Donovan Lucas M, Fernandes Laurie A, Williams Katherine M, Parsons Elizabeth C, O'Hearn Daniel J, He Ken, McCall Catherine A, Johnson Kelly A, Kennedy Michael W, Syed Adnan S, Thompson William H, Spece Laura J, Feemster Laura C, Kirsh Susan, Au David H, Palen Brian N
Seattle-Denver HSR&D Center for Veteran-Centered and Value-Driven Care, Seattle, Washington.
VA Puget Sound Health Care System, Seattle, Washington.
J Clin Sleep Med. 2020 Feb 15;16(2):279-283. doi: 10.5664/jcsm.8182. Epub 2020 Jan 13.
Incorporating registered nurses (RN-level) into obstructive sleep apnea (OSA) management decisions has the potential to augment the workforce and improve patient access, but the appropriateness of such task-shifting in typical practice is unclear.
Our medical center piloted a nurse triage program for sleep medicine referrals. Using a sleep specialist-designed decision-making tool, nurses triaged patients referred for initial sleep studies to either home sleep apnea test (HSAT) or in-laboratory polysomnography (PSG). During the first 5 months of the program, specialists reviewed all nurse triages. We compared agreement between specialists and nurses.
Of 280 consultations triaged by nurses, nurses deferred management decisions to sleep specialists in 6.1% (n = 17) of cases. Of the remaining 263 cases, there was 88% agreement between nurses and specialists (kappa 0.80, 95% confidence interval 0.74-0.87). In the 8.8% (n = 23) of cases where supervising specialists changed sleep study type, specialists changed from HSAT to PSG in 16 cases and from PSG to HSAT in 7. The most common indication for change in sleep study type was disagreement regarding OSA pretest probability (n = 14 of 23). Specialists changed test instructions in 3.0% (n = 8) of cases, with changes either related to the use of transcutaneous carbon dioxide monitoring (n = 4) or adaptive servo-ventilation (n = 4).
More than 80% of sleep study triages by registered nurses in a supervised setting required no sleep specialist intervention. Future research should focus on how to integrate nurses into the sleep medicine workforce in a manner that maximizes efficiency while preserving or improving patient outcomes.
将注册护士（RN级别）纳入阻塞性睡眠呼吸暂停（OSA）管理决策中，有可能增加劳动力并改善患者就医机会，但在典型实践中这种任务转移的适当性尚不清楚。
我们的医疗中心试点了一项针对睡眠医学转诊的护士分诊计划。护士使用睡眠专家设计的决策工具，将转诊进行初始睡眠研究的患者分诊为家庭睡眠呼吸暂停测试（HSAT）或实验室多导睡眠图（PSG）。在该计划的前5个月，专家审查了所有护士的分诊情况。我们比较了专家和护士之间的一致性。
在护士分诊的280例会诊中，护士在6.1%（n = 17）的病例中将管理决策推迟给睡眠专家。在其余263例病例中，护士和专家之间的一致性为88%（kappa值为0.80，95%置信区间为0.74 - 0.87）。在8.8%（n = 23）的病例中，监督专家改变了睡眠研究类型，其中专家将HSAT改为PSG的有16例，将PSG改为HSAT的有7例。睡眠研究类型改变的最常见原因是对OSA预测试概率存在分歧（23例中有14例）。专家在3.0%（n = 8）的病例中改变了测试指令，这些改变要么与经皮二氧化碳监测的使用有关（n = 4），要么与适应性伺服通气有关（n = 4）。
在有监督的环境中，注册护士进行的睡眠研究分诊中，超过80%不需要睡眠专家干预。未来的研究应侧重于如何以提高效率同时保持或改善患者结局的方式，将护士纳入睡眠医学劳动力队伍。
