This EBP project was generously supported, in part, by the Hawaii State Center for Nursing.This project was supported by grant number R13HS017892 from the Agency for Healthcare Research and

Quality. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality.

Don’t Ignore MY SNORE:

Evidence-based Practice Management of Patients at High Risk for Obstructive Sleep Apnea (OSA) in the

Perioperative SettingPresented by: Ludy P. Lemus, BSN, RN, CAPACNIV

ObjectivesState 3 risk factors for OSA

Gain an understanding of the process used to implement an OSA Guideline that is evidence-based into practice

OSA TeamHonorata Balinowski, RN-Project LeadHang Saito, RN-APRNBetty McMullin, RN-APRNLudy Lemus, RN-Change champion SDSCandace Hang, RN-Change champion PACUAd Hoc Members:

Alan Suyama, MD—AnesthesiaRoger Yim, MD—PulmonologistLinda Castro, RN—Sleep LabBrad Bransford--Respiratory

Identification of ProblemStudies link OSA to greater postoperative

complications

Presence of OSA associated with higher incidence of postop complicationsHypoxemiaICU transfersLonger length of stay(Kaw, et al, 2012)

At The Queen’s Medical CenterAudit Jan-Sept 2012•135 patients were identified as being high-risk•27% of those patients experienced adverse outcomes • Desaturation• EKG changes• MI• Re-intubation• ICU transfer• Death (2)secondary to

cardiopulmonary complication

Current practice (2012)

Screen for OSA in the perioperative setting STOP-Bang Tool

S=SnoreT=TiredO=Observed apneaP=Pressure (High Blood Pressure)

B=BMI greater 35.0A=Age Over 50N=Neck over 16 inchesG= Gender Male

No organizational guideline for OSA/High-Risk OSA

PurposeImplement EBP guideline for adult

perioperative patients identified as High-risk for OSA

Optimize nursing carePrevent adverse patient outcomes

MethodMultidisciplinary Team formed

RN Internship program: Hawaii State Center for Nursing (Spring, 2012)--Iowa Model of Evidence-Based Practice to promote quality care

Over 40 articles critiqued and synthesized

Guideline

Algorithm

Written Hand off Report

Nurse-to-Nurse Communication in EMR (Aug, 2015)

CommunicationEBP OSA team monthly meetingsNursing Practice Council Perioperative Nursing Practice CouncilUnit Councils

Anesthesia committeeSurgical Executive CommitteeMedical Records CommitteeEMR Committee: discharge instructions, Nurse-to-Nurse communicationEducation Committee—House wide self–learning module 10/2015

Poster/RN education-APEC, SDS, Cardiac Recovery, Preop, Endoscopy, T8DHSelf-learning Module

PIN Conference 2013 Queen’s Print Connection (April 2014)Nursing Grand Rounds (Nov, 2014; Oct, 2015)

Initiate OSA Guideline via Nurse to Nurse Communication

Same Day SurgeryMain OR Preoperative Unit Cardiac Recovery UnitEndoscopy

Nurse-to-Nurse Communication in EMRDiagnosed or High-Risk for OSA Nursing Diagnosis: Ineffective Breathing Pattern1. Communicate OSA status2. Verify CPAP orders for patient with at-home use3. Positioning: HOB elevated/lateral4. Pulse oximetry documentation every hour for 24

hours post-anesthesia time or discharge criteria met5. Consider Capnography6. If PCA—promote bolus dosing only7. Multimodal pain control8. Discharge instructions

(OSA algorithm, 2014)

Expected Outcome Maintain airway patency

Oxygen saturation within normal limits/baseline

Pitfalls from Pilot to House-wide Small pilot population

Paper handoff not effective

FYI—High risk for OSA eliminated

SLM not available online

Smaller team

Audit SDS 8/3-8/7/2015: 190 patients

100% compliance with screening for OSAOSA guideline initiation:

67% compliance for the week100% last day of audit

87%

9%

4%

No/minimal OSA risk p=166

Diagnosed OSA p=17

STOP-Bang score 5 or greater p=7

Factors for Success Internship support and EBP advisor assigned to our team

Change champions on the unit

Identify RN not compliant for re-education

Reminders during staff huddles and email

Change communication: Paper Handoff / FYI to Nurse-to-Nurse Communication

Management support

Positive reinforcement: Raffle prizes for RN’s that implement guideline Positive safety story shared

Implications for NursesGoal: Decrease adverse cardiopulmonary

events related to OSA

Change practice based on evidence: Increase communicationVigilant monitoring Higher standard of careEducation

Plan-Do-Check-Act Audit other areas for compliance of

guideline

Formulate plan to increase compliance

Audit of patient adverse outcomes

DisseminationNursing Grand Rounds (October 2015)

AONE conference November 5 and 6, 2015-Podium

HIPAN Conference November 7, 2015-Podium

ASPAN National conference abstract submission 4/10/2016-Podium/poster

Publication Workshop January-June 2016

Special Thanks…Cindy Kamikawa-VP Nursing/ED/CNO The

Queen’s Medical Center

Renee Latimer, Director of Queen Emma Nursing Institute

Deborah Bransford, BSN- EBP advisor

Debra Mark, Director of Doctor of Nursing Practice Program at UH Manoa

For a copy of the guideline

Email request to:Ludy P. Lemus, BSN, CAPA, CNIV

llemus@queens.org808-691-4798

Honorata Balinowski, RN, CNIIIHbalinowski@queens.org

808-691-5143

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