Sleep Disturbances Drift Off With Order Changes, Reminders

Marcia Frellick

May 09, 2017

LAS VEGAS — Education and "nudges" for providers can cut hospital sleep disruptions and boost patient-satisfaction scores, a new study suggests.

Previous attempts to reduce sleep interruptions have often failed. Although the education piece was there, behavioral reminders were not, said Vineet Arora, MD, a hospitalist and associate professor of medicine at the University of Chicago.

That's where the nudges come in, she said here at the Society of Hospital Medicine 2017 Annual Meeting. It's "like setting fruit at eye level so more people choose fruit."

The SIESTA — Sleep for Inpatients: Empowering Staff to Act — pilot project was designed to reduce major sleep disruptions for patients in the hospital. Dr Arora and her colleagues assessed interruptions in the 6 months before and the 6 months after implementation.

There is an urgency for better hospital sleep, Dr Arora told Medscape Medical News. Multiple studies have demonstrated the health benefits of sleep, and the Choosing Wisely campaign notes that when tasks are performed out of habit rather than necessity, the result is a wasteful system, she added.

Defaults in Health Records

The intervention involved changes to the default settings in the electronic health record (EHR) system. The default request for vitals had been set to four times a day and, because this option was hidden, doctors could not make a different choice.

Changes were also made to increase the number of patients treated with heparin for the prevention of venous thromboembolism every 12 hours, instead of every 8 hours.

"We built in a prompt in the EHR order set so that the clinician would have to choose the time frames for taking vitals, for venous thromboembolism prophylaxis, and for ordering labs," Dr Arora told Medscape Medical News.

The default order sets for labs had been set to 4 AM; these were changed to 10 PM or 6 AM.

The researchers also asked nurses to make SIESTA part of their huddle. At 4 AM and 4 PM, the nurses would gather to determine whether at least two patients experienced fewer interruptions.

"It was enough of a reminder that nurses could feel empowered to ask the doctor to change the orders," said Dr Arora.

The research team reviewed 612 admission orders. Orders with no request for overnight vitals rose from 3% to 34% (< .001). Orders that specified heparin every 12 hours or daily enoxaparin instead of heparin every 8 hours increased from 15% to 42% (P < .001).

During the study period, 200 patients were surveyed about sleep disruptions. Responses revealed that nighttime disruptions for vitals were more than three times less likely occur after the implementation of SIESTA than before (odds ratio [OR], 3.35; P < .05), and disruptions for medication administration were more than four times less likely to occur (OR, 4.08; P < .05).

Th researchers used heat sensors in hand-sanitizer machines to determine the number of times people entered a patient's room, and how often those people used the sanitizer. The machines proved to be a great way to see if fewer people entered the patient's room after the intervention, Dr Arora explained.

Innovative Use of Hand Sanitizer Sensors

For the 244 nights studied, there were 6.3 fewer nightly disruptions per room after the implementation of SIESTA, which is a decrease of 44% (P < .001).

Hospital Consumer Assessment of Healthcare Providers and Systems scores, which have implications for value-based care, were also substantially higher after implementation.

Before implementation, one of the lowest performing measures — at 61% — was the number of patients who reported a quiet room at night. After implementation, there was a 7% increase in the number of patients reporting a quiet room at night.

There was also a 9% increase in the number of patients reporting well-controlled pain. "While this does not look that impressive, when you look at the Medicare website, a 5% change in this question in score corresponds to a performance jump of 25%," Dr Arora pointed out.

This work is interesting because baseline order sets often default to 4 times a day, which is likely related the fear that something might be missed, said Emanuel Kokotakis, MD, from the Medstar Montgomery Medical Center in Baltimore.

With risk stratification, low-risk patients could be spared the automated intrusions, and the no-dose window could be broadened at night, he told Medscape Medical News.

"You just have to cohort patients appropriately, because you could get a low-risk patient in a room with a high-risk patient. Our hospital has single rooms, but in the winter, when our census goes up 20% to 30%, we go to semiprivate," he explained.

The next step is to roll SIESTA out to 15 more hospitals. "We are also expanding to pediatrics, and we've partnered with Comer Children's Hospital" in Chicago, Dr Arora reported.

In that partnership, the team will look at not only children's sleep, but also the sleep of parents who stay with them, because that often plays a role in how well the hospital stay goes, she pointed out.

Dr Arora is a board member of the American Board of Internal Medicine. Dr Kokotakis has disclosed no relevant financial relationships.

Society of Hospital Medicine (HM) 2017 Annual Meeting. Presented May 3, 2017.

Follow Medscape Internal Medicine on Twitter @MedscapeIM and Marcia Frellick @mfrellick

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