BACKGROUND:Hospitalized patients often experience poor sleep, which is associated with worse health outcomes, increased rates of delirium, and readmissions. OBJECTIVE:To improve overnight sleep for clinically stable general neurology patients at a single academic center. METHODS:We conducted a quasi-experimental pre-post clinical trial of two sleep-protective interventions: (1) a sleep-friendly order set that reduced overnight interruptions by discontinuing vital sign checks/neurological examinations and retiming medications/blood draws; and (2) a "sleep menu" of comfort items. The primary outcome measure was sleep duration. Secondary outcomes were awakenings and patient responses to the Richards-Campbell Sleep Questionnaire. Safety outcomes were rates of delirium, ICU transfers, and 30-day readmissions. We compared the groups using linear mixed-effects models to account for repeated measures (multiple nights per participant). RESULTS:We analyzed data from 66 pre-intervention participants (238 nights) and 61 post-intervention participants (244 nights). The interventions did not increase sleep duration (pre-intervention median 5.5 h [interquartile range (IQR) 4.0,6.6], post-intervention median 5.4 h [4.1, 6.7], p = .84). There was marginal improvement in nightly awakenings (pre-intervention 2 [1, 4], post-intervention 2 [1, 3], p = .04). There were no significant differences in subjective sleep measures or safety outcomes. Targeted care team interruptions all significantly decreased post-intervention, though staff intrusions remained a common patient-reported barrier to sleep. CONCLUSION:Fragmented and reduced sleep was common in our general neurology population. Although our interventions did not improve sleep outcomes-apart from a modest drop in nocturnal awakenings-there was a significant decrease in care team interruptions. Poor inpatient sleep is multifactorial, and meaningful change likely requires comprehensive interventions.

Study Objectives Excessive daytime sleepiness (EDS) is common in patients with sleep disorders, particularly obstructive sleep apnea (OSA). The Epworth Sleepiness Scale (ESS) and the Psychomotor Vigilance Test (PVT) are often used to measure sleepiness and attention/vigilance, respectively. However, whether these measures are correlated and their relationship to OSA severity/treatment remains understudied. This study examined these associations in a sleep center population.Methods We performed a prospective study of 165 participants (119 [72.1%] with diagnosed OSA) presenting to a sleep disorders clinic and completing ESS and PVT. Associations among ESS, PVT, OSA severity, and positive airway pressure (PAP) usage and efficacy were examined using Pearson's correlations, unadjusted and controlling for age, sex, and body mass index.Results Results showed no significant correlations between ESS and PVT measures of attention/vigilance. While higher ESS scores correlated with more severe apnea-hypopnea indices in patients with OSA, no association was found with OSA severity and PVT measures. Among participants using PAP, greater hours/night of usage was associated with lower ESS scores, but not with better PVT performance.Conclusions We found no association between sleepiness on the ESS and attention/vigilance on PVT among a sleep center population. ESS scores tracked more closely to OSA severity/treatment than PVT measures. The findings suggest that the sleepiness measured by the ESS and measures of sustained attention under monotonous conditions from the PVT capture distinct symptoms. While the ESS is commonly used, further research is needed to determine if the PVT should also be incorporated into clinical practice.

Background and ObjectivesSleep is a critical component of health and recovery. Awakening sleeping patients for routine vital sign monitoring overnight is a common inpatient practice, but its benefits are uncertain. This study asked 3 questions: (1) How often are routine overnight vital signs abnormal? (2) How often are those abnormal vital signs clinically actionable? (3) Are there patients who may not need routine overnight vital sign monitoring?MethodsWe analyzed observational retrospective data extracted from electronic health records of patients admitted to inpatient neurology floors at our institution between 2017 and 2024. We defined routine vital signs as collected by nursing assistants at least 3 hours apart. The outcome measure was an urgent clinical action (stat orders, rapid responses, or transfers to a higher level of care) within 1 hour of vital sign events. We compared the rate of urgent clinical actions after abnormal vital signs with the base rate of those events after normal vital signs. Statistical analysis used generalized estimating equations to account for repeated measures.ResultsWe analyzed 102,184 routine vital sign events from 5,569 neurology admissions. In total, 9% of vital sign events were abnormal. The likelihood of urgent clinical actions increased after abnormal vital sign events, compared with after normal vital sign events during the day (4.3% vs 2.4%, odds ratio (OR) 1.8 [1.6-2.1]); at night (2.4% vs 0.9%, OR 2.8 [2.2-3.7]); during the night in low-risk patients with normal daytime vitals (2.0% vs 0.7%, OR 3.0 [1.8-4.9]); and at night in high-risk patients with abnormal daytime vitals (2.6% vs 1.1%, OR 2.5 [1.7-3.6]). The number needed to treat (NNT), i.e., the number of vital sign events needed to initiate 1 extra urgent clinical action above the base rate, was 1,856 [943; 4,598] in low-risk patients. The NNT for low-risk stroke patients was 1,570 [679; 4,707] and for general neurology patients was 2,231 [797; 5,423].DiscussionUrgent clinical actions attributable to abnormal routine vital signs were uncommon in neurology inpatients, especially overnight in patients with normal daytime vital signs. Determining the risks and benefits of routine overnight vital sign monitoring will help hospitals and health care providers move toward more patient-centered inpatient neurologic care.

The Psychomotor Vigilance Test (PVT) is an established tool for assessing sleep deprivation or sleep loss related impairments in daytime function (i.e., fluctuations in attention and concentration that allow for inferences about sleepiness). With the wide adoption of mobile devices, text messaging and smart phone apps have emerged as a potential medium for delivering cognitive and human function tasks. A smart phone accessible, web-based PVT was developed (compatible with Apple and Android devices) to test the utility of PVT assessments as part of routine clinical care. Specifically, we will evaluate the feasibility of deploying a digital PVT via text messages and will monitor completion rates and solicit feedback about the experience. The study is ongoing. Ten participants have been enrolled in the ongoing pilot study. Protocol: Send invitations (text messages) to complete a 3-minute PVT along with the Karolinska Sleepiness Scale (single item) for a period of three months. The PVT and KSS are completed once a week during the first month and monthly for two months. As a feasibility study, the key metrics include completion rates, number of reminders administered per assessment day, and participant feedback on usability, clarity, and satisfaction. While the study is ongoing, during the first 2 weeks, all participants completed the PVT. Week 1: 80% completed the PVT after the first text message, 20% completed the PVT after the second text message. Week 2: 70% completed the PVT after the first text message, 20% completed the PVT after the second text message. This pilot study will provide insights into the feasibility and potential challenges of using a text message-based PVT and KSS assessments in a clinical setting. Results will inform future implementation strategies for integrating PVT into clinical workflows. By providing a scalable and easily accessible PVT and KSS assessment tool, this system has the potential to improve patient monitoring, enhance clinical decision-making, and support personalized care for individuals with sleep disorders.

There is shortage of sleep medicine specialists with a typical sleep clinic visit starts with one patient spending 60 minutes with a single provider (physician or APP). This traditional model of care limits access. One of the biggest hurdles in our sleep clinic is seeing patients for the required 31–90-day CPAP compliance visit, which is required by insurance carriers to keep their CPAP. Shared medical appointment (SMA) can increase access and still provide individualized care in group settings. After initial new patient visit with single provider, SMAs is used for CPAP compliance follow-ups. This pilot trial aims to improve access while maintaining patient satisfaction with a SMA for CPAP therapy through multi-disciplinary approach. We initiated a SMA in our sleep medicine clinic. A single provider worked with a sleep technician and nurse familiar with a typical CPAP journey to provide individualized care for a group of patients. Each patient signed a consent form prior to the SMA. Each SMA included 6-8 patients with obstructive sleep apnea (OSA) in a 60-minute group session. We started with a PowerPoint presentation to provide education about OSA and included CPAP therapy with details about airflow, mask issues, and oropharyngeal dryness. We reviewed each patient’s data download and adjusted CPAP settings as needed. We encouraged patients to interact with each other and with providers. In 2023 (N=12), the average follow up time for a CPAP compliance visit was 104 days. After the recent implementation of the SMA in 2024 (N=13), the average follow- up time dropped to 68 days. Patient feedback about the SMA has been extremely positive. Based on preliminary data, the SMA model is an innovative way to improve patient access by opening up more slots for new patients while accommodating follow up visits for CPAP compliance.

Background and ObjectivesTeleneurology usage has increased during the severe acute respiratory syndrome coronavirus 2 pandemic. However, studies evaluating physician impressions of inpatient teleneurology are limited. We implemented a quality improvement initiative to evaluate neurologists' impression following individual inpatient teleneurology consultation at a satellite hospital of a large academic center with no in-person neurology coverage.MethodsA REDCap survey link was embedded within templates used by neurologists for documentation of inpatient consultations to be completed immediately after encounters. All teleneurology encounters with completed surveys at a single satellite hospital of the University of Pennsylvania Health System Neurology Department between May 10, 2021, and August 14, 2022, were included. Individual patient-level and encounter-level data were extracted from the medical record.ResultsA total of 374 surveys (response rate of 54.05%) were completed by 19 neurologists; 341 questionnaires were included in the analysis. Seven neurologists who specialized as neurohospitalists completed 231 surveys (67.74% of total surveys completed), while 12 non-neurohospitalists completed 110 (32.36%). The history obtained was rated as worse (14%) or the same (86%) as an in-person consult; none reported the history as better than nonteleneurology encounters. The physician-patient relationship was poor or fair in 25% of the encounters and good or excellent in 75% of visits. The overall experience was judged to be worse than in-person consultation in 32% of encounters, the same in 66%, and better in 2%. Fifty-one percent of providers responded that there were elements of the neurologic examination that might have changed their assessment and plan of care if performed in-person. Encounters with peripheral or neuromuscular-related chief complaints had the most inadequate examinations and worse overall experiences, while the most positive impressions of these clinical experiences were observed among seizure-related chief complaints.DiscussionDetermining best practices for inpatient teleneurology should consider the patient chief complaint to use teleneurology in scenarios with the highest likelihood of a positive experience. Further efforts should be made to the patient experience and to improve the remote examination to enhance the applicability of teleneurology to the full spectrum of inpatient neurologic consultations.

Abstract Introduction Without consistent PAP data monitoring, clinics struggle to identify issues with patients' PAP receipt and usage. To address this, we created PennPALS (Penn PAP Automated Learning System), a cloud-based platform that filters PAP data extracted from the electronic medical record (EMR) through algorithms to identify common PAP issues, such as non-adherence, mask leaks, elevated residual AHI, or delayed setups. Patients are contacted about issues through two-way text messaging. Methods PennPALS auto-enrolls patients based on an EMR PAP order. Patients can opt out at any time during the 90-day monitoring program. We conducted a retrospective evaluation of PennPALS for patients enrolled June 2023. Results In one month, 279 patients were enrolled (mean age 54.9 (14.5) years, 56.3% male, 48.8% white, 40.5% Black or African American and 6% Hispanic). One hundred eighty-nine patients entered a 90-day data monitoring window (mean age 54.1 (14) years, 57.7% males, 45.5% white, 41.8% Black or African American, 3.8% Hispanic, and 58.7% new to PAP). Ninety patients never had PAP data in EMR. Two patients were ineligible due to invalid phone number in EMR and 25 opted out (4 at enrollment; 21 during monitoring). During the 90 day monitoring, the following number of triggers were activated: 247 non-adherence (7 day avg. < 4hrs), 571 adherence (7 day avg. >4hrs), 314 mask leak (Phillips: avg % time in large leak ≥ 30% for ≥3 of 7 days; ResMed: leak ≥ 24 L/min for ≥3 of 7 days), 8 high residual AHI (7 day avg ≥ 10 events/hr), 62 no data triggers (no data for 5 days), and 9 continued no data triggers. Of patients that completed the exit survey (n=20), average “how helpful” score (scale 0-10) was 7.9 (3.9) and Net Promotor Score (e.g., likelihood to recommend) was 87. Conclusion PennPALS demonstrates real-word feasibility to monitor patients and identify issues with algorithms based on discrete PAP data within EMR. Identified issues triggered two-way text messaging to improve PAP communications. The high number of patients without PAP data requires further investigation (e.g., patient did not pursue PAP, modem not linked). Patients reported that PennPALS was helpful and they would recommend it. Support (if any) K12HS026372

To characterize baseline sleep data for neurology inpatients and to develop and assess a multi-pronged intervention targeted at key drivers of poor sleep in the hospital.

Abstract Introduction Sleepiness, a common symptom of various sleep disorders, has been subjectively measured using the Epworth Sleepiness Scale (ESS) and objectively quantified using the Psychomotor Vigilance Test (PVT). The relative merit of these two measures of sleepiness has been debated, and both have shown inconsistent relationships with severity of obstructive sleep apnea (OSA) and responses to treatment. We report the relative associations of ESS and PVT with hours of CPAP use within a clinical sample. Methods Patients being evaluated for sleep disorders at the University of Pennsylvania’s Sleep Center competed both the ESS and PVT measurements in a single clinical visit. Thirty-nine patients had a diagnosis of OSA and were currently using CPAP. Pearson’s correlations were utilized to examine the association between CPAP adherence and both the ESS and PVT measures (transformed lapses [sum of square root of number of lapses and square root of lapses+1]) and mean reciprocal response time (RRT). Results total of 39 patients (64.1% males; 52.6% White, 39.5% Black) were studied, with a mean (SD) age of 61.1 (16.4) years and BMI of 35.2 (9.5) kg/m2; residual apnea-hypopnea index (AHI) was 6.5 (10.8) events/hour (23 [63.9%] had residual AHI < 5 events/hour). Participants used CPAP an average of 5.87 (2.27) hours/night in the past 30 days, 5.87 (2.47) hours/night over the past 7 days, and 5.91 (2.86) hours/night the day prior to ESS/PVT measurement. Overall, we observed a strong correlation between less subjective sleepiness based on ESS and more CPAP usage at 30-days (rho = -0.48, p=0.002), 7-days (rho = -0.43, p=0.006) and the prior day (rho = -0.38, p=0.017). However, there was no correlation between hours/night of CPAP adherence and objective function as measured on PVT. Conclusion Among patients with OSA using CPAP evaluated at University of Pennsylvania’s Sleep Center, greater amounts of CPAP use were significantly associated with lower ESS scores (e.g., less sleepiness). Conversely, no significant correlations were observed between CPAP use and objective data on PVT. Larger studies examining the causal effects of CPAP on subjective and objective sleepiness, including with repeat assessments of ESS and PVT during therapy, are warranted. Support (if any)

To characterize sleep in neurologic in-patients using objective and subjective measures.

OBJECTIVES:The Transition Experience of persons with Narcolepsy taking Oxybate in the Real-world (TENOR) study was conducted to provide real-world insight into the experience of people with narcolepsy switching from sodium oxybate (SXB) to low-sodium oxybate (LXB; 92% less sodium than SXB). METHODS:TENOR is a patient-centric, prospective, observational, virtual-format study. Participants were adults with narcolepsy (type 1 or 2) who were transitioning from SXB to LXB treatment (±7 days from LXB initiation). Effectiveness and tolerability data were collected online from baseline (taking SXB) through 21 weeks (taking LXB) via daily and weekly diaries and questionnaires, including the Epworth Sleepiness Scale (ESS), the Functional Outcomes of Sleep Questionnaire, short version (FOSQ-10), and the British Columbia Cognitive Complaints Inventory (BC-CCI). RESULTS:TENOR participants (N = 85) were 73% female with a mean (SD) age of 40.3 (13.0) years. Mean (SD) ESS scores decreased numerically throughout the transition from SXB to LXB (baseline: 9.9 [5.2]; week 21: 7.5 [4.7]), with 59.5% and 75.0% of participants having scores in the normal range (≤10) at baseline and week 21, respectively. Mean (SD) FOSQ-10 scores (baseline: 14.4 [3.4]; week 21: 15.2 [3.2]) and BC-CCI scores (baseline: 6.1 [4.4]; week 21: 5.0 [4.3]) also remained stable. The most common symptoms related to tolerability reported by participants at baseline were sleep inertia, hyperhidrosis, and dizziness (45.2%, 40.5%, and 27.4%, respectively), which decreased in prevalence by week 21 (33.8%, 13.2%, and 8.8%, respectively). CONCLUSIONS:Findings from TENOR confirm maintenance of effectiveness and tolerability when transitioning from SXB to LXB treatment.

Purpose:Real-world data regarding divided nightly dosing of oxybate and individualized prescribing in patients with narcolepsy are limited. Study objectives were to understand oxybate prescribing practices, including optimizing dose regimens and adjusting dosing per occasional changes in patients' routines, and physician recommendations for representative patient scenarios.Patients and Methods:A cross-sectional, web- and audio-based survey of physicians treating ≥2 patients with narcolepsy, prescribed nightly oxybate (sodium oxybate) dosing for ≥6 months, was conducted. Physicians were surveyed on patients' usual oxybate dosing regimens, frequency of and reasons for oxybate dosing-related discussions, and preferred methods for and perceptions of adjusting oxybate dosing. Physicians provided dosing-related guidance for 4 representative scenarios.Results:Participating physicians (N=25) were neurologists (52%), psychiatrists (44%), and neuropsychiatrists (4%). Individualized oxybate prescribing practices were reflected by the variability of physicians' reporting of the percentage of their patients being prescribed once-nightly, twice-nightly, and thrice-nightly dosing regimens. Most physicians (68%) reported discussing adjusting individualized treatment to accommodate occasional changes to patients' routines; the most common reasons were consuming contraindicated beverages (alcohol; 65%) and travel (59%). Adjusting total nightly dose (68%) and dose timing (68%) were preferred adjustment methods. Most physicians (88%) felt the ability to individualize oxybate dosing was important and had a positive impact on ability to provide care. For each representative scenario, physicians provided several dose-adjustment recommendations, and physician responses encouraged patient participation in treatment decision-making.Conclusion:Physicians provided guidance supportive of oxybate dose adjustments to accommodate occasional changes in patients' routines, and perceived individualized dosing as important in providing care.

Abstract Introduction Black or African American and Hispanic of any race (B/H) adults are disproportionately affected by obstructive sleep apnea (OSA). Positive Airway Pressure (PAP) treatment may reduce disparities, but short-term PAP outcomes are worse among under-represented minority (URM) adults compared to other, mainly White, adults. No studies have examined if adherence disparities persist/worsen long-term. We evaluated disparities in PAP usage between B/H adults and other race/ethnicities. Methods We defined a clinical cohort of adults with moderate-severe OSA (apnea-hypopnea index [AHI]≥15 events/h) that underwent diagnostic sleep studies and initiated PAP between 01/2015-03/2018. Logistic regression was used to examine differences in the likelihood of still using PAP or meeting adherence threshold of ≥4 hours/night at 18-24 months. We performed mixed model for repeated measures to examine differences in h/night of PAP use over two years. Analyses were controlled for age, sex, BMI, AHI, and 3-month PAP usage to understand whether disparities emerged independent of short-term differences. Results Analyses included 1,518 individuals (694 [45.7%] B/H) with PAP usage at 3 months, who were middle-aged (53.4±14.1 years-old), majority men (64.4%), obese (38.2±9.8 kg/m2) and had severe OSA (46.6±30.2 events/h). B/H adults had 70% higher odds (OR [95% CI] = 1.70 [1.33-2.17]) of no longer using PAP 18-24 months after initiation. B/H adults using PAP had ~2 hours/night less usage than other race/ethnicities at 18-24 months (2.72 [2.49-2.97] vs. 4.52 [4.31-4.73] hours/night; p< 0.0001). This difference was attenuated but remained significant after accounting for 3-month usage (mean [95% CI] difference = -0.64 [-0.92, -0.37] hours/night). B/H adults using PAP were also 3-times more likely to be non-adherent at 18-24 months (OR [95% CI] = 3.00 [2.28-2.95]), and remained 2-times more likely to be non-adherent controlling for 3-month usage (2.14 [1.56-2.92]). Conclusion At 18-24 months, Black or Hispanic of any race adults with moderate-severe OSA were less likely to use PAP, had less usage when still using PAP, and were less likely to achieve adherence thresholds. Long-term PAP disparities exist, even after accounting for short-term differences. Promoting longer-term PAP adherence for URM is a priority to reduce these disparities and address healthcare inequities. Support (if any) AHA (20CDA35310360), NIH P01 HL094307, AHRQ K12HS026372