Skipping Nighttime Checks No Remedy for Bad Sleep in Hospitals

Fewer disturbances from nighttime checks did not translate into better sleep in the hospital for patients, according to a randomized trial.

At one center, the electronic health record (EHR) system had an embedded real-time clinical decision support (CDS) tool alerting physicians to patients who were at low risk for abnormal nighttime vital signs and therefore candidates for a skipped nighttime vital sign check.

For the study’s primary endpoint, randomization to the sleep promotion intervention was not associated with a reduction in delirium compared with usual care in the general medicine service (11% vs 13%, P=0.32), and the intervention failed to improve sleep satisfaction as well, Nader Najafi, MD, of University of California San Francisco, and colleagues reported.

Notably, in 35% of study nights in which patients had an active sleep promotion order from a physician, at least one vital sign check was still performed, the study authors noted. Busy patient-care assistants and nurses may have checked nighttime vital signs for patients in the intervention arm out of habit, they wrote in JAMA Internal Medicine.

Study authors found a 31% reduction in vital sign checks per night in the intervention arm. This approach at least did no harm (in terms of excess code blues, rapid response calls, and ICU transfers), suggesting that for some patients, overnight vital sign checks can be reduced with no adverse effects, according to Najafi and colleagues.

“With greater fidelity to the intervention, avoidance of nighttime vital sign measurement could be an important ingredient in a delirium prevention strategy, as well as a way of increasing patient satisfaction and allowing hospital staff to focus on more useful interventions,” Hyung Cho, MD, of NYC Health and Hospitals, and Mitchell Katz, MD, of NYU Grossman School of Medicine, wrote in a corresponding editorial.

“Ironically, hospitals, a place people go for healing, are among the most difficult places to get sufficient sleep,” Cho and Katz said. Aside from frequent vital checks, shared rooms, ambient noise, nighttime procedures, and early morning phlebotomies are all factors that can detract from proper sleep in a hospital setting, they noted.

“It is not surprising that the intervention was not able to decrease the incidence of delirium. Hospital delirium has many contributors, and the reduction in vital signs checking, although statistically significant, was relatively small,” according to the editorialists.

Najafi’s team conducted the trial from March to November 2019. Of 3,025 total encounters screened by the CDS tool, 966 patient encounters were randomized to the intervention arm, and 964 to the usual care arm. In both arms, the mean patient age was 53 years, and a little over 40% were women.

The authors said that because their intervention was software-based, it is scalable, but they acknowledged that the data used to create their algorithm came from their institution alone and may not be representative of other medical centers.

Past studies have questioned the need for frequent vital checks in low-risk patients. Traditionally, these checks are conducted every 4 hours, though there is a lack of evidence supporting this practice, the study authors wrote.

Another group had reported fewer nighttime room entries and improved patient experience when nurses were encouraged by electronic nudges to refrain from nighttime vital checks for some patients.

“Reduced measurement of vital signs would be welcomed by staff because it would reduce their already busy workloads and eliminate the burden of wakening a patient,” Cho and Katz said.

“And if nothing else, think how appreciative each patient will be for just a good night’s sleep,” they added.