Improving Hospitalized Children’s Sleep by Reducing Excessive Overnight Blood Pressure Monitoring

From the 2019 HVPAA National Conference

Mr. David Cook (Pritzker School of Medicine), Mr. Michael Chamberlain (Pritzker School of Medicine), Ms. Samantha Anderson (Pritzker School of Medicine), Dr. Vineet Arora (Pritzker School of Medicine), Dr. Nicola Orlov (Pritzker School of Medicine)

Background

Although children require sleep to recover from illness, sleep is often disrupted during hospitalizations by routine vital sign (VS) checks. Recent literature discourages waking patients for routine care, and several institutions have reduced overnight VS checks for pediatric patients. Furthermore, blood pressure (BP) checks can be especially disruptive for pediatric inpatients. A yearlong needs assessment of caregivers at University of Chicago Medicine identified VS checks as the largest sleep disruptor, and objective room entry data showed an average of ten nightly room entries by medical providers.

Objective

The goal of this study was to combine EHR changes and clinician education sessions to reduce unnecessary overnight BP checks, thus promoting sleep for pediatric inpatients.

Methods

A multidisciplinary team of peer-champions was formed to ensure proper implementation of the initiative.Education targeted nurses and interns on evidence-based recommendations for who can forgoovernight BP checks. We consulted our team to create the mnemonic: “Who needs overnight BP monitoring? Do your BEST: BP fluctuations, Erratic VS, Sedating agents, Therapy monitoring” which was distributed on badge cards. Updated pediatric admission order sets allowed providers to forgo overnight BP checks on their patients. This change encouraged evaluation of each patient’s clinical status.EHR reports tracked adoption of sleep-friendly orders and objective room entry data counted overnight room entries. Patient caregiver surveys continued to assess sleep during hospitalization.

Results

Surveys administered to nurses and interns evaluated the effectiveness of our educational intervention on their knowledge, attitudes, and behaviors regarding the importance of sleep for hospitalized pediatric patients. After educating interns about the intervention, an increase was noted in those planning to actively work harder to reduce nighttime disruptions (26% pre, 83% post, p<0.001). A similar increase was seen among nurses (66% pre, 97% post, p<0.001).

Interrupted time series analysis shows a significant decrease in the proportion of patients with overnight BP orders post-intervention [95% CI -33.0%, -7.7%p=0.003], and on average 23.3% fewer patients have overnight BP orders (p<0.001). Surveys post-intervention show an increase in patient sleep duration while hospitalized [95% CI 5.75 min, 30.83 min, p=0.007] and a reduction in nighttime disruptions by clinicians (42% pre, 19% post, p=0.013). No major adverse events have been reported.

Conclusions

A combination of EPIC changes and clinician education decreased unnecessary overnight BP checks, increased patient sleep duration, and reduced nighttime disruptions by clinicians. Future work is focused on an EHR algorithm that uses objective data to automate VS orders.

Clinical Implications

EPIC changes were critical and spaced education sessions continue reinforce the implementation. Order set use data allowed crucial real-time feedback to clinicians. This initiative’s widespread adoption highlights its applicability for pediatric inpatients.

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