Kristina Weaver, EMT-P, RPSGT, ensures medical center colleagues across all specialties play the sleep advocate.
Kristina Weaver, EMT-P, RPSGT, cares deeply about her patients, but she’d rather not see them back at Parrish Healthcare. As director of Care Navigation for the Sleep Navigator/Educator Program at the Titusville, Fla, health system, Weaver has managed a 30% reduction in readmissions for newly identified sleep apnea patients over the last four years,1 a result of healthier patients with positive outcomes.
The improvement comes courtesy of what Weaver calls a more person-centered approach, with screening and education throughout the continuum of care. A person-centered approach gets patients actively involved in their own care, helping them take ownership of their treatment.
“If you have sleep apnea, you cannot effectively treat other comorbid conditions,” Weaver explains. “Take heart failure as an example. When a patient comes into the hospital with left ventricular heart failure and [has] untreated sleep apnea, that left ventricle has to work even harder because it lacks oxygen due to the sleep apnea. Getting that patient to understand how those things work together, and want to fix the problem for themselves, is vital.”
Before Parrish Healthcare started its Sleep Navigator program, many colleagues in the hospital did not even know an on-site sleep center existed. But now, according to Weaver, the mindset throughout the various subspecialties has dramatically changed. “Now when a heart attack patient comes into the [emergency room] who complains of chest pain, or complains of fatigue and poor sleep, they immediately think of sleep medicine,” she says. “In the past, the two and two may not have been put together. No matter if it’s in our diabetes support group, pulmonary rehab, physician practice—anywhere in our network—we treat sleep as a vital sign.”
Sleep Support Group
Once patients get treatment for their sleep apnea, they are often referred to the sleep support group, dubbed “Brevard A.W.A.K.E (Alert, Well and Keeping Energetic).” Of course, in this context, Weaver wants to see her patients again.
The group often attracts 40 to 50 people each month, a large number for Titusville, where the total population is less than 50,000. The annual holiday meeting routinely brings out a whopping 150 patients. It’s a legitimate community centered on a subspecialty that is relatively young within the medical world.
“Kristina helps with leading Parrish’s A.W.A.K.E. group every month,” says Michele Roberge, neurodiagnostics lead technologist at Parrish Medical Center. “She is just as eager to see the members as they are to see her. The relationships that she has built with these patients over the years is an awesome thing to see. What makes her a great leader is the combination of passion, compassion, dedication, determination, knowledge, and stewardship that she portrays daily.”
With A.W.A.K.E. meetings and ongoing sleep support calls, CPAP adherence has not dropped below 82% in five years. The number—a testament to the program’s effectiveness—is a quality measure that the sleep center reports monthly, based on online monitoring of patients’ device usage. It’s a large commitment, made possible, at least in part, by Weaver’s experiences with her own father.
She remembers: “Years ago, I did a sleep study on my dad. He had sleep apnea. He had resistant hypertension and snored horribly. On his study, he had an eight-beat run of ventricular tachycardia, and then later in the night a seven-second sinus pause—all related to apnea. He refused treatment. At 23 years old, I lost my 54-year-old dad to a heart attack in his sleep. That’s when I realized we could have done more. If he had support like an A.W.A.K.E. group to know he wasn’t alone and to learn from others like him, he might have been more successful.”
“Kristina developed the A.W.A.K.E. support group for our sleep apnea patients in the community many years ago,” adds Laurel Ivy, RPSGT, cardiac and sleep navigator at Parrish Medical Center. “These patients have watched Kristina grow in her career and personal life with the arrival of her children and the passing of her father. When A.W.A.K.E. members call the sleep lab, they only want to talk to Kristina, despite knowing she mainly works at the hospital now. She has a very special relationship with these patients and they absolutely love and trust her with their care.”
The culture change at Parrish Healthcare continues with additional features such as partnering with durable medical equipment companies and physicians. The sleep center monitors all patient CPAP modems. “Our goal is for 100% of our patients to receive a support follow-up call within their first week of using CPAP,” Weaver says. “By doing this we can help patients find solutions for better comfort early on. We can also identify any pressure adjustments earlier. If you create a habit within the first week, the likelihood of CPAP adherence within the first 30 days drastically increases.”
A Vital Sign
All too often, sleep medicine professionals see the consequences of their institutions failing to “get it.” With the creation of the Sleep Navigator program in 2014, Parrish Healthcare went that extra step, essentially viewing sleep as another “vital sign,” implementing sleep screenings in its cardiac cath lab, diabetes education forums, operating rooms, physician practices, cardiopulmonary rehab sectors—and in the acute care setting. Weaver speaks with confidence when she declares: “I know without a doubt we have saved many lives.”
The team at Parrish Healthcare justifiably takes pride in its many victories, but Weaver does not shy away from stories that do not have such happy endings. She recalls the case of a 53-year-old patient who received a lot of CPAP education. He was an elementary school teacher admitted for chest pain. Upon admission, the care team consulted a sleep navigator, and the patient eventually admitted that he had stopped wearing his CPAP a month ago.
Weaver continues the story: “I went up to his room. He had his 3-year-old granddaughter on his lap and his wife by his side. He had a number of excuses why he didn’t want to wear his CPAP machine. I educated him about the consequences of not wearing CPAP. He had an [apnea hypopnea index] of 88 with oxygen that dropped into the 60s. Multiple team members tried to convince him to wear his CPAP, but he refused. His nurse, nursing assistants, and doctors all warned him. He continued to refuse. Unfortunately, at 53 years old, he died of a heart attack at 3 am.
“This was a very unfortunate event, but I was proud of our care team for identifying the risk of this patient not wearing his CPAP. Years ago, many here would have never even thought to talk to him about his sleep apnea.”
The anecdote demonstrates the importance of the “vital sign” that is proper sleep, and the vital sign concept has indeed gained traction in recent years. Weaver believes the trend will only continue. “Sleep is one of our most basic human needs, but it’s rarely discussed by clinicians or providers,” she says. “When sleep is poor, chances are extremely good it’s due to an undetected or untreated health problem. It might be an undiagnosed medical condition, an underlying sleep disorder, medication problems, or even mental health concerns.
“Most doctors talk to you about your medications, diet, exercise. How many talk to you about sleep? Not many, but it’s obviously a question that should be asked,” Weaver continues. “I do think sleep techs understand and wish more doctors asked about sleep. However, it’s hard to get others outside of our sleep world to put two and two together. As sleep technologists, we need to advance our field and get sleep on the forefront. We need to be better advocates.”
Another example is atrial fibrillation, a condition in which patients with untreated sleep apnea routinely have a 70% reoccurrence rate. “When you treat sleep apnea, that brings risk down to 40%,”2 Weaver says. “By identifying and treating sleep apnea in patients with comorbid diseases, we are potentially treating the original underlying root cause of their illness.”
The sleep center at Parrish Healthcare is fully integrated with its physician practices and hospital. Integrating all providers with the “closed loop” sleep center bolsters communication and increases the sense of urgency to identify and treat underlying disorders. Weaver contends that screening for sleep apnea within the “inpatient acute care setting” is also crucial.
Early identification of sleep problems is a key component of care throughout the entire Parrish health network. Like many health concerns, the best time to identify sleep problems is “as early as possible,” but all too often Weaver finds patients in the sleep center with severe pulmonary hypertension, heart failure, arrhythmias, or worse. If these patients were identified years before, Weaver says it’s at least possible they may not have developed the conditions in the first place.
It’s a forward-thinking point of view that began in earnest five years ago when Sleep Navigator emerged within the context of a new way to look at health care. “Health care used to be a fee-for-service type of industry,” Weaver says. “Hospitals now are being held responsible for how well they can treat patients with the lowest costs possible. This means lower length of stay, fewer readmissions, fewer complications, and best short- and long-term outcomes.”
Weaver points out that sleep apnea is much more prevalent among hospitalized patients than in the general population—more complications, higher risk for mortality, and a high use of rapid response interventions. Done properly, sleep medicine brings all the roles into the fold, with “nurses, certified nursing assistants, patient care safety ‘sitters,’ ER techs, physicians, and even cardiac monitoring techs”—all of whom need to be educated in an effort to bring awareness to patients’ sleep needs.
“Many times the nurse may walk in the patient’s room and not think twice about their snoring,” Weaver says. “They may give the patient sleeping aids or pain medications and potentially make their patient’s undiagnosed sleep apnea worse. In our organization, any department from surgery, cath lab, to the physician practices can speak up and be an advocate for sleep apnea and understand the risks. The goal with the sleep navigator is to identify our sleep apnea patients earlier before they end up with multiple comorbid conditions.”
Ultimately, Weaver’s goals are accomplished through a day-to-day focus that transcends raw statistics. Patients are not numbers but recognized as human beings who benefit from education, attention, and expertise.
Inspiration Comes From Many Sources
Weaver credits a certified nursing assistant (CNA) named Patience Hall as a main source of inspiration. “I started my career in health as a CNA in an operating room with Patience,” says Weaver, who remains Facebook friends with Hall (who continues to work as a CNA). “She taught me to care with passion and to treat every individual as a person, not a patient. It’s easy to get wrapped up in your day and your work. I am motivated by patient success stories and the lessons from those that maybe weren’t so successful. Patience instilled in me that passion for every patient, every time.”
Greg Thompson is a Loveland, Colo-based freelance writer.
1. Weaver K. In-hospital sleep apnea screening decreases readmissions and improves quality of life. Poster presented at the AAST 2018 Annual Meeting, Indianapolis.
2. Kanagala R, Murali NS, Friedman PA, et al. Obstructive sleep apnea and the recurrence of atrial fibrillation. Circulation. 2003;107:2589–94.