IT’S NOT SECRET that many patients can’t get a decent night’s sleep in the hospital—and that a growing body of evidence details the problems inpatients have due to sleep deprivation.
So what can help? To find out, researchers at the University of Chicago created and tested the Sleep for Inpatients: Empowering Staff to Act (SIESTA) initiative, led by Vineet Arora, MD, MAPP, professor of medicine and associate chief medical officer-clinical learning environment. Results of that initiative were published in the January Journal of Hospital Medicine.
SIESTA had several parts. One called for using what Dr. Arora and her colleagues called electronic “nudges” designed to steer providers toward more sleep-friendly orders. Instead of having night-time vitals be the default order, for instance, the research team worked with clinical informaticists to instead ask physicians, “Continue vitals throughout the night?” Another nudge gave physicians the option of ordering q12 heparin for VTE prophylaxis instead of q8, so nurses wouldn’t have to wake patients to give them a shot.
“What’s new here is the interprofessional piece with doctors and nurses working together.”
~ Vineet Arora, MD, MAPP
University of Chicago
Hospitalists and residents were also given a 20-minute presentation on inpatient sleep deprivation, one that used the medical center’s own Hospital Compare and patient survey data. In that presentation, doctors were urged to identify stable patients who could forego night-time vitals, choose the q12 heparin option, and order daily labs at either 10 p.m. or 6 a.m. Doctors also received a pocket card with the SIESTA mnemonic.
Importantly, the initiative also has a nursing component, one researchers tested by designating a SIESTA-enhanced unit to compare to a standard one. (Physicians served on both units.) On the SIESTA-enhanced unit, nurses were taught to use the pocket cards and coached in how to talk to doctors about implementing more sleep-friendly orders. Customized signage near the huddle board urged nurses to advocate for better sleep for patients. Nurses were also encouraged to identify at least two stable patients eligible for sleep-promoting orders and to discuss those patients and SIESTA at both their 4 p.m. and 3 a.m. huddles.
It turns out that the nursing component may have had the biggest impact. While the number of sleep-friendly orders increased on both units, only the SIESTA-enhanced unit had fewer night-time room entries as well as improvement in patient-reported sleep outcomes. “Creating a sleep-friendly environment likely depends on the unit-based nurses championing the cause,” Dr. Arora and her colleagues wrote in the study.
“It’s not one-size-fits-all, and there are really two sides to high-value care,” she explains. “You want to not only reduce overuse of labs and vitals for stable patients, but also improve underuse for patients who are really sick.” Dr. Arora spoke to Today’s Hospitalist.
How did you develop SIESTA?
We did more than 100 patient surveys and more than 100 surveys with providers. In addition, we held three focus groups—one each for nurses, residents and hospitalists—to find out what they saw as the major barriers preventing them from helping patients sleep.
Each focus group uncovered a different barrier. The nurses fixated on the q8 heparin default, which meant waking patients at 1 a.m. The nurses felt that jeopardized their ability to have a good rapport with their patients.
The residents harped on how to change to more sleep-friendly orders for vitals and labs. While the SIESTA trial didn’t improve lab ordering, we worked harder on that particular issue the following year and we made progress. We presented a poster on those results that was a finalist at this year’s Society of Hospital Medicine meeting.
Why are electronic “nudges” a better way to go than implementing a hard stop on ordering vitals at night?
Hard stops are difficult to implement in terms of gray areas. In the case of ordering night-time vitals, for instance, a hard stop might actually be unsafe if doctors need them and have to figure out how to get around a hard stop.
Plus, hard stops can be perceived as paternalistic and overbearing. Nudges are a way to inform people on how to make better decisions and make it easier for them to make those better decisions.
Why aren’t interventions to improve inpatient sleep more widely implemented?
Most interventions rely primarily on staff education, which are usually not that helpful alone. It’s hard to sustain staff engagement with an educational initiative alone. You may at first see a big uptick in whatever you’re targeting, but sustainability is very hard.
Instead of just using education, we coached nurses in the SIESTA-enhanced unit in how to talk to doctors to promote better sleep. Part of that coaching was using a comic drawn by a nurse artist, M.K. Czerwiec, RN, MA—who goes by “Comic Nurse“—that suggests language nurses can use with doctors to advocate for sleep-friendly orders.
But importantly, we empowered nurses to make the SIESTA project their own in terms of identifying stable patients and discussing SIESTA in their huddles. That’s what made the difference.
We’ve now expanded SIESTA to our pediatric units, and we’re about to launch a study to add patient education to the initiative. Our next step will actually be empowering patients to ask for sleep-friendly orders themselves.
Is including nurses in quality improvement a new concept?
Nurses have very well-established quality infrastructure and are often leaders in quality improvement. What’s new here is the interprofessional piece with doctors and nurses working together.
Working with nurses on SIESTA led to the creation of a new project: IGNITE, which stands for Improving GME Nursing Interprofessional Team-based Experiences. We’re figuring out how to take the effectiveness of having residents, hospitalists and nurses all work together and spread it to the rest of our teams. We now have IGNITE teams in nine different service lines throughout the hospital. While they’re not working on improving sleep, they’re using these same tools and strategies to improve discharge planning and patient satisfaction.
Promoting better inpatient sleep
In addition to being the name of a project undertaken at the University of Chicago to curb night-time sleep disruptions, SIESTA is also a mnemonic that clinicians are taught to help them promote better patient sleep:
Screen patients for sleep disorders
Instruct patients on sleep hygiene
Alarm and noise control
Source: Journal of Hospital Medicine
Published in the August 2019 issue of Today’s Hospitalist