Purpose: To improve sleep among hospitalized patients through a resident-led project aimed at minimizing nighttime disruptions and changing culture.
Description: In a needs assessment survey, hospitalized patients reported nighttime disruptions, such as vital signs, beeping IV poles, and medication administration were the second most common cause of disturbed sleep (pain was number one). At baseline, 15% of patients were discharged from the hospital medicine service on “sleep promotion vital signs (VS)” defined as any VS less frequent than every 4 hours. Our goal is to increase this to 45% of patients having sleep promotion VS at least 24 hours prior to discharge. As balancing measures, we are tracking rapid response calls and intensive care unit transfers on the medicine service.
Housestaff with support from faculty, nurses and informatics began a yearlong project with several interventions including provider education, audit and feedback and electronic medical record (EMR) change – with the goal of decreasing nocturnal vital sign checks in stable patients. We promoted culture change by providing education regarding the minimal risks of deterioration after stabilization of VS at monthly resident orientation, encouraging housestaff to order sleep promotion VS on patients with stable VS for at least 24 hours and no anticipated medical changes. We also provided real-time feedback to each medicine team by emailing a performance dashboard every two weeks, fostering healthy competition (Figure 1). We embedded orders for “Sleep Promotion Vitals ” (three times daily while awake) into the core admission order set within our EMR as well as creating a stand alone order that can be used at any time.
Early results demonstrate an increase in sleep promotion VS from 15% to 55% (Figure 2) without any recorded adverse outcomes. Next steps involve working with nursing on strategies to ensure sleep promotion orders are followed — such as visual indicators of VS frequency on the door. We are also conducting surveys of patients to determine if vitals reduction is affecting sleep quality and duration.
Conclusions: Through a multifaceted approach with education, feedback and EMR changes, we have successfully increased the number of orders for sleep promotion vital signs. Further work is necessary to ensure changes in ordering behavior are resulting in improved sleep for patients.