Sensible. Simple. Effective.Reaching out to more patients.

DEVELOPING A PERIOPERATIVESLEEP MANAGEMENT PROGRAM

REASONS TO INTEGRATE A PERIOPERATIVE APNEA PROGRAM

Increasing Prevalence of Apnea

4% -Estimated prevalence of OSA in middle-aged men.

24% -Percent of U.S. men suffer from some form of sleep disordered breathing (SDB).

ASA Practice Guidelines

Joint Commission Focus

Reimbursement Changes

Reduce Liability Claims

Improving Patient Care

Reduce Adverse Events, Decreasing:

o Hospital Re-admissions

o Extended PACU stays

o Unanticipated ICU admissions

New England Journal of Medicine. 1993; 328; 1230-1235.ASA Task Force. Anesthesiology 2006; 104:1081–93.

REASONS FOR APNEA SCREENING

Undiagnosed Apnea Patients Pose the Highest Risk

Known apneics make up a small portion of the population undergoing surgery.

Over 28 million Americans suffer from OSA, 20 million going undiagnosed & untreated.

Research shows preoperative identification of OSA & use of perioperative precautionary measures improves patient outcomes.

Finkel, et. al. Sleep Review July-Aug 2006. Gupta, et. al.. Mayo Clinic Proc. 2001; 76:897-905. Moos, et. al. ANAA Journal. June 2005. Vol 3, No 3.ASA Task Force. Anesthesiology 2006; 104:1081–93.

SCREENING IDENTIFIES PATIENTS THAT WOULD NOT SEEK TREATMENT OTHERWISE.

A combination of factors

put apnea patients at

higher risk, including:

• Lingering anesthetics

• Amount/type of pain

medications used

• Decreased monitoring

• Marked REM rebound

APNEA, ANESTHESIA & PAIN MANAGEMENT

Finkel, et. al. Sleep Review July-Aug 2006. Gupta, et. al.. Mayo Clinic Proc. 2001; 76:897-905. Moos, et. al. ANAA Journal. June 2005. Vol 3, No 3.ASA Task Force. Anesthesiology 2006; 104:1081–93.

Anesthetics & Pain Medications Depress the Central Nervous

System

Decreased Muscle Tone

Obstructive Apnea Events

Light, Erratic Breathing

Central Apnea EventsHypoxemia

Respiratory Failure

Diminished Arousal Response

HypoxemiaRespiratory Failure

FINANCIAL RISK REDUCTION

Implementing a Perioperative Apnea Management Program Prevents or Reduces Risk of:

Never Events

o Waived Fees

o Possible Remunerative or Punitive Repercussions

Non-payment for Unexpected Medical Events

o National movement to stop paying for these types of events

CMS Recovery Audits

COST BENEFIT- CASE STUDY FINDINGS

Candidates for Monitoring a Year 20,000 patients

Post-operative Respiratory Failure Rate 17 per 1000

Number Patients at Risk 340 patients

Additional Length of Stay (Days) 9.08

Hospital Cost per Day $1,900

Additional Cost for Patients at Risk $5,865,680

Success of Orders with C02 Monitoring 30%

Savings with Monitoring $1 ,759,704

Capital Costs ( 100 @ $1,000/device) $100,000

Depreciation (5 year straight line) $60,000

Savings $1,723,104

Spin Off PSG Charges (244 * $2,500) $612,000

Costs PSG + Interpretation $165,920

Gross Revenue (PSG + Hospital Savings) $1,889,624

DME Spin Off if Available (Gross Revenue) S 170,000

Example Case Study Findings

-Savings on at-risk patients

-Increased revenue through PSG & DME

SAVING MONEY & INCREASING OPPORTUNITIES

Case Study Findings: At Risk Patients = Greater Costs for Hospitals

Not Identifying at Risk Patients?

Deduct from Your Bottom Line.*From a Patient Pool of 20,000:

o 340 Patients -

At Risk Of Post-operative Respiratory Failure

o 9 Additional Days -

Spent In Hospital By At-risk Patients on Average

o $1,900 –

Hospital Cost Per Day

= $5,865,680

Total Additional Costs

Case Study Findings

SAVING MONEY & INCREASING OPPORTUNITIES

Case Study Findings: Monitoring Saves Money & Creates Opportunity

Saving Money

o $1,759,704 - Amount Saved with Objective Screening in Case Study

Opportunity through the Sleep Lab & DMEo +$446,080 -

Gross margin for additional PSG testing (to confirm & initiate therapy) brought on by patients identified during pre-operative screening.

o +$170,000 -

Net Revenue for DME

PROBLEMS WITH COMMON SCREENING METHODS

o Subjective

o Simplistic stratification i.e. high or low risk

o Not specific i.e. high # of false-positives - Leads to unnecessary testing or delayed surgery

o Cannot indicate type/severity of SDB

QuestionnairesIn-lab Polysomnography (PSG)

o Costly

o Impractical for ScreeningPopulation is too large – Would delay surgery

o Can Take Days or Weeks to Receive Results

o Higher refusal/drop-out rates

Guidelines for the Perioperative Management of Patients with Obstructive Sleep Apnea. Anesthesiology 2006; 104:1081–93.STOP Questionnaire; A Tool to Screen Patients for Obstructive Sleep Apnea. Chung, et. al.. Finkel, et. al.. Sleep Review July-Aug 2006. Magalang, et. al. Chest 2003; 124; 1694-1701

META-ANALYSIS OF OSA QUESTIONNAIRES

Study Pooled Study n FN Rate

Ease of Use, 0-3

Test Accuracy, by Diagnostic Odds

Ratio (DOR)*Summary

Recommendations

ASA Checklist 117 0.123 - 0.279 1 Poor No preoperative value, unacceptable FN rate

BMI alone 406 0.228 - 0.298 0 Poor No preoperative value, unacceptable FN rate

Epworth Sleepiness Scale 46 0.714 1 Poor Unacceptable FN rate

STOP Questionnaire 177 0.205 - 0.344 1 Poor No preoperative value,

unacceptable FN rate

STOP-BANG 177 0.0 - 0.164 2 Average-ExcellentExcellent screening test for severe OSA, unacceptable FN rate for Dx of OSA

*DOR combines data on sensitivity and specificity to give an indication of a test’s ability to rule in or rule out a condition.

Screening Test Reliability & Summary Recommendations for Preoperative Use

Many of the most

commonly used

preoperative

screening

questionnaires are

considered to have

poor accuracy.

Derived from Ramachandran, et. Al. Anesthesiology, V 110, No 4, Apr 2009

THE S.O.S. APPROACH

Subjective Screen

Use questionnaire (e.g. STOP; STOP-BANG; Berlin) to screen everyone

o The population at risk is often large and will often include many patients with low risk.

A much smaller subgroup with very high risk will require pre-op intervention.

Objective Screen

Oximetry (e.g. SatScreen) devices are widely used because of affordability, high predictive value, & minimal patient impact.

o Identifies the high risk subgroup.

“S.O.S.”Subjective Objective Screening

Research shows a combination approach can be the most feasible & effective method

Hwang, et. al. Chest 2008; 133; 1128-1134.

Patents

High resolution oximetry with

Digital pattern analysis & recognition

SatScreen

Oximetry screening

FDA cleared acquisition, analysis & reporting software

Patient Safety Connection Center

Oximetry & HST software management platform

PATIENT SAFETY, INCTECHNOLOGY

BREAKTHROUGHS

WHY SATSCREEN?

Accurate & Cost-Effective

Results in Minutes

Easy to Read –Green to red indices for important information

Indicates Arousal Failure & Hypoventilation Syndromes-These patients are at higher risk of post-op respiratory failure

Highlights Frequency of Events & Severity of O2 Desaturations

Most oximetry

software only

report raw data,

ODI & O2 ranges.

Bloch. Chest 2003; 124; 1628-1630. ASA Task Force. Anesthesiology 2006; 104:1081–93.

Madani. Advance for Respiratory Care and Sleep Medicine. Posted on January 7, 2009.

GET STARTED

Define your protocol for at risk patients Determine your Screening Protocol

o Gather your team & assign responsibilities

Practice Guidelineso If patient is identified as at risk, follow ASA guidelines or

preferred protocol

Develop discharge instructions / plan

Questions?

We want to help you make your organization’s OSA screening program a success.

Please contact us at:

1-888-666-0635

support@patientsafetyinc.com