HARMONY IN THE SLEEP LAB: A FOCUS ON RECOGNITION OF HYPOVENTILATION AND DIRECT FEEDBACK IMPROVES QUALITY OF PEDIATRIC TITRATIONS

Abstract Introduction Over 350 pediatric polysomnogram titrations (T-PSGs) are performed each year at the Sleep Laboratory at Children’s Hospital of Philadelphia in three locations by 24 different polysomnography technologists (PSGTs) on a diverse patient population, typically performed as outpatient procedures and occasionally at the bedside as inpatients. PSGTs are responsible for titration of continuous or bilevel positive airway pressure based on flow, work of breathing, arousals, and/or gas exchange. PSGTs have varying degrees of experience; thus, maintaining quality of T-PSGs is challenging. We hypothesized that a quality improvement (QI) approach to reviewing T-PSGs with interdisciplinary education and regular feedback would improve T-PSGs. Our goal was to have >/= 80% of titrations of optimal quality. Methods Each T-PSG record was reviewed by a sleep physician for optimal quality, defined as appropriate signal integrity, titration, and documentation to permit definitive interpretation. Exclusion: RAM cannula use, illness, or external signal interference. Titration QI (T-QI) comments were reviewed by the sleep lab QI team bi-weekly to plan feedback. Improvement interventions for PSGTs included didactic education: lectures, presentations, and cases focusing on recognition of hypoventilation; direct feedback with teaching points by sleep physician and small group sessions with clinical supervisors to review areas for improvement; and communication of specific titration goals. Satisfaction surveys regarding recognition/titration for OSA/hypoventilation, transcutaneous CO2 signal integrity, and documentation were administered to sleep physicians. Results From September 2020-November 2021, PSGT education included: 1 synchronous and 2 asynchronous didactic presentations; 1:1 review of didactics with each night PSGT (n=24); T-QI feedback (2/week); and small group review sessions (4/week). 408 titrations were completed; 42 (10.3%, 2.8/month) were excluded; 366 (89.7%, 24.4/month) were reviewed for T-QI. 54.8% [50,71%] were deemed optimal during the first three months (pre-intervention) vs. 80.1% [63,96%] during the intervention period. QI satisfaction survey showed improvement in 3 of 4 domains. Conclusion Quality of T-PSG is enhanced by QI review of each titration, highlighting teaching points and areas for improvement via direct feedback and small group review. Education and communication among physicians, supervisors and technologists are important to support development which can result in better titrations and satisfaction. Support (If Any) none