At risk: Obstructive sleep apnea patients

As seen in the Consultant Connection September 2015 Issue
From The Joint Commission Quick Safety – Issue Fourteen, June 2015
Obstructive sleep apnea (OSA) is a common sleep-related breathing disorder characterized by repetitive, periodic, partial or complete obstruction of the upper airway during sleep, with periods of breathing cessation lasting for more than 10 seconds. OSA occurs in both adults and children, and patients with OSA can experience complications when receiving sedatives, such as opioid analgesia or general anesthesia. These medications “diminish the protective arousal reflex triggered by bouts of hypoxia, thereby increasing the risk of prolonged periods of apnea and respiratory arrest.” Sedatives and narcotics can decrease pharyngeal muscle tone, “which can worsen existing OSA and increase upper airway resistance.”1
The Joint Commission has received 61 sentinel event reports in which the patient was diagnosed with or suspected of having OSA. OSA may have been a contributing factor in some of these cases, however, the nature of OSA presents difficulties in directly associating OSA with the patient’s death or injury. OSA is associated with numerous comorbidities, such as diabetes, hypertension, stroke, heart failure and coronary artery disease.1 The risk factors for OSA are included in the box at the right.
OSA affects approximately one of four adults in the United States. Approximately 90 percent of people go undiagnosed.2
A common chronic disorder that requires lifelong care, OSA symptoms include:
  • Snoring, restlessness or resuscitative snorts during sleep
  • Respiratory efforts during arousals from sleep
  • Daytime symptoms due to disrupted sleep, such as sleepiness, fatigue or poor concentration

Staff in The Joint Commission’s Division of Healthcare Improvement cites the following concerns regarding OSA:
  • Lack of training for health care professionals to screen for and recognize OSA
  • Failure to assess patients for OSA
  • Lack of guidelines for the care and treatment of individuals at risk for, and those diagnosed with, OSA1
  • Failure to implement appropriate monitoring of patients with risk factors associated with OSA
  • Lack of communication among health care providers regarding patients with OSA or potential risk factors associated with OSA
  • Lack of postoperative evaluation and treatment for OSA

Safety Actions to Consider:
  • Screen and identify any patient suspected of having OSA. Appropriate screening would minimize the number of undiagnosed patients who present for surgery, and allow them to get the additional care and therapy they may need.
  • Evaluate the patient’s plan of care to ensure all precautions are taken while in your facility. Some aspects of care to consider include:
  • Assessing the use of sedating medications and narcotics
  • Continuous pulse oximetry monitoring of the patient in an observed environment
  • Use of supplemental oxygen or positive airway pressure device
  • Patient positioning
Risk factors for OSA
  • Obesity (BMI>35)
  • Male gender
  • Advancing age
  • Craniofacial or upper airway soft tissue abnormalities
  • Smoking
  • Congestive heart failure
  • Atrial fibrillation
  • Nasal congestion
  • Menopause
  • Family history
Source: Strohl,KP, overview of obstructive sleep apnea in adults. Up To Date, 2015, WoltersKluwer (accessed May 20, 2015)

1. Academic Medical Center | Patient Safety Organization. Patient Safety Alert: Obstructive sleep apnea – management considerations, Issue 19, December 2013
2. Shear TC, et al. Risk of sleep apnea in hospitalized older patients. Journal of Clinical Sleep Medicine, 2014;10(10)

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