Optimizing Oral Medication Schedules for Inpatient Sleep: A Quality Improvement Intervention.

OBJECTIVES: Hospitalized children experience frequent nighttime awakenings. Oral medications are commonly administered around the clock despite the comparable efficacy of daytime administration schedules, which promote sleep. With this study, we evaluated the effectiveness of a quality improvement initiative to increase the proportion of sleep-friendly antibiotic administration schedules. METHODS: Interprofessional stakeholders modified computerized provider order entry defaults for 4 oral antibiotic medications, from around the clock to administration occurring exclusively during waking hours. Additionally, care-team members received targeted education. Outcome measures included the proportion of sleep-friendly administration schedules and patient caregiver-reported disruptions to sleep. Pre- and posteducation surveys were used to evaluate education effectiveness. Balancing measures were missed antibiotic doses and related escalations of care. RESULTS: Interrupted time series analysis revealed a 72% increase (interceptpre: 18%; interceptpost: 90%; 95% confidence interval: 65%-79%; P < .001) in intercept for percentage of orders with sleep-friendly administration schedules (orders: n pre = 1014 and n post = 649). Compared with preeducation surveys, care-team members posteducation were more likely to agree that oral medications scheduled around the clock cause sleep disruption (resident: 71% pre, 90% post [P = .01]; nurse: 63% pre, 79% post [P = .03]). Although sleep-friendly orders increased, patient caregivers reported an increase in sleep disruption due to medications (pre 28%, post 46%; P < .001). CONCLUSIONS: A simple, low-cost intervention of computerized provider order entry default modifications and education can increase the proportion of sleep-friendly oral antibiotic administration schedules for hospitalized children. Patient perception of sleep is impacted by multiple factors and often does not align with objective data. An increased focus on improving sleep during hospitalization may result in heightened awareness of disruptions.

Improving Hospitalized Children's Sleep by Reducing Excessive Overnight Blood Pressure Monitoring.

BACKGROUND: Although required for healing, sleep is often disrupted during hospitalization. Blood pressure (BP) monitoring can be especially disruptive for pediatric inpatients and has few clinical indications. Our aim in this pilot study was to reduce unnecessary overnight BP monitoring and improve sleep for pediatric inpatients. METHODS: The intervention in June 2018 involved clinician education sessions and updated electronic health record (EHR) orders that enabled the forgoing of overnight BP checks. The postintervention period from July 2018 to May 2019 examined patient-caregiver surveys as outcome measures. These surveys measured inpatient sleep and overnight disruptions and were adopted from validated surveys: the Patient Sleep Questionnaire, expanded Brief Infant Sleep Questionnaire, and Potential Hospital Sleep Disruptions and Noises Questionnaire. Uptake of new sleep-friendly EHR orders was a process measure. Reported patient care escalations served as a balancing measure. RESULTS: Interrupted time series analysis of EHR orders (npre = 493; npost = 1472) showed an increase in intercept for the proportion of patients forgoing overnight BP postintervention (+50.7%; 95% confidence interval 41.2% to 60.3%; P < .001) and a subsequent decrease in slope each week (-0.16%; 95% confidence interval -0.32% to -0.01%; P = .037). Statistical process control of surveys (npre = 263; npost = 131) showed a significant increase in sleep duration for patients older than 2, and nighttime disruptions by clinicians decreased by 19% (P < .001). Annual estimated cost savings were $15 842.01. No major adverse events in patients forgoing BP were reported. CONCLUSIONS: A pilot study combining EHR changes and clinician education safely decreased overnight BP checks, increased pediatric inpatient sleep duration, and reduced nighttime disruptions by clinicians.

Characterizing pediatric inpatient sleep duration and disruptions.

OBJECTIVE: To contextualize inpatient sleep duration and disruptions in a general pediatric hospital ward by comparing in-hospital and at-home sleep durations to recommended guidelines and to objectively measure nighttime room entries. METHODS: Caregivers of patients four weeks - 18 years of age reported patient sleep duration and disruptions in anonymous surveys. Average at-home and in-hospital sleep durations were compared to National Sleep Foundation recommendations. Objective nighttime traffic was evaluated as the average number of room entries between 11:00pm and 7:00am using GOJO brand hand-hygiene room entry data. RESULTS: Among 246 patients, patients slept less in the hospital than at home with newborn and infant cohorts experiencing 7- and 4-h sleep deficits respectively (Newborn: 787 ± 318 min at home vs. 354 ± 211 min in hospital, p < 0.001; Infants: 703 ± 203 min at home vs. 412 ± 152 min in hospital, p < 0.01). Newborn children also experienced >2 h sleep deficits at home when compared to NSF recommendations (Newborns: 787 ± 318 min at home vs. 930 min recommended, p < 0.05). Objective nighttime traffic measures revealed that hospitalized children experienced 7.3 room entries/night (7.3 ± 0.25 entries). Nighttime traffic was significantly correlated with caregiver-reported nighttime awakenings (Spearman Rank Correlation Coefficient: 0.83, p < 0.001). CONCLUSION: Hospitalization is a missed opportunity to improve sleep both in the hospital and at home.

Caregiver and Staff Perceptions of Disruptions to Pediatric Inpatient Sleep.

STUDY OBJECTIVES: Sleep is critical to a child's health and well-being, but children are likely to sleep less and be awakened more often during the night in the hospital than at home. To date no studies have compared caregiver, nurse, and physician perspectives of nighttime sleep disruptions in the pediatric general medicine setting. Our aim was to assess caregiver, nurse, and physician perspectives on the most frequent in-hospital disruptors of sleep for pediatric patients. Additionally, we evaluated the degree of agreement of those opinions between the caregivers and medical team. METHODS: Caregivers, nurses, and physicians were surveyed using the Potential Hospital Sleep Disruption and Noises Questionnaire (PHSDNQ) regarding their opinions on factors that disrupt sleep. Caregiver responses were collected via a convenience sample of patients hospitalized from February to August 2017 and hospital staff was surveyed once regarding overall perception. The perceived percentage of patients disrupted by each factor was calculated and compared among groups using chi-square tests. Using caregiver rank order based on mean response as the reference gold standard, the absolute differences of nurse and physician rank orders were summed and analyzed using a two-sample test of proportion. In addition, staff was asked knowledge and empowerment questions about how to maximize patient sleep in the hospital and responses were compared using chi-square tests. RESULTS: A total of 162 caregivers, 77 nurses (84% response rate), and 81 physicians (90% response rate) completed surveys. Checking vital signs (50%), nurse/physician interruption (49%), and continuous pulse oximetry (38%) were the three most prevalent disruptors of pediatric inpatient sleep as reported by caregivers. Significant differences were observed between caregiver, nurse, and physician responses for pain, anxiety, alarms, noise, and tests (P ≤ .001 for all). Both nurse and physician rank orders were discordant when compared to caregivers; there was no significant difference between the two staff groups. When compared to physicians, nurses reported doing more to help children sleep in the hospital (33% versus 94%, P < .001). CONCLUSIONS: Although caregivers report medical interventions such as checking vital signs, nurse/physician interruption, and continuous pulse oximetry as the most frequent disruptors of inpatient pediatric sleep, pediatric staff has poor insight into these disruptions.