Increasing Provider Use of a Sleep Assessment Instrument at a VA Outpatient Mental Health Clinic: A Quality Improvement Project

Background: In the United States, sleep dysfunction occurs in 50-80% of patients seeking psychiatric treatment, compared to 10-18% of adults in the general U.S. population. In the veteran population, those numbers are magnified, and larger still in the veteran population who seek psychiatric treatment. Accurate diagnosis and thorough assessment of sleep is a vital precursor to treatment. Poor sleep contributes to poor health outcomes, including diabetes, obesity, accidental injuries, depression, cancer, and cardiovascular disease. Despite the high rates of sleep dysfunction, many healthcare settings, including Veterans Affairs (VA) settings, do not routinely screen for sleep dysfunction. Methods: The goal of this quality improvement project was to assess barriers to implementing a sleep dysfunction screening tool, the Insomnia Severity Index (ISI), and improve the use of the ISI in initial psychiatric assessments with Veterans. This project was conducted at the outpatient behavioral health unit at the Salt Lake City VA. A pre-intervention questionnaire was given to providers who treat veterans for psychiatric concerns. The questionnaire evaluated providers' attitudes and behaviors towards assessing sleep dysfunction. The questionnaire results, combined with the current literature on sleep dysfunction's relationship to psychiatric disorders, were then delivered to 30 clinic providers in an online presentation. The goal of the presentation was to increase providers' awareness of the ISI and the importance of diagnosing sleep dysfunction. Use of the ISI was assessed using Computerized Patient Record System (CPRS) electronic health record data. After the 84-day implementation phase, a post-intervention questionnaire was given to providers to assess beliefs and behaviors about assessing for sleep dysfunction. Results: Of the 37 providers invited to participate, 15 (40.5%) psychiatrists (n = 2) and nurse practitioners (n = 13) completed a pre-intervention questionnaire on their beliefs and behaviors about screening for insomnia and sleep dysfunction. Fourteen (37.8%) providers completed a post-intervention questionnaire. Confidence in diagnosing insomnia and sleep dysfunction increased from 66.7% (n = 10/14) to 92.9%, (n = 13/14). Confidence in ability to track patients sleep increased in agreeance from 60% (n=9/14) to 92.9% (n=13/14). Feasibility in implementing a sleep screening instrument increased in agreeance from 60% (n=9/14) to 92.9% (n=13/14). However, only 5 out of 37 providers used the ISI during the implementation phase. Ten (27.0%) providers reported a desire to use the ISI in their future practice. Conclusions: Providers state that assessing for sleep dysfunction is invaluable. However, providers minimally used the Insomnia Severity Index following the implementation phase. Future projects could be developed to mitigate expressed barriers for providers, such as the time it takes to employ screening tools or other methods of completing the screening tool, such as requiring the screening tool as part of the admission packet.