Enhancing primary care detection and referral of nightmare disorder: a quality improvement initiative : Journal name: Sleep and Breathing.

Background: Nightmare disorder (NDO) is a clinically under-recognized sleep disorder within the military population. We have previously reported that 31.2% of patients referred to our sleep disorders center incidentally had probable NDO, yet only 3.9% were specifically referred for NDO. Under-recognition and therefore under-treatment of NDO negatively impacts patients' health and military readiness.

Methods: The initial Plan-Do-Study-Act cycle involved updating the baseline referral rate for NDO at our academic sleep disorders center across a three-month period. Second, leaders from the Internal Medicine Clinic (IMC) were engaged and educated on NDO screening via email. This led to incorporation of the Nightmare Disorder Index (NDI) into routine patient intake within the IMC for a four-week period. Thirdly, leaders from the Family Health Clinic (FHC) were engaged with face-to-face education on NDO and interpretation of the NDI, resulting in incorporation of the NDI into routine patient intake for a four-week period. Finally, leaders and available providers from the Warrior Operational Medicine Clinic (WOMC) were engaged with face-to-face education on NDO, interpretation of the NDI, and nightmares as possible presenting symptoms of other sleep-related disorders. The WOMC incorporated the NDI into routine patient intake for a two-week period. Primary care providers reviewed NDI results and referred patients as appropriate, with subsequent sleep medicine review of NDI results and NDO referral rates for each of the specified time periods.

Results: Prior to intervention, zero referrals were received for NDO. Three PCCs agreed to participate for two to four weeks each. The IMC screened 614 patients, with 586 (95.5%) completing the NDI. At FHC, 69 patients were screened with 100% NDI completion. The WOMC screened 29 patients with 100% NDI completion. We subsequently received 74 total referrals from these clinics, with eight (10.8%) specifically for NDO. However, 22 (29.7%) screened patients met criteria for probable NDO.

Conclusion: The project successfully integrated the NDI into routine primary care, achieving a high completion rate and increasing NDO referrals from a baseline of zero. A discrepancy between positive screening and referrals persisted. Future steps for further process improvement to address this gap could include provision of more in-depth education on NDO, interpretation of the NDI with added clinical context, and education on the other sleep-related disorders associated with nightmares for primary care providers. The addition of the NDI to primary care sleep disorder screening practices can be generalizable to other institutions and practice settings.