Reducing Nighttime Checks Is Safe and Helps Patients Sleep

Nadine Eckert

January 14, 2022

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, Nader Najafi, MD, MAS, from the University of California, San Francisco, and his colleagues were able to significantly reduce the number of checks at night without increasing transfers to the intensive care ward or heart-alarm triggers.

"Sleep is crucial to health," writes Hyung J. Cho, MD, from the NYU Grossman School of Medicine in New York City, in an accompanying editorial. "Ironically, hospitals, where people go to recover from illness, are among the most difficult places to sleep."

Noise from the surrounding area, nighttime 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 nighttime 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 nighttime vital signs would be within the normal range. Each physician was free to decide whether they would forgo nighttime 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 1930 patients were randomized to the algorithm group and half to standard care. None of the patients were receiving intensive care.

Number of Nighttime Checks Successfully Reduced

The mean number of nighttime checks was significantly lower in the algorithm group than in the standard-care group (0.97 vs 1.41; P < .001).

The reduction in nighttime 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%; = .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%; = .32).

"The reduction in vital signs checking, although statistically significant, was relatively small," 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," 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, 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 nighttime 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, Najafi and his colleagues suggest.

This article originally appeared in the German edition of Medscape.

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