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.
Methods
The critical role of accurate CBD in health care administration is illustrated by the proper use of Stop Codes as a foundational step in tracking services provided to justify adequate resource allocation within VA. A complete redesign of tracking sleep service documentation was initiated in 2014 and resulted in national changes to sleep medicine Stop Codes. The Stop Code initiative was the first step of several to improve CBD for VA sleep services.
Primary Stop Code 349 designates sleep medicine encounters in VA facilities (Table). However, before changes were implemented in fiscal year (FY) 2015, Stop Codes for VHA sleep care did not differentiate between specific services provided, such as laboratory-based sleep testing, at-home sleep testing, education/training sessions, follow-up appointments, equipment consults, telephone or video consults, or administrative tasks. In early FY 2015, several changes were made to Stop Codes used for VHA sleep medicine services nationwide to capture the breadth of services that were being provided; services that had previously been performed but were not documented. A new standardized coding methodology was established for continuous positive airway pressure (CPAP) clinics (349/116 or 349/117); telephone consults for sleep care (324/349); and store and forward sleep telehealth encounters (349/694, 349/695, or 349/696).
In the VA, store-and-forward telehealth refers to asynchronous telemedicine involving the acquisition and storing of clinical information (eg, data, image, sound, or video) that another site or clinician reviews later for evaluation and interpretation. In sleep medicine, data uploaded from home sleep apnea test units or CPAP devices are examples of this asynchronous telehealth model. The goal of these changes in VA Stop Codes was to accurately assess the volume of sleep care delivered and the demand for sleep care (consult volumes); enable planning for resource allocation and utilization appropriately; provide veterans with consistent access to sleep services across the country; and facilitate reductions in wait times for sleep care appointments. Results of these changes were immediate and dramatic in terms of data capture and reporting.
Results
Figure 1 illustrates an increase in patient encounters in VA sleep clinics by 24,197 (19.6%) in the first quarter of Stop Code change implementation (FY 2015, quarter 2) compared with those of the previous quarter. VHA sleep clinic patient encounters increased in subsequent quarters of FY 2015 by 29,910 (20.2%) and 11,206 (6.3%) respectively. By the end of FY 2015, reported sleep clinic encounters increased by 190,803 compared with the those at the end of FY 2014, an increase of 42.7%.
Figures 2, 3, and 4 show the additional effects of sleep Stop Code changes that were implemented in FY 2015 for CPAP clinics, telephone encounters, and store-and-forward telehealth encounters, respectively. The large increases in reported sleep patient encounters between FY 2014 and FY 2016 reflect changes in CBD and are not entirely due to actual changes in clinical workloads. These results indicate that workloads in many VHA sleep medicine clinics were grossly underreported or misallocated to other specialty services prior to the changes implemented in FY 2015. This discrepancy in care delivery vs workload capture is a contributing factor to the understaffing that continues to challenge VHA sleep programs. However, the improved accuracy of workload reporting that resulted from Stop Code modifications has resulted in only a small proportional increase in VHA clinical resources allocated to provide adequate services and care for veterans with sleep disorders.
In response to the substantial and increasing demand for sleep services by veterans, the VA Office of Rural Health (ORH) funded an enterprise-wide initiative (EWI) to develop and implement a national TeleSleep Program.16 The goal of this program is to improve the health and well-being of rural veterans by increasing their access to sleep care and services.