Developing an Inpatient Sleep Navigator Program

I will go ahead and admit it right now- I'm old. An "original gangster" sleep technologist. Paper polygraphs, ink squirting all over my scrubs and I can "hear" when a patient goes into rapid eye movement (REM) sleep old. Thus, you will understand that when I write about developing an inpatient sleep navigator program, the history goes back a long time. In 1996, after selling a sleep center I founded to a large, multi-national hospital company, I was afforded the opportunity to meet with the chief executive officer. He was a very well respected hospital leader and to be honest, I was lucky he had agreed to spend five minutes with me, much less the entire hour we ended up discussing sleep and all of its possibilities on improving patient outcomes.

At that time, this health system owned and operated well over 100 locations across the United States, and we were experiencing the golden age of attended sleep study growth. As we looked ahead to the next five to 10 years, we discussed the fact that there were striking similarities between our patients suffering with untreated sleep apnea and many of the patients being seen in the intensive care unit (ICU). Multiple comorbidities, obesity, type II diabetes, multiple hypertension medications and of course, significant witnessed hypoxemia. Re-admission penalties were still on the horizon and were not yet a significant cost to most hospitals. I recall commenting during our discussion, "Wouldn't it be nice if we could screen everyone who comes in our hospital doors for untreated apnea, imagine the lives (and marriages) we would save!"

It only took me another 25 years to pull it off, and we certainly weren't alone. Across the country there were numerous, brilliant sleep physicians, technologists and leaders all struggling with the same thoughts and ideas. The turning point for me and my organization, with respect to getting appropriate inpatient screening in place, occurred on Jan. 24, 2017, when the U.S. Preventive Services Task Force released its recommendations about the effectiveness of screening for obstructive sleep apnea (OSA).¹ While they concluded that there was insufficient evidence for screening asymptomatic patients, they did find evidence that treating symptomatic patients did improve outcomes. Just one year earlier, the American Association of Sleep Medicine (AASM) had commissioned Frost and Sullivan to investigate the dynamics of sleep apnea diagnosis and treatment and its impact on health care and workplace economics in the U.S. The result was a 25-page report titled "Hidden Health Crisis Costing America Billions: Underdiagnosing and Undertreating Obstructive Sleep Apnea Draining Healthcare System."² This report was a gold mine in terms of actual financial data. Together, these two articles highlighted two key facts: 1) sleep apnea was (and continues to be) grossly underdiagnosed and 2) this was and still is costing health care providers and insurers billions of dollars each year.

Armed with this information, my team and I made our pitch: screen every inpatient for OSA and subsequently have sleep testing scheduled as part of the discharge plan for anyone identified at a high risk of untreated sleep apnea. Of course, this sounds simple, but the reality was not. There were so many factors to consider. What screening tool should we use? How would testing be ordered? Who would educate the patient? What would the flow even look like? How would success be tracked?

In the end, we opted to utilize the STOP-Bang, a tool originally developed and validated as a screening tool to identify surgical patients who are at high risk of OSA.³ Given the sensitivity results from the initial research on the STOP-Bang, we opted to use a positive score of 5 or higher, which has a 96% likelihood of detecting any OSA.⁴

While some centers across the globe screen specific inpatient populations, such as those status post myocardial infarction (heart attack), chronic obstructive pulmonary disease (COPD) or stroke, we decided to go with everyone. Literally everyone that gets admitted. Why? The prerequisite for suffering from untreated sleep apnea (or any sleep disorder, for that matter) comes down to two essential factors: 1) Are you human? and 2) Do you sleep? Believe it or not, all the patients admitted fell within these constraints.

We have seen car accident patients admitted with broken bones who scored a seven, for example. The cause of admission does not correlate directly to whether a person will yield a positive or negative STOP-Bang. Some admission types have a higher probability, yes, but everyone can suffer from an untreated sleep disorder. Screening takes about 27 seconds, faster if the patient knows their neck size, so why not screen everyone?

We also spent almost a year discussing by whom and how screening would take place and subsequently who would perform the necessary patient education and documentation. Initially, we utilized a nurse navigator. However, nursing is an incredibly busy field and even prior to the COVID-19 pandemic, nurses were in extremely short supply. After lengthy discussions with our medical director and talent acquisition teams, the decision was made to utilize technologists certified in clinical sleep health (CCSH)- a relatively new, and in my opinion, far underutilized credential awarded by the Board of Registered Polysomnographic Technologists (BRPT).

The process, although it took a lot of interaction and engagement from multiple departments, ended up being relatively smooth and effective. A high-level overview of the process can be viewed in the chart below.

Once we turned the process on, the results were immediate and to be honest, quite dramatic. I was expecting perhaps 5%-10% of admissions would end up with a positive STOP-Bang and of that subset perhaps 1% would be persuaded to undergo diagnostic sleep testing as part of their discharge plan. The actual results in the first 12 months ended up being much more remarkable.

Roughly 6,000 patients were screened at one hospital in the first year. A whopping 16% of those admissions screened positive with a STOP-Bang score of 5 or higher. Of that subset, nearly 50% decided to schedule a consult and/or sleep testing. Essentially, after factoring in all the math, 5% of all admissions were ending up having a sleep study and had never before been evaluated or treated for sleep apnea.

I've had a few people tell me that this number seems low. Five percent of 6,000 patients equates to roughly an incremental increase in testing of 300. That is above and beyond standard referrals. To a center struggling to keep attended sleep study volume up, that is a dramatic amount of new business volume. Finances aside however, that is also a lot of lives saved and we also experienced a marked drop in readmissions. In that first year, only six patients were readmitted and two passed away. This was less than 1% of our total positive screens. Considering that the mean and median hospital admission rate can range between 2.6% and 19% for all causes, our 1% was a notable improvement and statistically relevant.⁵ In July 2021, Dr. Bill Mayfeld, a thoracic surgeon at Wellstar Health System stated "the navigator is the glue to facilitate synchronous care" while speaking at a national conference. For our program, screening inpatients and utilizing a sleep navigator has been a source of extreme growth in positive patient outcomes, reductions in readmissions and an increase in lives saved. If you find your program is in need of reducing readmissions and you want to improve the lives of your patients in your community, investigate how you can implement inpatient screening to yield nothing but positive results.

References

1. US Preventive Services Task Force, Bibbins-Domingo K, Grossman DC, et al. Screening for Obstructive Sleep Apnea in Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2017;317(4):407-414. doi:10.1001/ jama.2016.20325.
2. org. 2016. Hidden Health Crisis Costing America Billions: Underdiagnosing and Undertreating Obstructive Sleep Apnea Draining Healthcare System. [online] Available at: https:// aasm.org/resources/pdf/sleep-apnea-economic-crisis.pdf. Accessed 25 July 2022.
3. Chung F, Abdullah HR, Liao P. STOP-Bang Questionnaire: A practical approach to screen for obstructive sleep apnea. Chest. 2016;149:631–638.
4. Nagappa M, Liao P, Wong J, et al. Validation of the STOP-Bang Questionnaire as a Screening Tool for Obstructive Sleep Apnea among Different Populations: A Systematic Review and MetaAnalysis. PLoS One. 2015;10(12):e0143697. doi:10.1371/journal.pone.0143697.
5. Wang Y, Eldridge N, Metersky ML, et al. Analysis of Hospital-Level Readmission Rates and Variation in Adverse Events Among Patients With Pneumonia in the United States. JAMA Netw Open. 2022;5(5):e2214586. doi:10.1001/jamanetworkopen.2022.14586.