Background: Overnight disruptions in sleep during acute care hospitalizations contribute to lower patient satisfaction, higher risk of delirium, and potentially, increased length of stay. One primary offender of quality sleep is high frequency collection of vital signs during overnight hours. Protocols for reduction in collection of overnight vital signs have been successfully implemented at other institutions and correlated with reduced length of stay, reduced readmission, improved emotional health, and improved patient experience. There was no documented increase in adverse events. In our institution, systematic process improvement strategies for reduction in nighttime vital signs checks has been limited by educational gaps and electronic health record structure.
Purpose: A collaboration among nursing, resident house-staff, and hospitalists crafted a global aim to reduce vital sign checks per patient-night by 25% in acute care inpatient units over a 3-month time frame.
Description: Two main interventions included education electronic health record (EHR) menu redesign. Nursing, house-staff, and hospitalists were educated on the benefits of reducing overnight vital signs and received a primer on the use of a newly designed “Sleep Friendly Vital Signs” order menu in the EHR. Our local informatics technologists designed a new vital sign ordering menu which systematized a protocol for omitting vital signs checks between 10pm and 6am. After initial education, informational flyers were placed in nursing and physician workstations. The frequency of physician ordered “Sleep Friendly Vital Signs” compared to physician ordered continuous vital signs was tracked from August through November 2019 as a process measure. The primary outcome is the reduction in vital signs per patient night for all comers to acute care inpatient units over a three-month time frame. Pre and post intervention rapid response data serve as a balancing measure.
Conclusions: Over a three-month period, weekly physician orders for “Sleep Friendly Vital Signs” compared to standard overnight vital sign collection ranged from 75.3%-96.9%. Because the EHR order for “Sleep Friendly Vital Signs” was created for this intervention, there is no baseline data for the process measure. The primary outcome measure of vital signs per patient night was reduced from 0.97 to 0.70. This marks a 27.8% reduction in vital signs per patient night for all comers to acute care units. Rapid response data does not demonstrate any significant increase in recognized clinical deterioration between 10pm and 7am. Prior to implementation of the “Sleep Friendly Vital Signs” protocol, several potential barriers were identified. Brief education was impactful and effective at curbing cultural norms and educational gaps. This is demonstrated by a robust physician usage of the newly designed sleep friendly vital signs protocol in the EHR. There were early signals of drift in weekly order usage reports which were successfully addressed by providing targeted reminders to inpatient wards teams. Further opportunities for reducing overnight interruptions include re-timing of medication administration, and phlebotomy.