Bakhai Smita Y, Nigam Mansi, Saeed Musa, Krishnan Amita, Reynolds Jessica L
Department of Internal Medicine, University at Buffalo, The State University of New York, Buffalo, New York, USA.
BMJ Open Qual. 2017 Nov 25;6(2):e000105. doi: 10.1136/bmjoq-2017-000105. eCollection 2017.
Obstructive sleep apnoea (OSA) is more prevalent in patients with hypertension (HTN), and associated morbidities include stroke, heart failure and premature death. In the Internal Medicine Clinic (IMC), over 70% of the patients had a diagnosis of HTN and obesity. We identified a lack of OSA screening in patients with HTN. The aim of this quality improvement (QI) was to increase OSA diagnosis to 5% from the baseline rate of less than 1% in patients with HTN between the ages of 18 and 75 years over 6 months at IMC. We used the Plan-Do-Study-Act (PDSA) method. The QI team performed root cause analysis to identify materials/methods, provider and patient-related barriers. PDSA cycle included: (1) integration of customised workflow of loud Snoring, Tiredness, Observed apnea, high blood Pressure (STOP)-Body mass index (BMI), Age, Neck circumference, and Gender (BANG) OSA screening tool in the electronic health record (EHR); (2) physician education of OSA and EHR workflow; and (3) completion of STOP survey by patients, which was facilitated by nursing staff. The outcome measure was the percentage of OSA diagnosis in patients with HTN. The process measures included the percentage of patients with HTN screened for OSA and the increase in sleep study referrals in hypertensive patients with STOP-BANG score of ≥3. Increase in patient wait time and cost of sleep study were the balance measures. Data analysis was performed using weekly statistical process control chart. The average increase in OSA screening rate using the STOP-BANG tool was 3.88%. The significant variation seen in relation to PDSA cycles was not sustainable. 32% of patients scored ≥3 on the STOP-BANG tool, and 10.4% had a confirmed diagnosis of OSA. STOP-BANG tool integration in the EHR and a team approach did not result in a sustainable increase in OSA screening. OSA diagnosis was increased to 3.3% in IMC patient population within the 6-month period. The team identified multiple barriers to screening and diagnosis of OSA in the IMC.
阻塞性睡眠呼吸暂停（OSA）在高血压（HTN）患者中更为普遍，其相关并发症包括中风、心力衰竭和过早死亡。在内科诊所（IMC），超过70%的患者被诊断为高血压和肥胖。我们发现高血压患者缺乏OSA筛查。这项质量改进（QI）的目的是在6个月内，将IMC中18至75岁高血压患者的OSA诊断率从基线水平的不到1%提高到5%。我们使用了计划-执行-研究-行动（PDSA）方法。QI团队进行了根本原因分析，以确定材料/方法、提供者和患者相关的障碍。PDSA循环包括：（1）将定制的大声打鼾、疲劳、观察到的呼吸暂停、高血压（STOP）-体重指数（BMI）、年龄、颈围和性别（BANG）OSA筛查工具的工作流程整合到电子健康记录（EHR）中；（2）对医生进行OSA和EHR工作流程的培训；（3）由护理人员协助患者完成STOP调查问卷。结果指标是高血压患者中OSA诊断的百分比。过程指标包括接受OSA筛查的高血压患者的百分比，以及STOP-BANG评分≥3的高血压患者睡眠研究转诊的增加。患者等待时间的增加和睡眠研究的成本是平衡指标。使用每周统计过程控制图进行数据分析。使用STOP-BANG工具的OSA筛查率平均提高了3.88%。与PDSA循环相关的显著变化不可持续。32%的患者在STOP-BANG工具上得分≥3，10.4%的患者被确诊为OSA。将STOP-BANG工具整合到EHR中并采用团队方法并没有导致OSA筛查的持续增加。在6个月内，IMC患者群体中的OSA诊断率提高到了3.3%。该团队确定了IMC中OSA筛查和诊断的多个障碍。
