Sleep disturbances are frequently identified following traumatic brain injury, affecting 30%–70% of persons, and often occur after mild head injury. Insomnia, fatigue, and sleepiness are the most frequent sleep complaints after traumatic brain injury. Sleep apnea, narcolepsy, periodic limb movement disorder, and parasomnias may also occur after a head injury. In addition, depression, anxiety, and pain are common brain injury comorbidities with significant influence on sleep quality. Two types of traumatic brain injury that may negatively impact sleep are acceleration/deceleration injuries causing generalized brain damage and contact injuries causing focal brain damage. Polysomnography, multiple sleep latency testing, and/or actigraphy may be utilized to diagnose sleep disorders after a head injury. Depending on the disorder, treatment may include the use of medications, positive airway pressure, and/or behavioral modifications. Unfortunately, the treatment of sleep disorders associated with traumatic brain injury may not improve neuropsychological function or sleepiness.

Background We developed and implemented a structured clinical documentation support (SCDS) toolkit within the electronic medical record, to optimize patient care, facilitate documentation, and capture data at office visits in a sleep medicine/neurology clinic for patient care and research collaboration internally and with other centers. Methods To build our SCDS toolkit, physicians met frequently to develop content, define the cohort, select outcome measures, and delineate factors known to modify disease progression. We assigned tasks to the care team and mapped data elements to the progress note. Programmer analysts built and tested the SCDS toolkit, which included several score tests. Auto scored and interpreted tests included the Generalized Anxiety Disorder 7-item, Center for Epidemiological Studies Depression Scale, Epworth Sleepiness Scale, Pittsburgh Sleep Quality Index, Insomnia Severity Index, and the International Restless Legs Syndrome Study Group Rating Scale. The SCDS toolkits also provided clinical decision support (untreated anxiety or depression) and prompted enrollment of patients in a DNA biobank. Results The structured clinical documentation toolkit captures hundreds of fields of discrete data at each office visit. This data can be displayed in tables or graphical form. Best practice advisories within the toolkit alert physicians when a quality improvement opportunity exists. As of May 1, 2019, we have used the toolkit to evaluate 18,105 sleep patients at initial visit. We are also collecting longitudinal data on patients who return for annual visits using the standardized toolkits. We provide a description of our development process and screenshots of our toolkits. Conclusions The electronic medical record can be structured to standardize Sleep Medicine office visits, capture data, and support multicenter quality improvement and practice-based research initiatives for sleep patients at the point of care.

A 16-year-old right-handed boy presented for consultation for recent development of seizures. He is the product of a normal pregnancy and delivery without a history of developmental delay, head trauma, or family history of epilepsy. A year and a half prior to our consultation, the patient noted that his hand would suddenly jerk across the page while writing in his morning classes. Stress would exacerbate the jerks. Six months later, after staying up late the previous night, the patient awoke early and began to play on the computer when both of his hands suddenly jerked multiple times. He then fell over and began seizing. His mother witnessed tonic contraction of his body followed by clonic activity. He was brought by ambulance to the nearest hospital where a CT head was reported normal.The patient had a routine EEG at an outside institution and was diagnosed with juvenile myoclonic epilepsy (JME). Valproic acid was started; however, despite increasing dosages, his jerks persisted. The patient then developed episodes of seeing blue, red, and white lights in his right eye followed by right-sided headaches. He underwent video EEG monitoring and was told that these visual symptoms were seizures. His valproic acid was increased and levetiracetam was added. Despite these medications, his jerks and visual seizures continued. Upon consultation with other neurologists, who all believed that the patient had JME, topiramate was added without clinical improvement. Immediately prior to the consultation at this institution, the patient had another generalized tonic-clonic seizure while attending an economics conference. Despite having been a straight-A high school student, he began to have increased difficulty with cognition and his mother pulled him out of school.Physical examination revealed a well-appearing boy. Mental status was notable for difficulty with serial 7s and spelling backwards. Cranial nerve examination was normal. Frequent twitches were noted around his mouth and eyes. Strength was full and sensation was intact to all modalities. Coordination, reflexes, and gait all were normal.

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