Preoperative sleep apnea screening protocol reduces medical emergency team activation in patients with atrial fibrillation

Abstract

Study objectives: The association of in-hospital medical emergency team activation (META) among patients with atrial fibrillation (AF) at risk for obstructive sleep apnea (OSA) is unclear. This study evaluates the performance of the DOISNORE50 sleep questionnaire as an OSA screener for patients with AF and determines the prevalence of META among perioperative patients with underlying AF who have a diagnosis or are at risk for OSA.

Methods: A prospective perioperative cohort of 2,926 patients with the diagnosis of AF was assessed for DOISNORE50 questionnaire screening. Propensity-score matching was used to match patients' physical characteristics, comorbidities, length of stay, and inpatient continuous positive airway pressure device usage. META and intensive care unit admissions during the surgical encounter, 30-day hospital readmissions, and 30-day emergency department visits were evaluated.

Results: A total of 1,509 out of 2,926 AF patients completed the DOISNORE50 questionnaire and were enrolled in the OSA safety protocol. Following propensity-score matching, there were reduced adjusted odds of META in the screened group of 0.69 (95% confidence interval: 0.48-0.98, P < .001) in comparison to the unscreened group. The adjusted odds of intensive care unit admissions and emergency department visits within 30 days of discharge were statistically lower for the screened group compared with the unscreened group.

Conclusions: Among perioperative AF patients, evidence supports DOISNORE50 screening and implementation of an OSA safety protocol for reduction of META. This study identified decreased odds of META, intensive care unit admissions, and emergency department visits among the screened group. The high-risk and known OSA group showed reduced odds of META following the implementation of an OSA safety protocol.

Citation: Saha AK, Sheehan KN, Xiang KR, et al. Preoperative sleep apnea screening protocol reduces medical emergency team activation in patients with atrial fibrillation. J Clin Sleep Med. 2024;20(5):783-792.

Keywords: DOISNORE50; OSA safety protocol; atrial fibrillation; complications; obstructive sleep apnea; perioperative.

Figure 1. Consort diagram for the study population.

Of a cohort of preoperative patients (60,129), 2,926 had underlying atrial fibrillation and 51.6% underwent screening for obstructive sleep apnea with the DOISNORE50 questionnaire. OSA = obstructive sleep apnea.

Figure 2. DOISNORE50 action items and OSA safety protocol illustration.

(A) DOISNORE50 action items. The 9 questions are weighted equally, to establish a score from 0–9. Patients with scores of 0–3 were considered “low-risk,” those with scores 4–5 “at-risk,” and those with scores 6–9 “high-risk” for OSA. (B) OSA safety protocol illustration. Patients are risk-stratified with the DOISNORE50 questionnaire in preoperative clinic. Safety interventions include EMR alert, safety wrist band, empiric autoPAP, sleep consultation, and outpatient follow-up. *EMR alert for OSA status remains present during present and future admission until patient undergoes sleep study outpatient. AutoPAP = automatic titrating positive airway pressure, BMI = body mass index, CPAP = continuous positive airway pressure, EMR = electronic medical record, OSA = obstructive sleep apnea.

Figure 2. DOISNORE50 action items and OSA safety protocol illustration.

(A) DOISNORE50 action items. The 9 questions are weighted equally, to establish a score from 0–9. Patients with scores of 0–3 were considered “low-risk,” those with scores 4–5 “at-risk,” and those with scores 6–9 “high-risk” for OSA. (B) OSA safety protocol illustration. Patients are risk-stratified with the DOISNORE50 questionnaire in preoperative clinic. Safety interventions include EMR alert, safety wrist band, empiric autoPAP, sleep consultation, and outpatient follow-up. *EMR alert for OSA status remains present during present and future admission until patient undergoes sleep study outpatient. AutoPAP = automatic titrating positive airway pressure, BMI = body mass index, CPAP = continuous positive airway pressure, EMR = electronic medical record, OSA = obstructive sleep apnea.

Figure 3. Adjusted odds of study outcomes for unscreened groups against DOISNORE50-screened groups.

CI = confidence interval, ED = emergency department, ICU = intensive care unit, META = medical emergency team activation, OR = odds ratio.

Figure 4. Adjusted odds of study outcomes for unscreened groups against DOISNORE50-screened groups among a propensity-matched cohort.

CI = confidence interval, ED = emergency department, ICU = intensive care unit, META = medical emergency team activation, OR = odds ratio.

Figure 4. Adjusted odds of study outcomes for unscreened groups against DOISNORE50-screened groups among a propensity-matched cohort.

CI = confidence interval, ED = emergency department, ICU = intensive care unit, META = medical emergency team activation, OR = odds ratio.