Routine checks of vital signs during the night often prevent hospitalized patients from getting sufficient recuperative sleep. But patients who are judged to be clinically stable by an algorithm that uses real-time data can be safely spared these checks, according to a recent study published in JAMA Internal Medicine.
In their study,
“Sleep is crucial to health,” writes Hyung J. Cho, MD, from the New York University Grossman School of Medicine, in an accompanying editorial. “Ironically, hospitals, where people go to recover from illness, are among the most difficult places to sleep.”
Dr. Hyung (Harry) Cho
Noise from the surrounding area, night-time examinations, multibed rooms, an unfamiliar environment, early morning blood sample collections, and frequent vital sign checks often prevent patients from sleeping through the night.
The goal of the study was to see if the elimination of one of these disrupting factors – the frequent checks of vital signs – would improve sleep and lead to a reduction in delirium, the primary endpoint.
To do this, the researchers incorporated a predictive algorithm they developed “to identify patients who are at low risk for abnormal night-time vital signs” into the hospitals electronic health records system. Attending physicians received a notification, based on real-time patient data, if it was predicted with a high degree of probability that a patient’s night-time vital signs would be within the normal range. Each physician was free to decide whether they would forgo night-time checks of the vital signs or whether they would turn off the notifications for a specific period.
The randomized clinical trial was conducted at a tertiary care academic teaching hospital from March to November 2019. Half the 1,930 patients were randomized to the algorithm group and half to standard care. None of the patients were receiving intensive care.
Number of night-time checks successfully reduced
The mean number of night-time checks was significantly lower in the algorithm group than in the standard-care group (0.97 vs. 1.41; P < .001).
The reduction in night-time checks had no effect on patient safety. There was no increase in transfers to the intensive care unit in the algorithm or standard-care groups (5% vs 5%; P = .92), and no difference between the number of heart alarms (0.2% vs. 0.9%; P = .07).
However, the reduction also had no effect on the incidence of episodes of delirium in the algorithm or standard-care groups (11% vs. 13%; P = .32).
“The reduction in vital signs checking, although statistically significant, was relatively small,” Dr. Cho explains. But the primary endpoint might have been different had the adherence to intervention been better, he notes.
In fact, the analysis confirmed that changes to routine daily practice in a hospital are not always easy to implement. In 35% of cases, the patients’ vital signs were checked at night, despite the physician’s order to the contrary.
“Busy patient-care assistants and nurses may check vital signs out of habit without noticing that the order has changed for some of the patients,” Dr. Najafi and his coauthors write. Many hospitals are used to thinking that regular measurements of the vital signs are part of good practice.
Include nursing staff
Future projects should use an interdisciplinary approach that includes nursing staff, Dr. Cho recommends. More user-friendly displays and optimized alerts in the electronic patient records could also encourage better implementation of the orders.
Less frequent checks of the vital signs would be welcomed by frontline staff because it would lighten their already heavy workload, he adds.
Although the study didn’t meet its primary endpoint, patients subjected to fewer night-time checks because of the algorithm were able to get a good night’s sleep. Other aspects of hospital care that are based on the patient’s stability, such as cardiac monitoring, could also potentially benefit from this type of intervention, Dr. Najafi and his colleagues suggest.
A version of this article first appeared on Medscape.com.