Quality Improvement Project Facilitates Preparation, Treatment Recommendations for Adolescents at Risk for Sleep Disorders

Osman Ipsiroglu, MD, PhD, FRCPC

After implementing a quality improvement project during the COVID-19 pandemic, investigators saw a reduction in preparation/assessment time and more timely identification for patients at risk for sleep disorders, which allowed for better evidence-based treatment recommendations during the wait time for subspecialty services.¹ 

Presented at the World Sleep Congress, March 11-16, in Rome, Italy, the study aimed to complete a few objectives, including characterizing patient load of a sleep/behavior clinic before and during the pandemic, identifying risk factors that could be then targeted at the referral level, understanding the needs of children and patients, and offering more individualized support to them.

In their quality improvement project, lead investigator Osman Ipsiroglu, MD, PhD, FRCPC clinical associate professor, British Columbia Children’s Hospital Research Institute, and colleagues evaluated children and adolescents with neurodevelopmental and psychiatric disorders, aged 2-19 years old, who underwent five 35-or-more hour weeks of ambulatory one-to-one service prior to and during the clinical shutdown. Investigators then added a restructured intake process with qualitative exploratory and quantitative validated questionnaires and assessed their impact on clinical care via virtual home visits and medication strategies.

The implementation of the revised intake and triage resulted in 108 patient encounters via telehealth, a 33% increase from the 81 patient encounters prior to the pandemic. This included short follow-ups by ad hoc phone calls. Prepandemic encounters that scheduled over 5 weeks of service delivery required on average 2.4 hours (165 hours in 24 workdays; without time allocation for breaks, additional administrational tasks, and CME events).

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"Red-flagged" patients, those who are 9-1-1 call eligible at any clinical worsening or needed on average 2-3 times more allocated time per patient, represented 18 of the 81 pre-COVID encounters (22%). Following the new process, the number of red-flagged patients increased by 79%. Furthermore, investigators saw preparation and assessment time cut by one-third, new patient encounters increased by 60%, and follow-ups reduced by 32%.

Ipsiroglu and his colleagues identified several main themes in their research, including the following:

• Unsuccessful treatment of intractable chronic insomnia, despite multiple therapeutic attempts that often build on off-label medication trials.
• Lack of implementation of firstline therapeutic measures
• Compromised family coping skills, affecting adherence to suggested nonpharmacological interventions, ultimately resulting in further medication trials.

Among those analyzed for medication strategies (n = 41), 81% had been medicated for disorders of initiating and maintaining sleep (n = 39) and sleep/wake-transition disorders (n = 37). Less than half (n = 17; 41%) of patients used medications such as melatonin to initiate sleep. Although, most of these patients used them concomitantly with other sleep medications and psychotropics (stimulants: 24%; selective serotonin reuptake inhibitors: 22%; antipsychotics: 15%).

No more than 6 medications were used at once for those who crossed medications for initiating sleep and other sleep medications. More than half (n = 24; 59%) of the patients included were subject to polypharmacy. In total, 40 and 22 patients, had symptoms of Restless Legs Syndrome (RLS)-induced insomnia and sleep disordered breathing, however, only 3 and 1 of each were on iron supplementation and a nasal spray, respectively.

REFERENCE
1. Ipsiroglu O, McWilliams S, Boldut R, Bhathella J, Elbe D, Wensley D. Lessons from the COVID-19 Shutdown: the Waitlist challenge & insights in medication pathways. Presented at: World Sleep 2022; March 11-16; Rome, Italy. 005