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Nurse-led triage of new sleep referrals is associated with lower risk of potentially contraindicated sleep testing: a retrospective cohort study
  1. Lucas M Donovan1,2,
  2. Brian N Palen2,
  3. Adnan Syed3,
  4. Richard Blankenhorn3,
  5. Kelly Blanchard3,
  6. William J Feser3,
  7. Kate Magid3,
  8. Justina Gamache2,
  9. Laura J Spece1,2,
  10. Laura C Feemster1,2,
  11. Laurie Fernandes4,
  12. Susan Kirsh5,
  13. David H Au1,2
  1. 1Health Services Research and Development, VA Puget Sound Health Care System, Seattle, Washington, USA
  2. 2Department of Pulmonary, Critical Care, and Sleep Medicine, VA Puget Sound Health Care System and University of Washington, Seattle, Washington, USA
  3. 3VA HSR&D Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, Colorado, USA
  4. 4Office of Community Care, VISN 20, Vancouver, Washington, USA
  5. 5Office of Veterans Access to Care, Department of Veterans Affairs, Washington, DC, USA
  1. Correspondence to Dr Lucas M Donovan, Health Services Research and Development, VA Puget Sound Health Care System, Seattle, WA 98108, USA; ldonovan{at}


Background The volume of specialty care referrals often outstrips specialists’ capacity. The Department of Veterans Affairs launched a system of referral coordination to augment our workforce, empowering registered nurses to use decision support tools to triage specialty referrals. While task shifting may improve access, there is limited evidence regarding the relative quality of nurses’ triage decisions to ensure such management is safe.

Objective Within the specialty of sleep medicine, we compared receipt of contraindicated testing for obstructive sleep apnoea (OSA) between patients triaged to sleep testing by nurses in the referral coordination system (RCS) relative to our traditional specialist-led system (TSS).

Methods Patients referred for OSA evaluation can be triaged to either home sleep apnoea testing (HSAT) or polysomnography, and existing guidelines specify patients for whom HSAT is contraindicated. In RCS, nurses used a decision support tool to make triage decisions for sleep testing but were instructed to seek specialist oversight in complex cases. In TSS, specialists made triage decisions themselves. We performed a single-centre retrospective cohort study of patients without OSA who were referred to sleep testing between September 2018 and August 2019. Patients were assigned to triage by RCS or TSS in quasirandom fashion based on triager availability at time of referral. We compared receipt of contraindicated sleep tests between groups using a generalised linear model adjusted for day of the week and time of day of referral.

Results RCS triaged 793 referrals for OSA evaluation relative to 1787 by TSS. Patients with RCS triages were at lower risk of receiving potentially contraindicated sleep tests relative risk 0.52 (95% CI 0.29 to 0.93).

Conclusion Our results suggest that incorporating registered nurses into triage decision-making may improve the quality of diagnostic care for OSA.

  • nurses
  • quality improvement
  • health services research

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  • Contributors Study concept and design: LMD, BNP, JG, LF, SK, DHA. Data interpretation and critical revision of the manuscript for important intellectual content: all authors. Data collection: LMD, AS, RB, KB, KM, WJF. Data analysis: LMD. Drafting of the manuscript: all authors. LMD and BNP contributed equally to the manuscript.

  • Funding This study was funded by VA Office of Veterans Access to Care and Health Services Research and Development (grant number:Career Development Award, CDA-18-187).

  • Competing interests DHA reports personal fees from Novartis for service on a data monitoring committee, personal fees from American Board of Internal Medicine for service on the exam writing committee and personal fees from Annals of the American Thoracic Society for service as a deputy editor, outside the submitted work. SK and DHA report being employed by the VA Office of Veterans Access to Care during the conduct of the study.

  • Patient consent for publication Not required.

  • Ethics approval The Office of Veterans Access to Care approved our data collection and analyses as part of a quality improvement evaluation, exempt from institutional review board approval.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request. Approval of the VA Collaborative Evaluation Center and VA Office of Veterans Access to Care is required prior to the sharing of data for this project.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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