Abstract
BackgroundClinical practice guidelines recommend further testing for people with tetraplegia and signs and symptoms of obstructive sleep apnoea (OSA), followed by treatment with positive airway pressure therapy. Little is known about how clinicians manage OSA in tetraplegia. The theoretical domains framework (TDF) is commonly used to identify determinants of clinical behaviours. This study aimed to describe OSA management practices in tetraplegia, and to explore factors influencing clinical practice.MethodsSemi-structured interviews were conducted with 20 specialist doctors managing people with tetraplegia from spinal units in Europe, UK, Canada, USA, Australia and New Zealand. Interviews were audiotaped for verbatim transcription. OSA management was divided into screening, diagnosis and treatment components for inpatient and outpatient services, allowing common practices to be categorised. Data were thematically coded to the 12 constructs of the TDF. Common beliefs were identified and comparisons were made between participants reporting different practices.ResultsRoutine screening for OSA signs and symptoms was reported by 10 (50%) doctors in inpatient settings and eight (40%) in outpatient clinics. Doctors commonly referred to sleep specialists for OSA diagnosis (9/20 in inpatients; 16/20 in outpatients), and treatment (12/20, 17/20). Three doctors reported their three spinal units were managing non-complicated OSA internally, without referral to sleep specialists. Ten belief statements representing six domains of the TDF were generated about screening. Lack of time and support staff (Environmental context and resources) and no prompts to screen for OSA (Memory, attention and decision processes) were commonly identified barriers to routine screening. Ten belief statements representing six TDF domains were generated for diagnosis and treatment behaviours. Common barriers to independent management practices were lack of skills (Skills), low confidence (Beliefs about capabilities), and the belief that OSA management was outside their scope of practice (Social/Professional role and identity). The three units independently managing OSA were well resourced with multidisciplinary involvement (Environmental context and resources), had ‘clinical champions’ to lead the program (Social influences).ConclusionClinical management of OSA in tetraplegia is highly varied. Several influences on OSA management within spinal units have been identified, facilitating the development of future interventions aiming to improve clinical practice.
Highlights
Clinical practice guidelines recommend further testing for people with tetraplegia and signs and symptoms of obstructive sleep apnoea (OSA), followed by treatment with positive airway pressure therapy
Most doctors who were referring to specialists for OSA management thought that the diagnosis and treatment of non-complicated OSA could potentially be performed within their unit, provided there was additional training for staff (Knowledge and skills), more resources for equipment and staff and changes to the funding rules for positive airway pressure (PAP) devices (Environmental context and resources). This is the first time the breadth of OSA management practices within a spinal unit has been investigated and documented, and the first time a behavioural model, such as the theoretical domains framework (TDF), has been applied to this area of clinical medicine to explore the influences on clinical practice
We found that people with tetraplegia tended not to recognise their symptoms of OSA until after they had been treated with continuous positive airway pressure (CPAP) and experienced the benefits
Summary
Clinical practice guidelines recommend further testing for people with tetraplegia and signs and symptoms of obstructive sleep apnoea (OSA), followed by treatment with positive airway pressure therapy. Little is known about how clinicians manage OSA in tetraplegia. This study aimed to describe OSA management practices in tetraplegia, and to explore factors influencing clinical practice. Obstructive sleep apnoea (OSA) is one such complication, with prevalence estimates of up to 83% in the acute phase, and up to 97% in the community dwelling chronic population [1, 2]. OSA has been associated with daytime sleepiness, poor memory, attention and information processing in both the acute and chronic populations, and is likely to impact on rehabilitation and vocational outcomes [4, 5]. A recent multicentre randomised controlled trial of treating CPAP following acute, traumatic tetraplegia found that while CPAP did not improve neurocognitive function, it did improve subjective daytime sleepiness [6]
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