1. Sensible. Simple. Effective. Reaching out to more patients. D EVELOPING A P ERIOPERATIVE S LEEP M ANAGEMENT P ROGRAM

2. R EASONS TO I NTEGRATE A P ERIOPERATIVE A PNEA P ROGRAM 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.

3. R EASONS FOR A PNEA S CREENING 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.

4. A combination of factors put apnea patients at higher risk, including: Lingering anesthetics Amount/type of pain medications used Decreased monitoring Marked REM rebound A PNEA, A NESTHESIA & P AIN M ANAGEMENT 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 Events Hypoxemia Respiratory Failure Diminished Arousal Response Hypoxemia Respiratory Failure

5. F INANCIAL R ISK R EDUCTION 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

6. C OST B ENEFIT - C ASE S TUDY F INDINGS Candidates for Monitoring a Year20,000 patients Post-operative Respiratory Failure Rate17 per 1000 Number Patients at Risk340 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 Monitoring30% 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

7. S AVING M ONEY & I NCREASING O PPORTUNITIES 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

8. S AVING M ONEY & I NCREASING O PPORTUNITIES 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 & DME o +$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

9. P ROBLEMS WITH C OMMON S CREENING M ETHODS 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 Questionnaires In-lab Polysomnography (PSG) o Costly o Impractical for Screening Population 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

10. M ETA - ANALYSIS OF OSA Q UESTIONNAIRES Study Pooled Study n FN Rate Ease of Use, 0-3 Test Accuracy, by Diagnostic Odds Ratio (DOR)* Summary Recommendations ASA Checklist1170.123 - 0.2791Poor No preoperative value, unacceptable FN rate BMI alone4060.228 - 0.2980Poor No preoperative value, unacceptable FN rate Epworth Sleepiness Scale 460.7141Poor Unacceptable FN rate STOP Questionnaire 1770.205 - 0.3441Poor No preoperative value, unacceptable FN rate STOP-BANG1770.0 - 0.1642Average-Excellent Excellent 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 tests 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

11. T HE S.O.S. A PPROACH 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.

12. 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 P ATIENT S AFETY, I NC T ECHNOLOGY B REAKTHROUGHS

13. W HY S AT S CREEN ? 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 O 2 Desaturations Most oximetry software only report raw data, ODI & O 2 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.

14. G ET S TARTED Define your protocol for at risk patients Determine your Screening Protocol o Gather your team & assign responsibilities Practice Guidelines o 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 organizations OSA screening program a success. Please contact us at: 1-888-666-0635 support@patientsafetyinc.com