Published in the November 2009 issue of Today’s Hospitalist.
HOSPITALIST MELISSA BARTICK, MD, had a very personal reason to conduct a recently published study. Admitted as an inpatient to her own ward, Dr. Bartick had her vitals read when she got to the floor at 10 p.m. Less than two hours later, she was roused awake so her vitals could be checked again, this time by the next shift.
“I thought, ‘This is really dumb,’ and by the next morning, I was designing the study,” Dr. Bartick says of the research she conducted at Cambridge Health Alliance’s Somerville Hospital in Somerville, Mass., between September 2007 and January 2008. That study, published online in September by the Journal of Hospital Medicine, shines a light on a subject that’s often ignored: how to promote sounder sleep among patients on wards and how to decrease their use of as-needed sedatives.
Dr. Bartick and her fellow researchers found that a series of small modifications resulted in a 38% reduction in the number of patients reporting disturbed sleep and a 49% reduction in the number of those receiving as-needed sedatives. The biggest change, she said, was moving away from a culture in the hospital that grew out of habit and was designed to meet the needs of staff and physicians, not patients.
“We go through our routine thinking of how convenient things are for us and not thinking of what they mean for the patient,” says Dr. Bartick. While staff is used to waking patients at midnight to check vitals and administer medications, “for a variety of reasons, that’s not really nice for the patient.”
Establishing “quiet time”
According to Dr. Bartick, most sleep-promotion studies in inpatients have been done in ICUs. “Helping people get a better night’s sleep is not on the radar screen for most quality-of-care interventions,” she says. It doesn’t help that patients themselves have really low expectations of how much sleep they’ll be able to get in the hospital.
Before the intervention at Somerville Hospital, the routines were very familiar: Vitals were checked every eight hours at 8 a.m., 4 p.m. and midnight, with patients being routinely awakened for medications ordered q-6 hours or q-8 hours. Not surprisingly, a pre-study survey found that more than 42% of patients reported “hospital staff” as the biggest factor disrupting their sleep.
The first step in a multi-pronged research protocol was to designate “quiet time” between 10 p.m. and 6 a.m. A Multiple interventions slash the number of sedatives that patients need lullaby was played over the public address system, and overhead hallway lights on a timer went off at 10 p.m.
More importantly, the times set to check vitals “and to administer medications and help toilet patients, if needed “were shifted. The evening shift started taking vitals at 10 p.m., instead of waiting for night staff to take them at midnight; the night shift started taking vitals at 6 a.m., while the day shift checked vitals at 2 p.m. (Hospital policy dictated that telemetry patients have vitals checked every four hours.)
According to Dr. Bartick, shifting those activities by two hours “was not a hard sell at all. The nurse manager said, ‘We are going to do this from now on,’ and they did it.” It helped, she notes, that nurses were involved in designing the intervention, so researchers had nursing buy-in from the beginning.
More flexible drug orders
Another modification, one that affected physicians, was a harder sell and involved more time and training to get right. Instead of physicians continuing to order medications “q” a certain number of hours, researchers told them to write orders as daily, BID, TID or QID instead. That way, patients would still get medications twice (or three or four) times a day, but not at set times that might disrupt their sleep.
To reach the more than two dozen providers, all on different services and shifts, who were writing orders, researchers put up signs, sent a lot of e-mails and educated the nursing staff.
That education involved convincing people that a q-6 order is different than QID. “They’d say, ‘That’s the same thing, isn’t it?’ " says Dr. Bartick. "They didn’t understand that QID can mean any four times in the day so you don’t have to wake patients for doses.” (Aminoglycosides and vancomycin were specifically exempt.)
Another intervention arm seems like a no-brainer: not administering standing doses of diuretics after 4 p.m. Other interventions included in the protocol were avoiding blood transfusions during quiet time because those require frequent monitoring; not running IV fluids overnight, if possible, so patients aren’t jolted awake by an alarm when a bag runs dry; and avoiding placing IV catheters in the antecubital fossae. (The occlusion that’s common sets off an alarm on the pump.)
Noise detectors were also set up in nursing stations, flashing warning lights when noise rose above a certain level. “That took,” Dr. Bartick concedes, “some getting used to.”
A new set-up
The study’s sample size, she points out, was too small to gauge the effect of fewer sedatives on rates of patient falls or of delirium. But results were so impressive that the protocol became standard practice at Somerville once the study was over.
As of June, however, that hospital campus is no longer being used for acute care. Instead, many of Somerville’s nurses and physicians, including Dr. Bartick, now work at Cambridge Health Alliance’s Cambridge Hospital campus. Once relocation issues settle down, she says, the Cambridge staff plan to implement the same sleep-promotion protocol.
One bottleneck at the new site that she’s looking into is the fact that the Cambridge staff take vital signs every four hours, even for non-telemetry patients. Once staff work out who really needs to have vitals checked so frequently, Dr. Bartick expects training in the protocol at the new campus to take four or five months.
“A lot of the nurses from the Somerville unit have come to Cambridge,” Dr. Bartick says. “They’d like to see the protocol implemented here.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.