Tang - Protocol Assignment #1

Tang - Protocol Assignment #1

by Victoria Tang -

What evidence are you proposing to translate into practice?

Decrease nighttime frequency of vital sign monitoring for low-risk medical inpatients. Routine practice of collecting vital signs every 4 hours in hospitalized ward patients have been perpetuated since as early as 1893, but little evidence supports this tradition. While vital signs may indicate impending clinical deterioration, routine nighttime vital sign monitoring adds to sleep disruptions has been shown to be the environmental factor most disruptive to patient sleep. Sleep disruptions are prevalent among the inpatients and are associated with negative health outcomes, such as delirium, and patient distress during inpatient care. Overnight vital sign checks can also deplete crucial health care resources.

 

1. Justify that this evidence is “ready for translation.”

A prospective study, published in 2013, evaluated nighttime vital sign monitoring frequency and risk of clinical deterioration. This single institution study found that overnight vital signs were collected frequently among ward patients regardless of their risk of clinical deterioration. The frequency of vital sign disruptions were a median of 2  vital sign checks per patient per night and at least 1 disruption from vital sign collection 99.3% of the nights regardless of the patient’s risk. Patients with low-risk accounted for 45% of nighttime vital sign disruptions.

While no RCT, systematic review, or guideline have been conducted on this topic, certain hospitals have adopted the reduction of nighttime disturbances for their low-risk medical inpatients, the SFVA being one of them.  

 

2. Identify a single, key behavior change target for your translational activity.

To reduce nighttime vital sign monitoring for low-risk medical inpatients

 

3. Conduct a “gap analysis” of your target behavior.  Look to diverse sources for “best guess” estimates if specific measures are not available.

Different institutions have different “ad lib” frequencies of vital sign checks-- some are performed every 4 hours and others every 6. There is also a range depending on provider orders and unit. Also, despite orders to defer nighttime vitals, vital signs are still performed by the staff.

 

B.  What is the quality (performance) gap?

Education of staff regarding the negative outcomes related to sleep disturbances and adherence to provider orders to forego nighttime vitals.

 

C.  What is the outcome gap?

Number of low-risk patients without nighttime vitals performed.

 

D.  Is there evidence that changing performance will improve health (clinical outcomes)?

There has been evidence that sleep disturbances in the inpatient setting lead to negative outcomes (patient dissatisfaction, increased risk of delirium) but there has not been a randomized control trial evaluating whether the change in performance will directly improve health.

Re: Tang - Protocol Assignment #1

by Lindsay Hampson -

Vicky - really like this proposal. A few things you might think about:

How would you define your low-risk population?

Would you consider implementing this in patients who are at a higher risk of delirium due to less sleep or being awoken in an unknown environment?

In educating staff, how would you structure that education for different groups?

Is there a way you can make this easy and get good adherence - for example in Apex a prompt would come up in admission orders where you select vital sign monitoring and it would allow you to see the criteria for low-risk/decreased vital signs monitoring and choose appropriately - this would then help make this an easy decision for people to make and prompt them to remember).

Re: Tang - Protocol Assignment #1

by Lisa Thompson -

Hi Victoria, This sounds like a sensible plan for low-risk patients.  I guess the prospective study you are referring to is Yoder, since your evidence is drawn from that abstract. I am surprised that more studies were not done on this in the past century! Will there be an algorithm to determine vital sign monitoring frequency during night, to avoid undetected decompensation? Perhaps something like Vitalpac™ Early Warning Score (ViEWS)? Lisa Thompson

Re: Tang - Protocol Assignment #1

by Heidi Moseson -

I think this is such a great project idea - something very simple and specific, that could potentially dramatically improve the patient experience, and possibly recovery.

Before promoting an intervention such as this, might a more important first step be to conduct an RCT to look at whether or not reductions in night time vital signs monitoring actually does have a beneficial health impact? I imagine it must, but it would make a much stronger case if you could point to specific reductions in hospital admission time, patient satisfaction, patient recovery, etc etc

Re: Tang - Protocol Assignment #1

by Christina Mangurian -

Hi Victoria

Great idea!  I really appreciate that you are working on this.  Too many people overlook the importance of sleep for our patients.  My initial thoughts:

In background, I’d add to the “negative health outcomes” of sleep disruption that will get the physicians more interested than patient distress (unfortunately)—e.g., prolonged healing, association with worsening metabolic abnormalities, etc.  You can find this information and it will help others be more interested since clinicians like hard clinical outcomes.

I’d also add something about the ACA and that improved sleep while an inpatient will likely add to patient satisfaction.

 

Add to A2: By nursing staff.

Add to A3:  I’d say “the majority” of hospitals do this.  Doesn’t the 2013 prospective study have the best guess?  I’d say it must be 90%.