Original Research
Steroid-Induced Sleep Disturbance and Delirium: A Focused Review for Critically Ill Patients
Steroid use is a modifiable risk factor in intensive care unit patients; however, reported mechanisms are often lacking.
Kathleen Sarmiento is the National VHA TeleSleep Lead and Bhavika Kaul is a Research Fellow, both at the San Francisco VA Healthcare System in California. Eilis Boudreau is a Neurologist, and Robert Folmer is a Research Investigator, both at VA Portland Healthcare system in Oregon. Connor Smith is an Informatics Research Associate, Eilis Boudreau is an Associate Professor of Neurology, and Robert Folmer is an Associate Professor of Otolaryngology, all at Oregon Health & Science University in Portland. Nancy Johnson is the Lead Clinical Analyst, Systems Design and Standardization in the Managerial Cost Accounting Office, VHA Office of Finance. Kathleen Sarmiento is an Associate Professor of Medicine, and Bhavika Kaul is a Critical Care Medicine Fellow, both at the University of California, San Francisco.
Correspondence: Robert Folmer (robert.folmer@va.gov)
Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies.
Background: Computer-based documentation (CBD) is used commonly throughout the world to track patient care and clinical workloads. However, if capture of clinical services within the electronic health record (EHR) is not implemented properly, patient care services and workload credit will be inaccurate, which impacts business decisions related to demand for care and resources allocated to meet the demand. Understaffing of medical personnel can contribute to delays in treatment, missed treatments, and workforce turnover.
Objective: To illustrate the impact of CBD procedures on health care workload assessment and resource allocation, this article uses data from the US Department of Veterans Affairs Corporate Data Warehouse to provide examples from the Veterans Health Administration (VHA) sleep medicine programs.
Discussion: Inaccurate CBD led to underreporting of sleep medicine services provided at VHA facilities nationwide and contributed to insufficient allocation of resources and personnel. Recent modifications in CBD protocols (Stop Codes) improved the accuracy of data capture and reporting while providing VHA sleep programs with data they can use to advocate for workforce expansion to meet patient care needs.
Conclusions: Inaccurate CBD of clinical workloads can result in inadequate allocation of health care personnel and resources to meet the needs of patients. Untreated sleep disorders are associated with increased risk of depression, anxiety, impaired neurocognitive functions, cardiovascular disease, motor vehicle accidents, and premature death. Educating health care providers and administrators on the importance of accurate designation of clinical services within the EHR is necessary to facilitate improvements in health care availability and delivery.
Health care systems are faced with the challenge of meeting increasing patient care demands with finite resources.1 Advocating for additional capital—specifically, human resources—requires compelling data that accurately capture workload credit. When workload is not captured accurately, clinicians may be tasked with providing care to a high volume of patients without appropriate resource allocation. This understaffing can delay care delivery and increase the risk of diagnostic and treatment errors.2 Furthermore, workers in understaffed medical facilities are more likely to experience burnout, which leads to high workforce turnover.
Computer based documentation (CBD) is used often in medical practices to track patient care and clinical workload. However, improperly designed and implemented CBD systems can contribute to cumbersome documentation tasks and inaccurate or incomplete data capture.3 Conversely, CBD can be a useful tool to capture workload credit and can subsequently facilitate justification for medical staff allocation to meet patient care demands. This article uses our experience with US Department of Veterans Affairs (VA) national sleep medicine programs to illustrate the impact of CBD procedures on health care workload assessment and allocation. Specifically, we examine how appropriate workload capture facilitates growth and improves the efficiency of health care programs.
The VA is the largest integrated health care system in the US, serving 9 million veterans at 1,255 facilities, including 170 VA Medical Centers (VAMCs).4 As veterans’ demands for VA medical services have outpaced available resources, there have been several media reports of lapses in timely care delivery.5-7 These lapses have been due, in part, to insufficient workforce resource allocation within the Veterans Health Administration (VHA) facilities. A 2012 audit of physician staffing levels conducted by the VA Inspector General concluded that the VA did not have an effective staffing methodology to ensure appropriate staffing levels for specialty care services.8 The lack of staffing plans and productivity standards limits the ability of medical facility officials to make informed business decisions regarding the appropriate number of specialty physicians required to meet patient care needs.8 In 2017, the Government Accountability Office (GAO) issued a report to Congress that stated the “VA’s productivity metrics and efficiency models do not provide complete and accurate information, they may misrepresent the true level of productivity and efficiency across VAMCs and limit the VA’s ability to determine the extent to which its resources are being used effectively.”9 To understand how and why many VA medical facilities remain understaffed, and therefore struggle to provide health care to veterans in a timely fashion, a description of VA CBD procedures is provided.
Steroid use is a modifiable risk factor in intensive care unit patients; however, reported mechanisms are often lacking.
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