Reducing frequency of unnecessary vitals checks overnight on an inpatient medical stepdown unit

From the 2019 HVPAA National Conference

Dr. Eleanor Yang (Northwestern Medical Center), Dr. Lauren Lee (Northwestern Medical Center), Dr. Elisa McEachern (Northwestern Medical Center), Dr. Whitnee Caldwell (Northwestern Medical Center), Dr. Rachel Joseph (Northwestern Medical Center), Ms. Jennifer Landon (Northwestern Medical Center), Ms. Jhanvi Soni (Northwestern Medical Center), Ms. Kelsey Sundwall (Northwestern Medical Center), Ms. Rebecca Sweeney (Northwestern Medical Center), Ms. Sharon Ward (Northwestern Medical Center)

Background

Despite known adverse effects of poor sleep quality on health outcomes, patients admitted to inpatient medical wards are frequently disrupted multiple times overnight. We identified nocturnal vitals checks as the most common source of unnecessary awakenings in medically stable patients. Physicians typically order vitals checks to occur every four hours (Q4H) for patients newly admitted to the ward, which is appropriate for a medical stepdown unit. However, vitals checks were not subsequently spaced out in clinically stable patients. This study aims to improve patient sleep quality by reducing unnecessary night-time vitals checks.

Objective

To evaluate the effectiveness of an interdisciplinary intervention to reduce utilization of vital signs ordered Q4H in patients being discharged home (i.e. patients who are deemed medically stable), reducing unnecessary nocturnal disruption and improving quality of sleep.

Methods

The study was conducted in the medical step-down unit run by internal medicine housestaff at a large academic hospital. Baseline data was obtained between August 1 and October 31, 2018. The baseline percentage of patients being discharged with Q4H vital signs was retrospectively determined through the electronic medical record. Baseline patient satisfaction regarding sleep was obtained via the Press Ganey HCAPS survey. During the intervention phase (November 1 to February 28, 2019), education was provided to all staff including nurses, housestaff, pharmacists, and respiratory therapists regarding this study’s aim and rationale. Staff were also surveyed regarding provider attitudes towards patient sleep. All patients’ vital sign orders were reviewed during daily Interdisciplinary Rounds (attended by the above-mentioned staff), and housestaff were prompted to consider reducing vital sign frequency if a stable patient was ordered for Q4H vitals. The primary outcome was the percentage of patients discharged with Q4H vital signs post-intervention (March 1 to March 30, 2019).

Results

The provider surveys showed that at baseline, most staff did not proactively reschedule interventions to avoid interrupting sleep (61%) or prioritize discussing sleep with patients (62%) [Figure 1]. Baseline pre-intervention data showed that 81% of patients were discharged home from the medicine unit with vital signs ordered Q4H. Post-intervention, only 54% of patients were discharged home on Q4H vitals (p < 0.0001) [Figure 2]. Patients’ response to the survey question “how often was the area around your room quiet at night?” improved from 33.3% in October 2018 to 85.7% in March 2019.

Conclusions

The combination of staff education and incorporating review of Q4H vitals into daily Interdisciplinary Rounds helped reduce unnecessary vitals checks at night, and improved patient satisfaction with sleep quality. This study aims to highlight the importance of uninterrupted sleep to change provider practice. We hope to expand the scope of this study, particularly to lower acuity medicine floors in our hospital.

Clinical Implications

Hospitalized patients’ vital sign orders should be re-assessed during the course of a hospitalization to see if frequency can be reduced. This results in fewer nocturnal interruptions/overnight disruptions for our patients and reduction of unnecessary work for the nursing staff.

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