The purpose of this chapter is to provide sleep programs with a fundamental approach to developing a program for identifying, assessing, and managing hospitalized patients at increased risk for sleep-disordered breathing (SDB). The complex interactions between SDB and other common disorders such as treatment-resistant hypertension, chronic obstructive pulmonary disease (COPD), type 2 diabetes, atrial fibrillation, stroke, and congestive heart failure (CHF) have been associated with multiple hospitalizations and readmissions in many patients as well as an increased risk of sedation complications and medication interactions.

Despite widely available information about the clinical importance of screening for SDB, and the citation of SDB as a patient safety issue by the Joint Commission (1), the majority of patients with SDB remain unrecognized and undiagnosed. There may be a variety of reasons for this. The symptoms and risk factors for SDB are neither sensitive nor specific for SDB and overlap with many other important medical conditions, some of which may be the conditions driving admission to the hospital.

The recent declaration by the US Preventive Services Task Force that “the current evidence is insufficient to assess the balance of benefits and harms of screening for obstructive sleep apnea (OSA) in asymptomatic adults” has led to some unfortunate confusion (2). Health care professionals may mistakenly apply this recommendation to the acute care setting, where symptoms are often present, and where the balance of risk and benefit favors screening for SDB.

Adult and pediatric patients with SDB are at risk for complications during hospitalization or surgery. These patients may experience complications when receiving sedatives, opioid analgesics, or general anesthesia, increasing the risk of prolonged apnea and respiratory arrest. SDB can be worsened by the use of sedatives and narcotics.

Evidence suggests an association between SDB and COPD and CHF readmissions, conditions monitored closely by Medicare’s Hospital Readmission Reduction Program. Untreated obesity hypoventilation syndrome increases the risk of acute and chronic hypercapnic episodes, as well as having a significant impact on long-term survival. SDB screening programs are an important way
to identify these patient populations. Implementation of treatment in these patients has been shown to convey benefits. Studies have shown that patients hospitalized with CHF and/or COPD with SDB who are adherent to treatment have a lower 30-day readmission rate than untreated SDB patients.

Sleep technology professionals, especially sleep health educators with established core competencies, have an opportunity to participate in implementing procedures that help reduce readmission by establishing screening solutions. These strategies include building processes that identify, screen, and facilitate testing and initiate treatment of patients with SDB.

The Joint Commission issued an advisory on safety and quality issues relating to patients with OSA in June 2015 (2). The advisory cites sentinel events in which patients were diagnosed or suspected to have OSA, which may have been a contributing factor in some of the cases. In this advisory, staff in The Joint Commission’s Division of Healthcare Improvement cite the following concerns regarding OSA:

These concerns should be kept in mind as you develop your program to assure that they are addressed.

Screening of inpatients for SDB is intended to prevent SDB-related complications, protect patients from potential harm, reduce readmissions, and provide exceptional patient-centered care by improving patient wellness. The role of the sleep center technologist or clinical sleep health educator is to collect and summarize patient health information including vital signs and questionnaire results necessary for evaluation of risk for SDB. There should be set protocols in place to alert appropriate health care providers when patients meet criteria for an elevated risk of SDB. The clinical sleep health staff can manage the process of monitoring patients during hospitalization and work with the patient care team to coordinate an appropriate sleep care follow-up plan.