1. Robyn Woidtke MSN,RN, RPSGT,CCP,CCSH OCTOBER 24 KASP 2014 Sleep in the Hospitalized Patient 1

2. Objectives At the completion of the session, the attendees will: Summarize contributors to sleep loss Describe the impact of sleep loss in the hospitalized patient Explain the rationale for screening for sleep apnea in patients admitted to the hospital Emphasis The perioperative environment The ICU 2

3. Why is sleep important? Animal models, sleep loss leads to Failure of body temperature regulation Increased metabolism Deterioration of hypothalamic neurons Progressive breakdown of host defenses Death Redeker &McEnany, 2011 3

4. Functions Conserve energy and metabolism Physiologic systems within homeostatic mechanisms Maintain host defenses Reverse/restore physiologic processes that degrade during wakefulness Memory Consolidation Learning Redeker &McEnany, 2011 4

5. Factors Contributing to Sleep Loss Voluntary curtailment (social) Environment (i.e. work, technology, etc) Role (new mom, school) Sleep Disorders Medical and psychiatric disorders Redeker &McEnany, 2011 5

6. Sleep Deprivation Poor job performance Cognition Impaired Lose the ability to make sound judgment; interpretation of events is affected Reduced ability to handle stress Greater alcohol use Higher incidence of drowsy driving Redeker &McEnany, 2011 6

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8. Acute Sleep Deprivation 8 Excess diuresis and natriuresis during acute sleep deprivation in healthy adults (Kamperis, 2010). Acute sleep deprivation reduces energy expenditure in healthy men (Benedict, 2011) Increase levels of ghrelin in the morning Declines in neurocognition, increased sympathetic and decreased parasympathetic modulation (Zhong et al., 2004)

9. Outcomes of Disturbed Sleep 9 Alterations in immune function Increased stress hormones (catacholamines) Insulin and glucose regulation Ability to perform activities of daily living Lack of mental processing of self care activities upon discharge Decrease in SWS HGH Alterations in processing and consolidating newly acquired information

10. Correlates and Consequences 10 Sleep Quantity Continuity Diurnal Timing Quality Perceptions Acute Illness Age, Gender, Comorbidity Symptoms Hospital Environment Treatment Sleep Disorders Functional Status Physiologic Status Adapted from Redeker and Hedges, 2002

11. General Sleep Assessment (1) Challenges Sleep problems typically occur gradually; patients may not be aware or concerned May attribute daytime symptoms to other causes Assessment BEARS (all ages) B-bedtime problems E-Excessive Sleepiness A-Awakenings R- Regularity of sleep S-Sleep disordered breathing Redeker &McEnany, 2011 11

12. General Sleep Assessment (2) General health Specific Conditions Co-morbid/bi-directionality (heart disease, asthma, diabetes, Parkinsons, pain, depression and anxiety) Anthropometric data HT/Wt (BMI >30), neck circumference (17 m, 16 f) correlate with OSA in adults Waist circumference and BMI>95 th percentile in children Inspection of the profile, oral and nasal cavities Mallampati Cardiovascular (BP, EKG, heart sounds) Pulmonary system (scoliosis, muscle tone) Neuromuscular (restless legs syndrome) Glycemic control Redeker &McEnany, 2011 12

13. Nursing Staff: Do Not assume “ While knowledge of findings like these (referring to sleep apnea) have raised my awareness of the dangers of untreated sleep apnea, I can tell you that a majority of the nurses at my hospital, and even those within my own critical care unit still do not aggressively address the issue of having the MD order studies to diagnose and/or treat OSA which has been diagnosed” (2012, Personal Communication, Anonymous Critical Care RN, MSN student)

14. Sleep in the ICU Sleep ParameterChanges Total Sleep TimeUnchanged/decreased Sleep LatencyUnchanged/increased Sleep EfficiencyDecreased NREM Stage 1Increased NREM Stage 2Increased NREM Stage 3Decreased REMDecreased Friese, R. (2008) Crit Care Med 14

15. Environmental and Pathophysiological Factors Sleep Deprivation Noise Lighting Practices Patient Care Activities Diagnostic Procedures Sedatives Analgesics Stress Organ Dysfunction Inflammatory Response PainPsychosis Friese, R. (2008) Crit Care Med 15

16. ICU Delirium 16 Delirium affects up to 80% of ICU patients, and it is estimated that ICU costs associated with delirium equal between $4 billion and $16 billion annually in the US.(1) This form of acute brain dysfunction is associated with increased length of ICU and hospital stays, time on the ventilator, mortality, and long-term neuropsychological deficits (1) Characteristic features of the syndrome include impaired short- term memory, impaired attention, disorientation, development over a short period of time, and a fluctuating course(2) Caused by a general medical illness, intoxication, or substance withdrawal (2) OSA has been demonstrated as a risk factor (3) 1.American Association of Critical Care Nurses, 2014 2.Cavallazzi, et al., 2012 Annals of Intensive Care 3.Flink, et al.2012 Anesthesology

17. Medications 17 Opioids Increase arousal Precipitate osa Worsen hypoxia Ventilator asynchrony Benzodiazapines Increase theta; reduce SWS Loss of SWS has been shown to increase delirium Dexmedetomidine Reduces ventilator days Reduces delirium

18. Interventions 18 Reduce Effects of Environmental Stimuli Decrease noise Cluster patient care interventions Provide eye masks and ear plugs if appropriate Complementary and Alternative Medicine Relaxation, music and biofeedback White noise may improve sleep quality in cardiac post op patients Massage Meditation Review Drug interactions, understand the consequences

19. Interventions Plan for uninterrupted time for sleep Minimize night time assessments Set monitor alarms down to reasonable loudness Orient patient frequently If possible, cycle light to day/night frequency Sleep may change ventilator synchrony, proportional assist has demonstrated improved ventilatory matching requirements and improved sleep Friese, R. (2008) Crit Care Med 19 "We haven't recognized the importance of prescribing sleep“ Friese, R 2007

20. Measuring Sleep Quality Richards-Campbell Sleep Questionnaire Brief validated 5 item questionnaire; visual analog scale (100mm), higher numbers= better Study to determine nurses vs. patients subjective ratings of sleep; inter-rater reliability Johns Hopkins (June-July 2010; 16 bed private room MICU; nurse to patient ratio 1:2; 12 hour shifts); questionnaires completed 30 minutes prior to the end of shift; 33 patients/92 paired assessments  Results: Patient/Nurse agreement was slight to moderate; nurses tended to over estimate sleep quality Kamdar et al. (2012) AJCC 20

21. OSA in the Hospital 21 25% of candidates for elective surgery OSA undiagnosed in 80% at the time of surgery Estimates of OSA in hospitalized patients >50% National Hospital Discharge Survey 5.8% received CPAP with a diagnosis of OSA (Spurr, 2008) <20% with a diagnosis of OSA received therapy during hospitalization (Premier Inc, Database, Memtsoudis, 2013, NEJM)

22. Screening for OSA 22 Variety of questionnaires Epworth, Berlin, STOP/STOP BANG, Sleep Apnea Clinical Score Pulse Oximetry Home sleep testing for all elective surgical procedures Full polysomnography

23. STOP-BANG 23

24. High STOP-BANG score = higher probability of OSA Evaluation of the association between STOP-Bang scores and the probability of OSA. METHODS: Patients answered STOP questionnaire and underwent either laboratory or portable polysomnography (PSG). PSG recordings were scored manually. The BMI, age, neck circumference, and gender (Bang) were documented. Over 4 yr, 6369 patients were approached and 1312 (20.6%) consented. Of them, 930 completed PSG, and 746 patients with complete data on PSG and STOP-Bang questionnaire were included for data analysis. 24 Chung, F. Br. J of Anesthesia doi: 10.1093/bja/aes022

25. High STOP-Bang score indicates a high probability of obstructive sleep apnoea RESULTS: The median age of 746 patients was 60 yr, 49% males, BMI 30 kg m(-2), and neck circumference 39 cm. OSA was present in 68.4% with 29.9% mild, 20.5% moderate, and 18.0% severe OSA. STOP-Bang score of 5, the odds ratio (OR) for moderate/severe and severe OSA was 4.8 and 10.4, respectively. STOP-Bang 6, the OR for moderate/severe and severe OSA was 6.3 and 11.6, respectively. STOP-Bang 7 and 8, the OR for moderate/severe and severe OSA was 6.9 and 14.9, respectively. The predicted probabilities for moderate/severe OSA increased from 0.36 to 0.60 as the STOP-Bang score increased from 3 to 7 and 8. CONCLUSIONS: In the surgical population, a STOP-Bang score of 5-8 identified patients with high probability of moderate/severe OSA. The STOP-Bang score can help the healthcare team to stratify patients for unrecognized OSA, practice perioperative precautions, or triage patients for diagnosis and treatment. 25

26. 26 Identification of Patients at Risk for Postoperative Respiratory Complications Using a Preoperative Obstructive Sleep Apnea Screening Tool and Postanesthesia Care Assessment Gali, et al., Anesthesiology 2009; 110:869–77

27. OSA in the Hospitalized Patient Why OSA is an important assessment Association with MI, arrhythmias, CHF, stroke, sudden cardiac death Sudden death ~ 50% those with OSA compared to 21% without OSA Die during the sleep hours (12-6 AM) Sudden death related to the AHI, the more severe the higher the risk Depressed arousal mechanisms due to sleep fragmentation and deprivation; acquired arousal failure in obese patients Narcotics further delay arousal Kaw & Mokhlesi (2012) Sleep and Breathing 27

28. Types of patients at high risk for OSA CHF Obese Patients undergoing bariatric surgery Atrial Fibrillation Refractory Hypertension Type 2 diabetes Stroke Nocturnal cardiac arrhythmia Pulmonary Hypertension AASM Task Force, 2009 JCSM 28

29. Patterns of Unexpected Hospital Death 29

30. 30 ALARM FATIGUE

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32. Perioperative Environment -OSA Difficulty with intubation (8 times as often) Unanticipated transfers to ICU Overall LOS longer; longer ICU 5 fold increase in intubation and mechanical ventilation after surgery Kaw & Mokhlesi (2012) Sleep and Breathing 32

33. Impact of Anesthesia 33 Exacerbates the anatomical alterations which result in pharyngeal collapse Blunt the arousal mechanisms Reduce tone of the upper airway Depress ventilation Diminish ventilatory response to carbon dioxide  In children, apneic episodes were increased 50% after modest doses of fentenyl (0.5µg/Kg)

34. Perioperative Outcomes-Other 34 Higher rates of Hypercapnia Oxygen desaturations Cardiac arrhythmias Myocardial injury Delirium Adesanya, et al. 2012 CHEST OSAOSA

35. Key Take Away 35 OSA patients live in a state of perpetual “arousal dependent survival” (Lynn & Curry,2011) Acquired arousal failure Nursing staff may not be educated Protocols may/may not be in place or followed

36. Mitigating Risk Studies demonstrate that patients who are treated for OSA have reduced complications and improved outcomes 36

37. 2 Relevant Joint Commission Directives 37

38. Clinical Practice Guidelines 38 “The consultants agree that, in the absence of a sleep study, a presumptive diagnosis of OSA may be made based on consideration of the following criteria: increased body mass index, a weight or body mass index greater than 95th percentile for age (pediatric patients), increased neck circumference, snoring, congenital airway abnormalities, daytime hypersomnolence, inability to visualize the soft palate, and tonsillar hypertrophy. They strongly agree that observed apnea during sleep is an additional criterion.”

39. New Guidelines 39

40. Post Operative 40 Postoperative concerns in the management of patients with OSA include (1) analgesia, (2) oxygenation, (3) patient positioning, and (4) monitoring. Risk factors for respiratory depression include the systemic and neuraxial administration of opioids, administration of sedatives, site and invasiveness of surgical procedure, and the underlying severity of the sleep apnea. In addition, exacerbation of respiratory depression may occur on the third or fourth postoperative day as sleep patterns are reestablished and “REM rebound” occurs.

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43. Pre-operative Evaluation 43

44. Extended Stay PACU Protocol 44

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48. Risk Management The Perils of Litigation 48

49. ADVOCATE, ADMIT and MONITOR……. 49

50. Value of a program 50 Analysis of the WestLaw Data base on osa cases 54 cases included in analysis 61% in favor of defendant 12% resolved out of court 9% jury award most frequent factors in litigation Failure to diagnose OSA; failure to use CPAP postoperatively Failure to use CPAP, all cases resolved with payment > 1 million Svider, et al., AAO 2013

51. Cost of CPAP in the Hospital 51 Prospective cohort study tertiary academic medical center (JH); evaluate costs associated with hospital vs patient provided CPAP All new pt admissions >18 prescribed CPAP as an in-patient (1/1-2/28, 2012) N=162; 1.2% of admissions Cost to provide CPAP to hospitalized patients vs use of home CPAP (avg nights of use 5.3±5.5) RVUs (110; 8--$2.68) Patient Provided=$0.00 (27.50 for the RT charge) Hospital provided 27.50/day; differential charge = 416.10 (daily rental fee and RT follow ups) for a patient who stayed more than 1 day Avg stay 5.3±5.5 Cost savings to the hospital and insured can be significant >1.1 million per year Smith et al., 2014, doi.1002/lary.24604

52. Summary Sleep deprivation can be acute or chronic Both have resulting physiological consequences Sleep in hospitalized patients is disturbed resulting in sleep deprivation. A large proportion of patients who enter the hospital have not been diagnosed with sleep apnea or have CPAP initiated or continued from home Increased awareness of sleep deprivation and sleep apnea can provide for improvement in interventions and early recognition of patients with a potential for adverse consequences Program implementation can have important financial considerations 52

53. 53 Contact Information Robyn.Woidtke@gmail.comRobyn.Woidtke@gmail.com, Office 510-728-0828.