NR 730 Week 8 Manuscript Discussion Section Example

Discussion Section for a Quality Improvement Report: Preoperative Sleep Apnea Screening in a Freestanding Ambulatory Surgery Center

Student Name

College of Nursing, Chamberlain University

NR 730: DNP Project

Instructor Name

Month Day, Year

Discussion Section for a Quality Improvement Report: Preoperative Sleep Apnea Screening in a Freestanding Ambulatory Surgery Center

Summary of Principal Findings

In a freestanding ambulatory surgery center, STOP-Bang screening for obstructive sleep apnea reached 90.0% of eligible patients within twelve weeks, once neck measurement was moved from the preoperative telephone call to admission, and 86.4% of patients scoring 5 or more received all four elements of a high-risk pathway. Recovery respiratory events rose steadily with score band, from 2.0% in low-risk patients to 8.9% in high-risk patients, but the overall event rate, 3.9%, did not differ from the 4.1% recorded in the six months before screening began. Only about a quarter of high-risk patients reached at 30 days had arranged a sleep evaluation.

Comparison With Prior Work

The gradient in respiratory events across score bands was consistent with what the screening literature would predict. A meta-analysis of validation studies found that the probability of severe sleep apnea in surgical patients rose with each additional STOP-Bang point (Nagappa et al., 2015), and in this center the score sorted patients by their risk of a respiratory event in recovery in the same direction. That the tool behaved in a phone-first ambulatory setting much as it does in the hospital preoperative clinics where it was developed (Chung et al., 2008) supports its use in centers like this one.

The high completion rate was reached only after a workflow change, which the published evidence did not anticipate. Validation studies measured patients in person; this center's first design asked telephone nurses to complete an item that requires a tape measure. The fix, measuring on arrival, was simple, but it shows that a tool validated in one setting can fail operationally in another for reasons unrelated to its accuracy.

The pathway's content followed professional guidance for patients with known or suspected sleep apnea (American Society of Anesthesiologists Task Force, 2014), and its delivery rate suggests that the guidance can be applied routinely in a same-day setting. The override rate of 8%, mostly for procedures expected to be painful, is consistent with guidance that treats opioid limitation as a goal to be balanced against adequate analgesia rather than a rule.

Where the Project's Expectations Were Not Met

The project did not reduce overall recovery respiratory events. This was anticipated as a possibility in the planning stage, when a power estimate showed that only a fall to about 2.5% could be distinguished from the baseline in twelve weeks, but the result should be stated plainly rather than explained away. Several readings are possible. The pathway may have prevented events among high-risk patients that would otherwise have occurred, while events in other groups continued unchanged; without a baseline by score band, this cannot be tested. Extended monitoring may have detected events that were previously missed during shorter recovery stays, offsetting any reduction. Or the pathway may not reduce events in recovery at all, its value lying instead in safer discharge, which this project did not measure.

The second shortfall was follow-through. A letter to the primary care clinician led to a scheduled sleep evaluation in about a quarter of high-risk patients reached at 30 days. Screening without a reliable route to diagnosis leaves patients at risk at their next procedure and leaves their sleep apnea untreated. Guidance recommending preoperative screening notes that screening identifies risk but does not establish a diagnosis (Chung et al., 2016), and this project's results suggest that ambulatory centers need a more active referral process than a letter if screening is to benefit patients beyond the day of surgery.

Limitations Specific to This Project

Four limitations are specific to this project rather than generic. First, there was no baseline by score band, because no one was screened before the project; the only comparison available is the overall rate. Second, events after discharge were not captured, and the routine next-day call reached only 171 of 213 high-risk patients, so the period of greatest concern for same-day surgery remains largely unmeasured. Third, the neck measurement fix changed the screening process in week 3, so the first two weeks reflect a different intervention from the remaining ten. Fourth, 169 patients were not screened, and their event rate, 4.1%, is closer to the high-risk group than to the low-risk group, which suggests that unscreened patients may differ from screened ones.

Implications, Sized to One Center

These results come from one center over twelve weeks, and they support claims of that size and no larger. They show that screening every adult, and running a pathway for high scorers, can be delivered reliably in a phone-first ambulatory center once measurement is designed for the setting. They show that the score sorts recovery risk in this population. They do not show that screening reduces respiratory events, and they suggest that a letter is not enough to connect patients to diagnosis. Other centers considering the approach should expect to adjust the measurement workflow, plan for about thirty additional recovery minutes for each high-risk patient and decide in advance who will follow up after discharge (Joshi et al., 2012).

What This Center Will Do Next

The center has taken three decisions from these findings. Screening and the pathway continue as policy, adopted by the medical executive committee in July. The routine next-day call has been extended to ask every high-risk patient about breathing pauses or unusual sleepiness overnight, so that events after discharge begin to be recorded. And the referral letter is being replaced, as a test in the autumn, with a direct offer to schedule a home sleep study through the health system's sleep service before the patient leaves the center. Each change answers a specific shortfall in the results rather than adding new activity for its own sake, and each will be measured in the same way as the original project so the before and after can be compared.

Conclusion

Preoperative sleep apnea screening was feasible and well delivered in a freestanding ambulatory surgery center, and it identified a group at clearly higher risk of respiratory events in recovery. It did not lower the overall event rate within twelve weeks, and it rarely led to diagnosis. The next step for this center is to measure events after discharge and to replace the referral letter with direct scheduling of sleep evaluation for high-risk patients.

References

American Society of Anesthesiologists Task Force on Perioperative Management of Patients with Obstructive Sleep Apnea. (2014). Practice guidelines for the perioperative management of patients with obstructive sleep apnea. Anesthesiology, 120(2), 268-286. https://doi.org/10.1097/ALN.0000000000000053

Chung, F., Memtsoudis, S. G., Ramachandran, S. K., Nagappa, M., Opperer, M., Cozowicz, C., Patrawala, S., Lam, D., Kumar, A., Joshi, G. P., Fleetham, J., Ayas, N., Collop, N., Doufas, A. G., Eikermann, M., Englesakis, M., Gali, B., Gay, P., Hernandez, A. V., . . . Auckley, D. (2016). Society of Anesthesia and Sleep Medicine guidelines on preoperative screening and assessment of adult patients with obstructive sleep apnea. Anesthesia & Analgesia, 123(2), 452-473. https://doi.org/10.1213/ANE.0000000000001416

Chung, F., Yegneswaran, B., Liao, P., Chung, S. A., Vairavanathan, S., Islam, S., Khajehdehi, A., & Shapiro, C. M. (2008). STOP questionnaire: A tool to screen patients for obstructive sleep apnea. Anesthesiology, 108(5), 812-821. https://doi.org/10.1097/ALN.0b013e31816d83e4

Joshi, G. P., Ankichetty, S. P., Gan, T. J., & Chung, F. (2012). Society for Ambulatory Anesthesia consensus statement on preoperative selection of adult patients with obstructive sleep apnea scheduled for ambulatory surgery. Anesthesia & Analgesia, 115(5), 1060-1068. https://doi.org/10.1213/ANE.0b013e318269cfd7

Nagappa, M., Liao, P., Wong, J., Auckley, D., Ramachandran, S. K., Memtsoudis, S., Mokhlesi, B., & Chung, F. (2015). Validation of the STOP-Bang questionnaire as a screening tool for obstructive sleep apnea among different populations: A systematic review and meta-analysis. PLOS ONE, 10(12), Article e0143697. https://doi.org/10.1371/journal.pone.0143697