSA patient, the focus of this quality improvement project was to promote best practice for nurses when screening patients with OSA. This project implemented an EBP change to validate the use of an OSA screening tool within a shared leadership environment. Background and Significance OSA is a common condition caused by a decrease in upper airway size and patency during sleep. 1 Individuals with OSA are aroused repeatedly from deep sleep by hypoxemia and hypercapnia, which occur during episodes of apnea. These arousal LindaLakdawala,DNP,RN,CPAN,isaMedicalSurgicalAdvanced Practice Nurse, UPMC Shadyside Hospital, Pittsburgh, PA. Address correspondence to Linda Lakdawala, Medical Surgical Advanced Practice Nurse, UPMC Shadyside Hospital, 5230 Centre Avenue, Pittsburgh, PA 15232; address: lakdawalald@upmc.edu. Ó 2011 by American Society of PeriAnesthesia Nurses /$36.00 doi: /j.jopan events are protective because they permit breathing to resume. Residual effects of general anesthesia, opioid analgesics, and sedative agents may blunt the arousal cycle mechanism, resulting in a potential for respiratory arrest. 2 The term apnea is defined as a cessation of airflow for 10 seconds or longer. Hypopnea is a decrease in airflow lasting more than 10 seconds, with a 30% reduction in airflow and at least a 4% oxygen desaturation. The Apnea Hypopnea Index (AHI) score is determinedduringasleepstudyandisdefinedasthenumber of apnea and hypopnea episodes that occur per hour of sleep. This score reflects the severity of OSA. An AHI of 5 to 14 events per hour is considered mild, 15 to 30 events is considered moderate, and more than 30 events per hour is considered severe. 3 Much of the preoperative assessment is focused on the patient s heart and lung history, but little emphasis is placed on sleep disorders. Patients with an unremarkable medical history have developed unexpected postoperative respiratory complications. Considering that an estimated 2% to 26% of the U.S. adult population is afflicted with OSA and 80% to 90% are unaware that they have it or have not Journal of PeriAnesthesia Nursing, Vol 26, No 1 (February), 2011: pp

2 16 LINDA LAKDAWALA yet been diagnosed, it is important that the patient be screened for OSA preoperatively. 3-5 The preoperative interview typically includes a question about sleep apnea; however, patients often respond by saying that they don t have a sleeping problem. The nurse should be aware that many patients do not fully understand the true meaning of OSA. Additional questions should be added to assess for OSA. It is important for nurses to recognize that not all OSA patients are male, obese, sleepy, snoring, and middle-aged. 6 OSA patients who are exposed to anesthesia and/or opioid analgesia are at a vulnerable state, and patient safety is a priority. The first 24 hours after surgery is considered the most critical phase, although complications could occur up to five days post-procedure. 7 Opioid administration should be monitored with extreme caution in patients with OSA. Policies and guidelines for assessment are helpful tools to aid in identification of the presence of OSA. 7 The Pennsylvania Patient Safety Authority reported more than 250 cases from acute care facilities and ambulatory surgery centers in which OSA was a factor in a poor patient outcome, sentinel events noting respiratory arrests. 6 These facilities did not have a specific guideline or policy to assess the patient for OSA. The development of standards to assess and care for the sleep apnea patient was supported by the Joint Commission (TJC) as a Direct Impact issue. 8,9 Recommendations from TJC included using a sleep apnea screening tool for the perioperative area. Evidence Used for the Practice Change There is no universal approach to diagnosing OSA, which continues to be a problem today. Most patients with OSA are undiagnosed; symptomatic patients can be assessed for OSA in a sleep laboratory. The gold standard for sleep apnea diagnosis is a sleep laboratory study called polysomnography, which requires an overnight analysis. 10 The method is time consuming and often the patient does not follow through with the procedure. A simpler method, but not proven as the gold standard in diagnosis, is the apnea risk evaluation system (ARES) unicorder. The device is operated through an internal computer chip and stores continuous data of the patient s oxygen saturation, pulse rate, airflow, head position, and snoring decibel level. 10 Polysomnography and the ARES unicorder tests must be preplanned, making the diagnosis of OSA time-consuming and inconvenient. Comparison of Clinical Guidelines Clinical guidelines for assessing and managing perioperative OSA susceptible patients have been designed by scholars and task force members. Such tools are significant and imperative for discovery of the undiagnosed OSA patient. Currently, no screening tool has been validated for preoperative assessment. 7 In 2008, Dr. F. Chung published a simple and effective screening tool. 11 The STOP questionnaire was given to 2,467 patients in the preoperative clinics of Toronto Western Hospital and Mount Sinai Hospital, Ontario, Canada. The four questions were related to Snoring, Tiredness during the daytime, Observed apnea, and high blood Pressure (STOP). For validation, the score from the STOP questionnaire was evaluated versus the apnea-hypopnea index (AHI) from monitored polysomnography. When combined with Body mass index (BMI), age, neck circumference, and gender (Bang), the STOP questionnaire sensitivities were increased from 65.6% to 83.6% and 79.5% to 100%. When incorporating Bang into the STOP scoring (STOP-Bang), the sensitivity significantly increased (Table 1). 11 Chung et al 11 have conducted systematic reviews to evaluate and compare additional OSA screening tools since In 2009, The STOP-Bang scoring model was compared with the Berlin screening tool (Table 2) and the American Society of Anesthesiologists (ASA) screening tool (Table 3). 12 The Berlin questionnaire is a widely used OSA screening tool, validated in studies in various populations including sleep clinic patients, and the general and surgical populations. 12 The Berlin tool consists of 10 questions organized into three categories (Table 2). The Epworth Sleepiness Scale (ESS) was used in one study to clinically screen for behavioral morbidity associated with OSA (Table 4). 13,14 The purpose of the study was to assess the sensitivity of the ESS to diagnose OSA. Daytime sleepiness occurred in one of five individuals and was not the single determining factor of OSA. 13,14

3 OSA SCREENING TOOL FOR A SAFER PERIOPERATIVE ENVIRONMENT 17 Table 1. The STOP-Bang OSA Screening Tool Assessment/Follow-Up With Anesthesia Answer Yes or No to each question and place an X in the corresponding column Questions Yes No 1. Snoring: Do you snore loudly (louder than talking or loud enough to be heard through closed doors?) 2. Tired: Do you often feel tired, fatigued, or sleepy during the daytime? 3. Observed: Has anyone observed you stop breathing during your sleep? 4. Blood Pressure: Do you have or are you being treated for high blood pressure? 5. Height: ft in Weight: lbs BMI Calculator BMI.35? 6. Age:.50 years old? 7. Neck Circumference:.17 in or 40 cm? 8. Gender: Male gender Total for Yes: The patient is at high risk for OSA if they answered yes to three or more items. The patient is at low risk for OSA if they answered yes to less than three items. Alert Anesthesia if patient is at high risk: Yes: No: Anesthesiologist will determine proper postoperative guidelines. Anesthesiologist Signature: Data used with permission from references 7 and 11. The American Sleep Apnea Association has developed a Snore Score (Table 5). Six questions are asked of the patient. If the patient answers yes to one or more of the questions, then he or she is at a higher risk for having sleep apnea. 15 The Pennsylvania Safety Authority web site has developed a sample tool to screen for OSA. The site states, Itmayhelpidentifyat-riskpatientsduringthepreoperative period. 5 Nine yes-or-no questions comprise the screening tool. If the patient answers yes to any of the questions, the nurse should alert Anesthesia. 6 The most complete study of screening tools was a meta-analysis compiled by the ASA Task Force for the perioperative management of patients with OSA. The guidelines are recommendations that were systematically developed to assist the practitioner and patient in making decisions about health care. 7 The patient is assessed for predisposing physical characteristics. A history is obtained by asking questions of apparent airway obstruction during sleep, and questions about somnolence follow. In addition, a scoring system was allocated in four areas to estimate the perioperative risk (Table 3). 7 Critical Appraisal of Evidence To screen patients for a disease with an important health impact, a high sensitivity with an acceptable specificity is a basic requirement for a screening tool. 11 An expert panel compiled of the chief anesthesiologist, the author, and the risk management board chose the STOP-Bang tool for use in our facility (Table 1). Chung compiled the screening tool using theasataskforceguidelines 7 for assessment and treatment of perioperative patients with OSA. The STOP-Bang scoring model results supported patients undergoing anesthesia, whereas the ESS, the Snore Score, and the Pennsylvania Safety Authority assessment generalized questions assessing for sleepiness. The Berlin questionnaire is 89% predictive of OSA when followed by a polysomnography; however, it has been used more for assessing the general population. 12 The number of questions and the difficult scoring system make the Berlin system less userfriendly. The STOP-Bang scoring model demonstrated a positive predictive value with 95% confidence interval. 11 A study of screening tools by Chung, 3,12 in which STOP-Bang, the Berlin questionnaire, and the ASA questionnaire were included, could not come to a definite conclusion regarding the most accurate screening tool. However, of the screening tools reviewed, the STOP-Bang scoring model received the highest consistency with regard to criteria for screening tools: feasibility, accuracy, and generalizability. 12 The acronym STOP (Snoring, Tiredness, Observed apnea, high blood Pressure) is easy to remember, user-friendly, accurate, and can be used for the surgical patient.

4 18 LINDA LAKDAWALA Table 2. Berlin Questionnaire Questions Answers Scoring Category 1 1. Do you snore? 2. If yes, how loud is it? 3. How often do you snore? 4. Has snoring bothered others? 5. Has anyone noticed that you quit breathing during sleep? Category 2 6. How often do you feel tired or fatigued after sleep? 7. During your waking time, do you feel tired, fatigued, or not up to par? 8. Have you ever nodded off or fallen asleep while driving? 9. If yes, how often does this occur? Category Do you have high blood pressure? OSA, obstructive sleep apnea. Data used with permission from reference 12. Items 1, 4, 8, 10: Yes (1) No (0) Don t know (0) Item 2: Slight louder than breathing (0) As loud as talking (0) Louder than talking (1) Very loud heard in adjacent rooms (1) Item 5, 6, 7, 9: Nearly every day (1) 3 4 times a week (1) 1 2 times a week (0) 1 2 times a month (0) Never or nearly never (0) Category 1: positive: Sum #2 Category 2: positive: Sum #2 Category 3: positive item 10 is yes or if BMI.30 kg/m 2 High risk of OSA: 2 or more categories scored as positive OSA Project Plan The Iowa Model of Evidence-Based Practice was used as a framework to facilitate the OSA project. Evidence-based practice models have been developed to move nurses into an organized practice change. 16 The relevance of a model for an evidencebased project served as an algorithm or an outline to incorporate the necessary steps. By following a model, one can enhance organization and create a communication process with the EBP team. The model is a team approach to organize and collaborate on decisions for enhanced outcomes. Unique to the Iowa Model is the focus on triggers 16 that initiate the project. A gap in safe care of the OSA patient triggered the practice change. The Iowa Model is a lengthy but detailed process that is helpful when implementing a practice change in a large organization (Table 6). Shared Leadership The facility has a shared leadership approach to patient-centered care for all evidence-based projects. Shared leadership welcomes nurses to guide projects for problem-solving practice change. The nurses research and share information through five councils professional practice, quality, research, informatics, and administration to update patient care. 17 Questions regarding the planning and organization of the project were discussed with the various council members. Often, nurses are dismayed to conduct projects because of a lack of support or guidance. Shared leadership was an effective brainstorming approach to assist the author for quality review, information technology support, and networking with colleagues. Multiple departments were consulted to achieve success throughout the project. The anesthesia and respiratory departments, risk manager, quality

5 OSA SCREENING TOOL FOR A SAFER PERIOPERATIVE ENVIRONMENT 19 Table 3. The American Society of Anesthesiologists Checklist Questions All Items: Yes/No Answers Scoring Category 1: Predisposing Physical Characteristics 1. BMI #35 kg/m 2 2. Neck circumference.43 cm/17 in (men) or 40 cm/16 in (women) 3. Craniofacial abnormalities affecting the airway 4. Anatomical nasal obstruction 5. Tonsils nearly touching or touching the midline Category 2: History of Apparent Airway Obstruction 1. Snoring (loud enough to be heard through closed door) 2. Frequent snoring 3. Observed pauses in breathing during sleep 4. Awakens from sleep with choking sensation 5. Frequent arousals from sleep Category 3: Somnolence 1. Frequent somnolence or fatigue despite adequate sleep 2. Falls asleep easily in a nonstimulating environment 3. Parent or teacher comments child appears sleepy during the day, is easily distracted, is overly aggressive, or has difficulty concentrating* 4. Child often difficult to arouse at usual awakening time* Reprinted with permission from reference 7, 14. *Refers to pediatric patients. If # items in Category 1 are positive, Category 1 is positive. If # items in Category 2 are positive, Category 2 is positive. If # 1 items in Category 3 are positive, Category 3 is positive. High risk of OSA: 2 or more categories scored as positive. Low risk of OSA: 1 or no categories scored as positive. director, critical care advanced practice nurse, and members of the risk management council (critical care physicians, chief nursing officer, attorneys) reviewed and approved the process to promote patient advocacy for the OSA practice change. Pilot Project The preoperative nurses were taught to use the STOP-Bang scoring model through a one-hour educational session. A lecture using a PowerPoint (Microsoft, Inc, Redmond, WA) slide show included information about OSA diagnosis, risks, and the process to complete and carry out the screening tool. The staff partnered and completed a STOP-Bang screening tool on each other for understanding. A written quiz and evaluation was completed to ensure competency. Education was also conducted with the PACU staff and orthopedic unit regarding the practice change. All nurses received information and validation for the STOP-Bang scoring model. The nurses in the orthopedic unit were made aware of the responsibilities of monitoring the OSA patient postoperatively with a continuous pulse oximeter, telemetry cardiac monitoring for at least 24 hours, and until intravenous (IV) opioids were discontinued. Staff would also educate the high-risk OSA patients to watch educational OSA material on the

6 20 LINDA LAKDAWALA Table 4. The Epworth Sleepiness Scale Use the scale to choose the most appropriate number for each situation: 0 5 would never doze or sleep 1 5 slight chance of dozing or sleeping 2 5 moderate chance of dozing or sleeping 3 5 high chance if dozing or sleeping Situation Chance of Dozing or Sleeping Sitting and reading Watching TV Sitting inactive in a public place Being a passenger in a motor vehicle for an hour or more Lying down in the afternoon Sitting and talking to someone Sitting quietly after lunch (no alcohol) Stopped for a few minutes in traffic while driving Total score (add up the scores) The Epworth Sleepiness Scale is used to determine the level of daytime sleepiness. A score of 10 or more is considered sleepy. A score of 18 or more is very sleepy. If you score 10 or more on this test, you should consider whether you are obtaining adequate sleep, need to improve your sleep hygiene, and/or need to see a sleep specialist. 13,14 Data used with permission from references 13, 14. hospital educational channel and follow-up with their medical physicians to obtain a formal sleep study after discharge from the hospital. A one-month pilot for a smaller surgical orthopedic population was completed. The STOP-Bang tool was designed as a Print on Demand electronic health record form. The preoperative nurse printed a hard copy and completed the form during the preoperative assessment. Patients meeting the OSA high-risk criteria (scoring $3 on STOP-Bang) were labeled as high risk for OSA (Table 1). An interview with the anesthesia provider and the patient finalized the perioperative plan of care. The anesthesia provider can elect to complete an electronic OSA postoperative order set for the patient to be monitored with a continuous pulse oximeter and a portable cardiac monitor while receiving IV opioids (Table 7). The physician order is located on the PACU postoperative patient order set. In addition, an OSA green label was displayed on the front of the patient s chart. The green label was the only method used at our facility to designate the care for an OSA patient before the screening assessment. The process had not been a formal one. The labels were selectively used for patients formally diagnosed with OSA or if the nurse/physician noted postoperative episodes of apnea. Evaluation Method The evaluation process determined quality screening outcomes for the perioperative patient and proper implementation of the OSA scoring model. There were four areas of evaluation. First, the nursing staff completed a learning competency to Table 5. American Sleep Apnea Association Snore Score Are you a loud and/or a regular snorer? Yes No Have you ever been observed to gasp or stop breathing during your sleep? Yes No Do you feel tired or groggy upon awakening, or do you awaken with a headache? Yes No Are you often tired or fatigued during the wake time hours? Yes No Do you fall asleep sitting, reading, watching TV, or driving? Yes No Do you often have problems with memory or concentration? Yes No If you answered yes to one or more of these questions, you are at a higher risk for having obstructive sleep apnea. 15 Data used with permission from reference 15.

7 OSA SCREENING TOOL FOR A SAFER PERIOPERATIVE ENVIRONMENT 21 Table 6. Algorithm of the Iowa Model* for Obstructive Sleep Apnea (OSA) Screening Tool Emphasis/Stages Algorithm of the Iowa Model for Obstructive Sleep Apnea (OSA) Screening Tool Emphasis/Stages 1. Trigger Problem or new knowledge: The Pennsylvania (PA) Safety Authority and The Joint Commission (TJC) noted the need for safer assessment and care of the OSA surgical patient. 2. Organizational priority: Current PA Safety Authority and TJC recommendations were prioritized by the facility to implement an OSA screening tool. 3. Team formation: Expert team included doctorate in nursing student, chief anesthesiologist, quality director, critical care advanced practice nurse, risk management nurse. 4. Evidence gathered: The databases used for searching the literature were Ovid and the Cumulative Index of Nursing and Allied Health Literature (CINAHL). National Guidelines Clearinghouse Database, supported by The Agency for Healthcare Research and Quality (AHRQ) was used to search for clinical guidelines Research base critiqued and synthesized: The literature review was shared with the team of experts. Accuracy, minimal bias, and ease of use were key elements when choosing a screening tool for OSA. 6. Sufficient: Findings were presented to the risk management board. A unanimous decision chose the STOP-Bang scoring model. 7. Pilot change: A one-month pilot project was conducted on the orthopaedic surgical population, chosen for the suspected higher incidence of OSA patients and IV postoperative pain medication. The Health System Total Quality Council approved the evaluation method as an institutional review board (IRB) exempt project. 8. Decision: As a result of the pilot, the risk management board approved to use STOP-Bang for all surgical patients (Table 1). 9. Widespread implementation with continual monitoring of outcomes: Education sessions for nursing and anesthesia providers will be ongoing in the perioperative area. Data will be recorded to further assess for quality outcomes: pulse oximetry readings, 90%, naloxone use, respiratory or cardiac arrests. 10. Dissemination of results: Patients and health care staff are educated according to EBP outcomes of the pilot project. All perioperative staff must follow the OSA screening protocol and follow through. OSA, obstructive sleep apnea; EBP, evidence-based practice. *Data used with permission from the University of Iowa Hospitals and Clinics. 16 provide validation of understanding and proper use of the screening tool. Second, data were compared for one month before and after STOP-Bang only using the green label assessment method (Fig 1). Third, critical events were noted for one month before and after use of STOP-Bang (Table 8). The variables used were respiratory or cardiac arrests (condition A), near arrest (condition C), naloxone (opioid reversal agent) administration, and pulse oximeter readings, 90%. Fourth, the preoperative nursing staff completed a Likert scale evaluation to assess for understanding and ease of Table 7. Postoperative Physician Order Set Continuous pulse oximeter and cardiac monitor for 24 hours postoperative or until intravenous opioids are discontinued. Consult respiratory therapy postoperative oxygen requirements: maintain oxygen saturation.90%. Consider CPAP, BiPAP. Notify physician if unable to maintain SaO 2.90%. Consult medical physician regarding follow-up for formal sleep study. Postoperative nurse OSA discharge education protocol: OSA patient education channel, instruct need for formal sleep study as prescribed. CPAP, continuous positive airway pressure; BiPAP, bilateral positive airway pressure; SaO 2, oxygen saturation in the blood; OSA, obstructive sleep apnea. The OSA order is located in the PACU postoperative order set in the electronic health record. Data used with permission from reference 7.

8 22 LINDA LAKDAWALA Number of Patients Labeled As OSA use of the STOP-Bang scoring model (Table 9). The results were presented to the risk management board to determine the justification of the STOP- Bang pilot. Outcomes 4 25 Before STOP-Bang STOP-Bang January February Figure 1. Comparison of obstructive sleep apnea patients before and after STOP-Bang Scoring Model. This figure is available in color online at The results of the one-month pilot were reported to the risk management board. All 15 nurses scored 100% on the educational quiz, noting confidence in the staff during the cognitive training process. Nurses using the STOP-Bang tool noted five additional minutes to complete the preoperative assessment. Ten nurses (67%) noted outstanding confidence to complete the STOP-Bang scoring model. Five nurses (33%) noted an above-average ability to complete the STOP-Bang assessment (Table 9). The percentage of patients in January 2010 labeled as OSA before implementing STOP-Bang was 3% (n 5 124). The percentage of patients in the February 2010 pilot project labeled as high risk for OSA was 17% (n 5 143). This represents a 14% increase using the STOP-Bang scoring model (Fig 1). In addition to the increase in identification of high-risk OSA patients diagnosed with STOP- Bang, no respiratory or cardiac arrests, near arrests, or naloxone use occurred for the high-risk population. Continuous pulse oximetry readings were.90% for every patient (Table 8). The STOP-Bang scoring model was found to be a necessary component for preoperative assessment of the surgical patient. The lack of awareness or under-diagnosis of OSA reinforced the importance and value of a screening tool for OSA. The results were not alarming: 80% to 90% of the population is unaware of having OSA. 3-5 As a result of the pilot project, the risk management board instructed the pilot team to implement a process to use STOP-Bang for all surgical patients. A policy and procedure was completed as part of the formal process. Steps included an educational pamphlet that guides the patient and family and includes instructions on how to obtain a formal sleep study examination. Perianesthesia Nursing Implications Although the OSA screening tool was an additional responsibility for nursing, the method proved to be valuable to safeguard our OSA patients. The perils of the OSA patient are clear. Perianesthesia nurses must take accountable actions to strive for safe follow through of patients receiving anesthesia, IV sedation, and IV analgesia. Discussion Because of the high incidence of undiagnosed OSA patients with acute and long-term complications, Table 8. Occurrences of Adverse Events Before and While Using STOP-Bang Adverse Events Before STOP-Bang (n 5 124) January 2010 STOP-Bang (n 5 143) February 2010 Respiratory arrest 0 0 Cardiac arrest 0 0 Condition C 3 0 Naloxone administration 0 0 Deaths 0 0 Totals 3 0 Adverse events were compared for one month to determine safe patient outcomes when using the STOP-Bang scoring model. Condition C refers to near cardiac or respiratory events requiring critical care intervention. Naloxone is an opioid reversal agent.

9 OSA SCREENING TOOL FOR A SAFER PERIOPERATIVE ENVIRONMENT 23 Table 9. Course Evaluation Self-Reported (n 5 15) Likert Scale Results Questions Presenter expertise Ability to use STOP-Bang 5 10 Ability to measure neck circumference and obtain BMI Quality of teaching methods Unbiased presentation Overall satisfaction with course 3 12 Program s organization Location Likert scale: 1 5 Needs Improvement; 2 5 Satisfactory; 3 5 Above Average; 4 5 Outstanding preoperative nurses course evaluation comments. a screening tool is critical to the assessment of OSA. 18 An environment of shared leadership has promoted the practice change. The overall project has heightened the awareness of our facility to respect current literature for best practice. The shared leadership environment has inspired projects throughout our facility. Nurses are empowered to solve burning questions. As a result, the positive culture of the shared leadership team facilitated the improved processes in perioperative management of the patient with OSA. Conclusion Quality improvement in health care is an essential component for the safe care of patients in the perioperative environment. Health care professionals are accountable in providing safe patient care across the surgical continuum. The OSA project was a specific entity through which nurses advocated for patient safety and best care for the OSA population. As a result of the project, the OSA patients at our facility now receive the best possible treatment to afford a safe patient outcome during and after their surgical intervention. Acknowledgments I would like to acknowledge the staff at UPMC Presbyterian Shadyside Hospital who were instrumental in the implementation of the OSA screening tool project: Dr. Robert Boretsky, MD, Chief Anesthesiologist; Lisa Anne Donahue, DrNP, RN, Director Inpatient Quality and Innovation; Patricia W. Kammerer, MA, BA, RN, Informatics Nurse; Nicolette C. Mininni, MEd, RN, CCRN, Advanced Practice Nurse, Critical Care; and Lois Pizzi, BSN, RN, Pain Management Nurse for triggering the capstone subject. References 1. Tomlinson M. Obstructive sleep apnoea syndrome: Diagnosis and management. Nurs Stand. 2007;21: Finkel K, Saager L, Becker C, et al. The silent perioperative pandemic. Available at: 07_09.asp. Accessed October 11, Chung F, Imarengiaye C. Management of sleep apnea in adults. Can J Anesth. 2002;49: Ross J. Obstructive sleep apnea: Knowledge to improve patient outcomes. J Perianesth Nurs. 2008;23: Dobbin K. Wake up to the risks of sleep apnea. Nursing ;36: ECRI Institute and Ismp. Obstructive sleep apnea may block the path to a positive postoperative outcome. Pennsylvania Safety Authority. April, Available at: Accessed September 24, Gross J, Bachenberg K, Bellingham W, et al. American Society of Anesthesiologists Task Force on Perioperative Management of Obstructive Sleep Apnea. Practice guidelines for the perioperative management of patients with obstructive sleep apnea. Anesthesiology. 2006;104: Arnstein P. The Joint Commission: More clear, refined, and relevant than ever. Report from The Joint Commission Liaison Conference June American Society for Pain Management Nursing. ASPMN E-News: October 2008:1. 9. The Joint Commission Joint Commission Fact Sheet. Available at: Fact_Sheets/joint_commission_facts.htm. Accessed October 30, Westbrook P, Levendowski D, Cvetinovic M, et al. Description and validation of the apnea risk evaluation system: A novel method to diagnose sleep apnea-hypopnea in the home. Chest Cardiopulm Crit Care J. 2005;128:

10 24 LINDA LAKDAWALA 11. Chung F, Yegneswaran B, Liao P, et al. STOP questionnaire: A tool to screen patients for obstructive sleep apnea. Anesthesiology. 2008;108: Abrishami A, Khajehdehi A, Chung F. A systematic review of screening questionnaires for obstructive sleep apnea. Can J Anesth. 2010;57: Rosenthal L, Dolan D. The Epworth Sleepiness Scale in the identification of obstructive sleep apnea. J Nerv Ment Dis. 2008;196: Hanlon JG, Hayter MA, Bould MD, et al. Perceived sleepiness in Canadian anesthesia residents: A national survey. Can J Anesth. 2009;56: American Sleep Apnea Association. Snore Score Available at: snorescore.html. Accessed October 11, Melnyk B, Fineout-Overholt E. Evidence-Based Practice in Nursing & Healthcare: A Guide to Best Practice. Philadelphia: Lippincott Williams & Wilkins; Watters S. Shared leadership: Taking flight. JONA J Nurs Admin. 2009;39: Institute for Clinical Systems Improvement. Health Care Guidelines. Available at more/gl_os_prot/other_health_care_conditions/. Accessed October 19, 2008.