In June 2013 physician Peter Ubel wrote an article in The Atlantic about his own experience as a hospital patient (Ubel 2013). His sleep was disrupted for routine vital sign monitoring, blood draws, and the alarm on his IV pump sounding. He notes that between 10 PM and 6 AM he did not go more than an hour without some sort of interruption. Unfortunately, his experience is the norm for hospitalized inpatients.
There are a number of interventions we can do that improve sleep in hospitalized patients. However, the two most important potentially avoidable interruptions to patient sleep in the hospital are vital sign monitoring and blood draws. Don’t get us wrong! Patients should be awakened for vital signs when appropriate (see our February 12, 2013 Patient Safety Tip of the Week “CDPH: Lessons Learned from PCA Incident”). But very often we wake patients who are clinically stable, in whom a set of middle-of-the-night vital signs may have no clinical impact.
A new study looked at ward inpatients stratified by the MEWS (Modified Early Warning Score) score (Yoder 2013). Patients with a MEWS score of 1 or less had an adverse event rate of 5.0 per 1000 patient-days whereas those with a MEWS score of 7 or more had an adverse event rate of 157.3 per 1000 patient-days. Yet the number of nighttime vital sign interruptions was no different, averaging 2 vital sign check per patient per night. At least one vital sign interruption occurred for 99% of nights. Almost half the nighttime vital sign interruptions occurred in patients with MEWS score of 1 or less.
The obvious implication is that we might be able to avoid sleep interruptions in a large proportion of hospitalized patients by tailoring vital sign frequency to the clinical risk profile of the patients, improving their sleep and overall health and, at the same time, potentially reducing costs associated with that monitoring.
Just as we often automatically (and inappropriately) order prn sleep meds in admission orders, we also often order without much thought vital signs at a frequency that is unnecessary. Moreover, a frequency of vital signs that may be appropriate on admission or in the perioperative period may no longer be necessary several days later. Yet we seldom review and modify such orders. Simply tying vital sign frequency to a MEWS score might be risky. For example, it is conceivable that a patient at risk for neurological deterioration might have a low MEWS score yet need frequent nocturnal vital sign monitoring. Perhaps a better way would be to use computerized systems to prompt the clinician to review the need for frequent vital signs when the MEWS score is low.
The accompanying editorial by Sharon Inouye outlines the many hospital factors that impair patients’ sleep in the hospital and the potential adverse effects on their health (Inouye 2013). Many of you will recognize Dr. Inouye for her work on the Hospital Elder Life Program (HELP). In that program a systemic effort is made to improve sleep in hospitalized patients by noise reduction, a nonpharmacologic sleep protocol, and coordination of nighttime care. Inouye points out that besides vital sign monitoring and blood draws, patients’ sleep is often disrupted by medication administration, IV changes or IV alarms, intermittent pneumatic compression devices, breathing treatments, fingersticks for glucose monitoring, paging systems, room or hallway lights, conversations, cleaning and waxing floors at night, etc. Moreover, she notes there is often a striking lack of coordination amongst staff that could minimize these disruptions. Simply having the phlebotomist tag team with the nurse or aide doing vital signs could avoid one disruption.
In addition to the interventions in the HELP program there have been a few intervention programs tailored to improve hospitalized patients’ sleep. One study (Bartick 2010) implemented the “Somerville Protocol” and documented a 38% reduction in patients noting sleep disruption due to hospital staff and a 49% reduction in patients receiving prn sedatives (actually a 62% reduction for patients aged 65 and older). The protocol consisted of 10 components:
1. “Quiet Time” designated as 10PM to 6AM
2. Timing of “routine” vital signs changed to 6AM, 2PM and 10PM
3. Getting physicians to understand the difference between daily, BID, TID, QID vs. q24 hours, q12 hours, q8 hours, q6 hours
4. Avoid standing diuretic doses after 4PM
5. Avoid blood transfusions during Quiet Time where possible
6. Use of a noise detection device in the nursing station
7. Lullaby over the PA system at 10PM to alert patients, staff, visitors, etc. to Quiet Time
8. Timer to dim hallway lights automatically at 10PM
9. Nurses perform a bedtime routine before Quiet Time (vital signs, bedtime meds, toilet patient, ensure IV bag won’t empty at night, close patient door, etc.)
10. Avoid antecubital IV catheter site where possible (easier to occlude flow here and set off alarm at night) and even avoid nighttime IV fluids if possible
A couple of those interventions merit further discussion. At many (perhaps most) hospitals, the incoming nursing staff gets vital signs when their shift starts. Hence, many patients get their vital signs checked between 11PM and midnight. Simply changing policy and procedure so that vital signs are checked by the outgoing staff at 10PM can help avoid one obvious potential sleep disruption. (Of course, you’d have to look for potential unintended consequences such as interfering with shift handoffs).
Getting physicians to understand that “three times daily” and “every 8 hours”, for example, are not the same takes some time and hard work. If I order a medication today at 10AM and enter it as “every 8 hours” my patient will be wakened at 2AM to get a dose. On the other hand, if the order is written for “three times daily” the hospital will have standard times that such are given to avoid that disruptive nighttime dose. (Note that you have to be very careful. Today’s CPOE systems often don’t make it clear when the first dose will be given. We have seen some systems where the first dose or even all the first day’s doses will not be given when the order is written this way.)
A noise monitoring device for the nursing station doesn’t need to be expensive. If a teacher can use a free or $0.99 decibel meter for his/her iPhone to alert him/her to classroom noise exceeding a specified level, we can certainly find a cheap solution to avoiding excessive noise at the nursing station or elsewhere.
But even Bartick and colleagues note that reduction in noise and light probably did not significantly improve patients’ sleep. Rather reduction in the physical disruptions probably played the major role.
Ubel, in his Atlantic article (Ubel 2013), notes that even if your hospital has such a protocol to reduce sleep disruptions we need to ensure physicians order it. He points out that making it the default option is a great way to implement change. See our July 7, 2009 Patient Safety Tip of the Week “Nudge: Small Changes, Big Impact” for more on use of the default option.
Note that we have largely avoided reference to use of sleep meds in hospitalized patients. We’ve written numerous columns on the downside of sleep meds (see the list at the end of today’s column).
In our August 2009 What’s New in the Patient Safety World column “Bold Experiment: Hospitals Saying No to Sleep Meds” we wrote about a Pennsylvania hospital’s attempt to avoid sleep meds in attempt to reduce falls and other adverse events. Doylestown Hospital implemented a significant noise reduction program and implemented other interventions to help foster natural sleep including lowering the lights, closing doors, allowing masks or earplugs, using more private rooms, and allowing personal stereos to be used.
Our March 23, 2010 Patient Safety Tip of the Week “ISMP Guidelines for Standard Order Sets” and several of our other columns have cautioned against including “prn” sleep meds in any standard order sets. And our What’s New in the Patient Safety World columns for May 2012 “Safety of Hypnotic Drugs”, November 2012 “More on Safety of Sleep Meds”, March 2013 “Sedative/Hypnotics and Falls”, and June 2013 “Zolpidem and Emergency Room Visits” highlighted many of the safety issues associated with sleep meds.
A 2009 review of sleep disturbances in hospitalized patients (Young 2009) has a good algorithm and several tables for how to approach the hospitalized patient with a sleep disturbance. While it does cover pharmacologic interventions, it also discusses non-pharmacologic interventions to help improve sleep.
Prescribing sleep meds, whether for inpatients or outpatients, is often done without much thought. All too often they are thought of as being relatively harmless. Knowing the downside is an important first step. But putting in place various system fixes (eg. removing them from standardized order sets, using clinical decision support tools, etc.) may play a more important role. Knowing and understanding how to promote good sleep hygiene is extremely important in helping patients avoid the need for such drugs in the first place.
What is your hospital doing to avoid unnecessary sleep disruptions in your inpatients?
Some of our previous columns on safety issues associated with sleep meds:
August 2009 “Bold Experiment: Hospitals Saying No to Sleep Meds”
March 23, 2010 “ISMP Guidelines for Standard Order Sets”
May 2012 “Safety of Hypnotic Drugs”
November 2012 “More on Safety of Sleep Meds”
March 2013 “Sedative/Hypnotics and Falls”
June 2013 “Zolpidem and Emergency Room Visits”
Ubel P. Sleep Deprivation in Hospitals Is a Real Problem. Simple changes can make recovery more restful, and better overall. The Atlantic 2013; June 19, 2013
Yoder JC, Yuen TC, Churpek MM, et al. A Prospective Study of Nighttime Vital Sign Monitoring Frequency and Risk of Clinical Deterioration (Research Letter). JAMA Intern Med. 2013; (): Published online July 1, 2013
Inouye SK. No Rest for the Weary…or the Sick: Comment on “A Prospective Study of Nitghtime Vital Sign Monitoring Frequency and Risk of Clinical Deterioration”. JAMA Intern Med. 2013; (): doi:10.1001/jamainternmed.2013.7809 Published online July 1, 2013
Bartick MC, Thai X, Schmidt T, et al. Decrease in As-needed Sedative Use by Limiting Nighttime Sleep Disruptions from Hospital Staff. Journal of Hospital Medicine 2010; 5: E20–E24
Young JS, Bourgeois JA, Hilty DM, Hardin KA. Sleep in Hospitalized Medical Patients, Part 2: Behavioral and Pharmacological Management of Sleep Disturbances. Journal of Hospital Medicine 2009; 4: 50-59
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