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Quality assurance in the sleep center.

Many of the procedures and processes used in a sleep center are unique; and comparable goals for development exist in all areas of health care. One of these goals is to monitor items that are "high volume" or "high risk" as well as those that influence outcomes. Outcome measurement has thus become highly valued.

There are many ways to measure quality in the sleep center. The process, however, can overwhelm the individual in charge of QA, thus it is useful to have the entire staff work on the program, both in the development and implementation stages.

The process by which a patient comes in for a sleep evaluation provides a road map to the many steps involved, with each step providing a variety of potential monitoring points. The manner in which a patient enters the system for polysomnography varies from center to center. Although there is no required process, how well the clinical notes, orders and other pre-test data are gathered offers many opportunities for evaluation. This can be as simple as having a staff member complete a checklist about the presence or absence of information. As with many quality assurance monitors, we often do this on a daily basis in a less formalized way. Simply adding a place for writing down information gathered as you go then, can make monitoring less cumbersome.

Once a patient arrives for a sleep test, the technologist performs a number of tasks. These are high volume activities and provide a rich area for development of monitors. Other staff or supervisors can evaluate the technologist's placement of electrodes against a standard. Sleep centers can consider using a representative sample, such as every fourth patient or a percentage of those studied. Impedance testing of the electrodes can be stored in the record and the staff can set acceptable impedance for various electrodes. Consideration of these standards and your center's unique circumstances will influence the ultimate limits. The overnight staff or scoring technologists can collect the aggregate as they work with each record. Maintenance of high quality recordings thru the night is another item to consider. The interpreting physician should look at the raw data for each record as they interpret. Having a log provides a way to include the physicians in the process. Staff physicians can note the quality of each test while she/he looks at the records. Alternately, a center may record the incidence of artifacts, electrode problems or other factors which limit the ability to score.

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Of course, sleep centers also use treatment interventions. It is useful therefore to look at these interventions so as to ascertain their effectiveness. Probably the most important thing to do in this regard is to first define the meaning of effective. Is it the reduction in AHI to a normal range or by a certain percentage? Is it a significant improvement in sleep quality? Another tactic may be to look at the refusal rate for PAP devices.

After the test, scoring the record is the next area to consider. However, looking at the quality of the scoring requires additional evaluation. Again, the interpreting physician may give an overall appraisal of the quality of scoring on each record as the record is interpreted. Multiple individuals can score a common record and then compare their results to find the "scoring reliability" or agreement among scorers. Looking at sleep staging may be done on an epoch-by-epoch basis or in a more generalized manner. Likewise, identification of events such as limb movements, hypopneas or apneas may be done on an occurrence-by-occurrence basis or with overall indices (apnea index, hypopnea index, etc.) comparisons. Turnaround time for reports following the test is another item to consider monitoring. This may be broken into scoring time, time to dictation, time from dictation to final signed report.

The important outcome measure is the impact of the test on the health of the individual. This can be more difficult for those patients accepted for testing without seeing a staff physician or who are unlikely to return for follow-up. Whatever the challenge, collecting information on whether patients receive treatment based on test results is a way to measure outcomes. A log of "treatment prescribed" versus "none prescribed" after a pre-determined timeframe is a possible measure. Another way to measure out-comes is to use more detailed info such as pre and post-testing Epworth Sleepiness Scale scores or changes in blood pressure.

As with all quality assurance programs, data collection begins the process. It is important to review data on a regular basis and create a plan for intervening when necessary. Interventions may be as simple as education or discussion or as complex as requiring major revamping of processes used. A good Q.A. program will tell you what your lab has to do.

by Robert Turner RPSGT
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Title Annotation:SLEEP MEDICINE
Author:Turner, Robert
Publication:FOCUS: Journal for Respiratory Care & Sleep Medicine
Date:Mar 22, 2005
Words:800
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