Capnography, Monitoring Liability and Costs, Patient Safety, Post-Operative Monitoring

Improving Hospital Efficiency and Patient Safety: Bedside Monitoring with Capnography Achieves Better Management of Surgical Patients with Obstructive Sleep Apnea

by Michael Wong

Like many hospitals in North America, Kelowna General Hospital (KGH) in British Columbia was challenged with providing safe and appropriate perioperative and postoperative management of patients with obstructive sleep apnea (OSA). KGH is a 345-bed tertiary hospital in the interior of British Columbia, Canada.

Richard Milo, RRT (Professional Practice Leader, Central Okanagan Respiratory Services, Interior Health, at KGH) described for me the situation they faced:

Prior to utilizing EtCo2 technology our site had a significant backlog of OSA/possible OSA patients requiring surgery.  Our capacity was approx. 5-8 patients/week and they were observed post-op by an LPN [licensed practical nurse] for 24 hours.  

Moreover, as Richard and his colleagues describe in their report published in Canadian Nurse the drawbacks to the three approaches most healthcare facilities use:

  • Pulse Oximetry deceptive: “The results of pulse oximetry may be deceptive, especially when the patient is receiving supplemental oxygen, because it may detect an adequate level of arterial oxygen even when the patient’s respirations are depressed. Pulse oximetry does not detect changes in respiration rate, pauses in breathing or exhaled carbon dioxide levels, which are important early indicators of respiratory depression. In addition, declining ventilation in patients on supplemental oxygen may not be recognized until bradypnea progresses to apnea, which can lead to harm or even death.
  • CPAP not sufficient: “Although many patients with OSA are effectively treated at home with established CPAP, CPAP alone is not sufficient to manage patients postoperatively. The addition of general anaesthetic and opioid therapy places the patient at higher risk. Knowing the patient is receiving CPAP may also give care providers a false sense of security.”
  • One-to-One Care costly: “Providing one-to-one care is costly, and cohorting of postoperative OSA patients does not always allow for care by providers who have the specific knowledge and competencies required for individual patients.”

So, what did KGH do?

Following an extensive review of the literature and attendance by KGH’s respiratory clinical supervisor at an AARC American Association for Respiratory Care conference, KGH implemented bedside monitoring and became the “first facility in Canada to implement continuous bedside capnography monitoring for postoperative patients with a history of OSA who are discharged from the recovery room to patient care wards.”

The results?

Lynn Gerein, RN, BScN (Network Director, Emergency & Trauma Services, Interior Health Medical Affairs and Clinical Networks) explained in an email:

Implementing this process has increase the capacity to monitor more patients with diagnosed sleep apnea and allow them to be recovered on the unit with the appropriately trained staff that aligns with their surgical needs.

Moreover, as the report describes:

A review of the program after one year showed a 70 per cent reduction in operating costs on the surgical unit in which these patients had previously been cared for, because one-to-one monitoring was no longer required.

However, the real benefit of the program has been improved patient safety. As Lynn says:

The process that was put in place was in the interest to safely and effectively monitor post surgical patients with sleep apnea.

More patients treated, at less operating costs, for better patient safety — that’s a triple win!

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