Obstructive Sleep Apnea: Project Proposal

Obstructive Sleep Apnea: Project Proposal
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Abstract
Obstructive sleep apnea is when an individual has recurrent apnea episodes, related to the narrowing or closure of pharyngeal airway during sleep. Various deleterious complications are associated with OSA, including daytime somnolence, cardiovascular complications, cerebral vascular complications and impairment in glucose control. These complications are associated with a high socioeconomic burden. Viewed with the numerous complications of OSA, it is imperative to find a solution that will tackle the disease at an early stage (mild disease). The proposal seeks to change the management of mild OSA, by incorporating continuous positive airway pressure (CPAP) as an additional intervention to nurse initiated weight reduction and positional intervention during sleep. The proposed changes are supported by 15 up-to-date articles. This is to ensure evidence-based implementation. CPAP should be recommended for all patients presenting with features suggestive of OSA. This is in combination with nurse initiated weight reduction, with education provision by the nursing staff to the patient. In addition, the implementation plan recommends regular follow-up visits by specialist nurses. The implementation will be carried out for one year, whereupon an evaluation will be conducted so as to discern the effectiveness of the proposed intervention. Various outcome objectives will be evaluated, including decreased complications rates in OSA, improvement in the patient`s quality of life and improvement in patient and nursing staff satisfaction. The evidence gathered from the project will be disseminated to pertinent stakeholders. This will be via journal publishing, organization/hospital based education meetings.
Keywords: Obstructive sleep apnea, evidence-based intervention, Continuous positive airway pressure, apnea/hypopnea index, weight reduction and positional intervention.
 
1 Introduction
Obstructive sleep apnea (OSA) is a disease where an individual has recurrent episodes of apnea attributed to the narrowing or closure of the pharyngeal airway during sleep (Kapur, 2010). The closure leads to pauses and reduction in the breathing process. This causes abrupt reduction in oxygen saturation levels leading to various complications. Currently, continuous positive airway pressure (CPAP) is a modality that is used in the treatment of advanced disease. This means that is often utilized for the treatment of OSA, when the apnea/Hypopnea index (AHI) is more than or equal to 15. OSA is regarded to as mild when the AHI ranges between 5 and 14 (Kapur, 2010).
OSA can be classified into mild, moderate and severe disease depending on the clinical characteristics of the disease (Butt et al., 2012). OSA has been identified as a chronic and progressive non-communicable disease whose management is costly. Over the years, advancements in technology have revolutionized the management and prognosis of OSA. Currently, the application of Continuous Positive Airway Pressure (CPAP) in moderate and severe cases has significantly contributed to the improvement in the prognosis of the disease. The study seeks to employ nursing practices, for example, patient-weight reduction, and early treatment of CPAP in the management of OSA.
2.0 Description of problem
OSA is a chronic disease that is associated with frequent episodes of airway collapse during sleep. OSA affects an estimated 3% to 7% of the world population with high-risks subgroups reporting a higher prevalence rate (Butt et al., 2012). Higher incidence rates are reported in patients with obesity, male gender and elderly population. Epidemiological studies report that OSA has been diagnosed in both developed and developing countries. Despite the advancements in technology and understanding of the pathogenesis involved in development of OSA, high morbidity and death rates associated with OSA and its complications are reported.
CPAP decreases complications attributed to severe OSA. The complications of OSA include increased daytime somnolence leading to increased accidents rate and machine handling errors (Kapur, 2010). The complications also include heart related complications, chronic daytime blood pressure elevation, cerebral vascular accidents and impaired glucose tolerance due to irregular cortisol rhythm (Kapur, 2010).
For this study, the research question will be "In adult patients with mild Obstructive Sleep Apnea (OSA) (P); is CPAP therapy (I) or other modalities (C), for example, surgery, administered in early disease more effective in reducing the occurrence of complications (O)?" The study will focus on the adult population diagnosed with early disease which refers to mild OSA. Currently, CPAP treatment is implemented for moderate and severe OSA.
3.0 Proposed Solution
Continuous positive air pressure should be recommended for all patients presenting with the features of OSA. Therefore, CPAP should not only be used for moderate and severe OSA, but also for mild cases. This means that hospital/departmental policy with regards to the treatment of OSA should change. CPAP should be used even when AHI is below 15. The nurse should provide the patient with education materials/brochures on how to use the devices, and any precaution therein. Conventional nasal masks should be recommended in the use of CPAP. This plan recommends regular follow-up visits by specialist nurses on patients under CPAP. Regular follow-up by specialist nurses will increase patient satisfaction.
CPAP should be used in combination with other treatment modalities, so as to improve the quality of life in mild OSA. Another intervention that should be undertaken concomitantly with CPAP is weight reduction initiated by the nursing staff. Intervention on weight reduction will principally involve nurses educating the patient, and empowering them to undertake measures to lower their Body Mass Index to a favorable level. The BMI should be lowered to less than 24 kg/m2. The nurse should educate the patient in conjunction with the physical therapy department. Nurses should avail educational materials inclusive of the necessary interventions and schedule to the patient with mild OSA. The nurse should also educate the patient on positional therapy during sleeping. Sleep studies should be performed on these patients so as to document individual improvement after positional intervention.
In patients who cannot tolerate CPAP, intraoral protrusion devices should be utilized. Nonetheless, nasal pillows or Oracle oral mask are a useful alternative as a CPAP delivery method, before the use of protrusion devices. Mandibular Advancement Devices should be recommended for this subgroup of patients. These devices should be tailored to the individual patient. Evaluation should be undertaken. The device should be able to advance the mandible for at least 50 percent of the maximum protrusion.
3.1 Rationale for Selecting Change
There is an increasing prevalence of OSA among the general populace (Butt et al., 2012). This is associated with changing lifestyles, and with the increasing obesity and overweight cases in the society. At least 2 percent of women and 4 percent of men have OSA (Kapur, 2010). It is estimated that more than 80 percent of adults with OSA remain undiagnosed. This means that a person presenting to the hospital with signs and symptoms of OSA has surpassed this "undiagnosed" bracket, and though the patients AHI may be less than 15, early intervention will improve the quality of life. CPAP decreases cognitive impairment and sleepiness, (when gauged by subjective and objective measures) (Butt et al., 2012). It will have the same benefits in mild OSA with symptoms, and will decrease daytime somnolence and other complication. Additionally, CPAP normalizes the risk of workplace and traffic accidents. This is one of the reasons for proposing to incorporate CPAP in the management of early disease. Regular follow-up visits by a specialist nurse retain high patient satisfaction, while optimizing on health care resources (Kapur, 2010).
Combination of CPAP with other treatment modalities will help the nurse and other staff combat the disease in a multifaceted approach from an early stage (Veasey et al., 2009). CPAP in itself does not allow for a permanent solution of respiratory disturbances. It only suppresses them whilst the patient is on the device. Therefore, it is necessary to combine CPAP with other comfortable/curative options in the management of mild OSA. Weight reduction decreases OSA risk factor of obesity. Positional intervention during sleep alters the airway in a manner supporting breathing. Mandibular advancement devices are better tolerated, hence they are proposed to be utilized in patients who cannot tolerate CPAP (Butt et al., 2012).
4. Implementation Plan
4.1 Methods of Obtaining Approval
Hospital approval will be sought for the implementation of the project. Hospital approval is necessary so as to track the impact of proposed changes in the management of obstructive sleep apnea (OSA) (Butt e al., 2012). Early consultations will be sought with the relevant department and other nurses. This will ensure that a feasible plan is prepared, before seeking hospital approval. A detailed plan will be provided to the hospital administrators. This will also have signatures of the project executer, the operational administrators of the involved departments and the department head.
In addition, other nursing staff members will be made aware of the proposed intervention for mild OSA. Most of these staff will have been engaged in the preparation for the project; hence will be aware of the plan beforehand. It is imperative to engage all the relevant staff to ensure smooth running of the proposed change process. The nursing staff will be engaged in an active manner.
4.2 Logistics
Implementation of the proposed changes will be undertaken by the involved departments which include nurses, physicians, physical therapists and hospital administrators. The nurses will principally be involved in the implementation process. The outpatient department concerned with respiratory care/internal medicine will also be involved. The nurses and physicians working in the unit will be responsible for change. This is an addition to physical therapists that will assist in weight reduction measures. The implementation will be carried out over one year duration where upon an evaluation will take place to determine the efficacy of intervention.
4.3 Resources Required
Educational materials will be required during the dissemination of knowledge to the various nurses and other staff involved. The educational materials will detail the disease, disease complications and the effectiveness of treatment modalities. For this purpose, posters will be designed showing the complications of OSA. In addition, they will also depict the benefits of CPAP. Handouts will also be given, showing the importance of intervening early in patients with OSA. A laptop and a projector will be utilized in delivering a power point presentation to the staff. There will also be assessment tools, which will include questionnaires, pre and post- tests to evaluate whether the education process was successful.
Funds will be needed for the above resources which include papers and other writing material. For the technology bit, there is already a laptop and a projector which can be obtained on request. Staff who will be requested to attend include all the nurses dealing with service delivery to patients with respiratory problem, in addition to physical therapy department staff and the administrative leaders. The session does not, however, lock any other interested health care giver.
5.0 Evaluation Plan
After implementation of the proposed changes, an evaluation will be undertaken in order to discern the effectiveness of the intervention. This plan will cover evaluation of implementation objectives, outcome objectives and the procedures for managing and monitoring the evaluation process. The target populations during the evaluation include adult patients with mild obstructive sleep apnea (OSA) and nursing staff. Mild OSA is patients with apnea/hypopnea Index (AHI) of less than 15 (Colm & Maxine, 2011). The intervention to be evaluated is the incorporation of CPAP as an additional treatment modality to weight reduction and positional intervention during sleep. The outcomes are related to enhancement of OSA patient`s quality of life, decreased complications rates in OSA, and increased patient and nursing staff satisfaction.
On the evaluation of implementation objectives, measurable terms will include the timeframe, the project implementers and the patients treated. The implementation timeframe will be one year. The Project implementers include the nursing staffs working in the internal medicine outpatient clinic and those that deal with service delivery to patients with respiratory problems. The information to be collected includes the number of nursing staff attending to patients with mild OSA in the given duration. The number of patients treated for mild OSA will also be collected. Confidentiality of information will be maintained during the evaluation (Melnyk & Fineout-Overholt, 2010). The data will be collected from the first implementation date to the last date during the one year duration. Patients` records will be accessed in assessing this information.
On the evaluation of the outcome objectives, data will be collected on various outcomes. To begin with, the rate of complications of OSA will be analyzed before and after implementation of interventions. Any of the following complications will be counted- increased daytime somnolence, heart related complications, chronic daytime blood pressure elevation, cerebral vascular accidents and impaired glucose tolerance (Colm & Maxine, 2011). The sources of information will be hospital records. The data will be collected before the intervention, and after one year of implementation. All the records pertaining to OSA patients will be utilized. An assessment of the impact of the intervention on the rates of OSA complication will be undertaken.
Another outcome objective is the improvement in the quality of life in patients suffering from mild OSA. Qualitative data will be utilized for assessing this information. The source of information will be from the treated patients, whereupon a representative sample will be chosen so as to discern the changes in the quality of life after intervention. Semi-structured interviews will be utilized for collection the information, and the data collected will be transcribed verbatim (Holloway & Wheeler, 2009). The next outcome objective is the improvement in the nursing staff satisfaction in relation to the service delivery in the management of OSA patients. Again, qualitative data will be collected from nursing staff involved in the management of OSA patients. Interviews will be utilized as methods of data collection, where upon the satisfaction levels will be noted. Closely related to this objective is patient satisfaction with the new intervention. The sample population will also be derived from the patients with mild OSA treated during the implementation timeframe.
Colleagues will be trained in collecting evaluation-related information. In addition, quality control checks of process of information collection will be undertaken, where upon information will be compared betw...