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Should hospitals scale back on vitals at night?

August 2013

Published in the August 2013 issue of Today’s Hospitalist

Time to scale back on vitals at night?

NEARLY HALF OF THE PATIENTS in a recent prospective study were at low risk for clinical deterioration at night, yet they were awakened every four hours to have their vitals taken.

A research letter published online last month by JAMA Internal Medicine suggests that hospitals can scale back on nighttime vital signs for such patients, particularly because depriving inpatients of sleep is associated with hypertension, delirium and perhaps more readmissions.

Researchers looked at records for more than 54,000 patients and calculated each patient’s modified early warning score (MEWS) based on vitals taken at 11 p.m. They wanted to see if MEWS could identify patients at high risk of an adverse event, such as cardiac arrest or a transfer to the ICU.

A higher evening MEWS was linked to higher adverse event rates, but 45% of patients had a MEWS of 1 or less. Forgoing vital signs at night for low-risk patients, the authors wrote, would not only safeguard patients’ sleep, but could help moderate nighttime nurse staffing needs or allow nurses to more effectively monitor high-risk patients.

What’s the return on investment for CPOE?

HOW MUCH OF A RETURN on investment (ROI) can community hospitals expect from implementing CPOE? Researchers say that may depend on the level of clinical decision support built into the CPOE system.

A research team writing in the July issue of the Joint Commission Journal on Quality and Patient Safety looked at four community hospitals in Massachusetts, which represented two separate hospital systems and two different CPOE systems.

The costs of implementing CPOE for hospital group A were much lower than for hospital group B ($83 per admission vs. $113), although hospital group A also recouped less in preventable adverse drug event-related and -avoided costs ($7.9 million vs. $16.6 million). A cost-benefit analysis found that hospital group A had an ROI of 11.3% and would break even on its CPOE investment within eight years. Hospital group B had a negative ROI of -3.1%.

The authors noted, however, that the system with the negative ROI had minimal decision support capabilities and that enhanced decision support could have led to avoiding more preventable adverse drug events and a more robust ROI.

Time and tissue

THE SOONER PATIENTS suffering an acute ischemic stroke receive IV tPA, the lower their risk of dying in the hospital and the more likely that they will be discharged to their home.

That was the conclusion of a study published in the June 19 issue of the Journal of the American Medical Association. Researchers looked at registry data on outcomes for nearly 60,000 ischemic stroke patients treated in nearly 1,400 hospitals. The authors found that the magnitude of treatment benefit increased for every 15 minutes sooner that IV tPA was administered after symptom onset.

Patients who received IV tPA within 90 minutes, for example, had a 26% lower mortality risk and a 33% higher likelihood of being discharged home than patients receiving the therapy between 181 and 270 minutes post-onset. Treatment benefits also included lower risk of intracranial hemorrhage and greater independent function at discharge.

IV tPA is approved for ischemic stroke patients for up to 4.5 hours after the onset of stroke symptoms.