Perspective: leveraging the electronic health record to improve sleep in the hospital

Evaluating the impact of patient-staff interactions on sleep opportunities using the electronic health record

BACKGROUND

Hospitalized patients often experience disrupted sleep due to nighttime patient-staff interactions (PSIs). This study evaluates how PSIs impact sleep opportunities in neurology inpatients using electronic health record (EHR) data and introduces surrogate measures of sleep such as longest uninterrupted sleep opportunity (LUSO) and interruptive episodes.

OBJECTIVE

To develop a methodology leveraging time-stamped EHR data to quantify and visualize the impact of PSIs on inpatient sleep opportunities.

METHODS

We analyzed 3305 patient nights in an inpatient neurology unit, categorizing PSIs into six types: vital signs, neurological checks, medication administration, bedside diagnostic testing, off-unit diagnostic testing, and bed changes. We calculated LUSO and interruptive episodes and used a linear mixed model to assess the relationship between PSIs and LUSO.

RESULTS

PSIs occurred in 92% of patient nights, averaging 2.81 interruptive episodes and 4.06 h of LUSO per night. Vital signs and medication administrations were the most frequent PSIs. Neurological checks and off-unit diagnostic testing were associated with the largest reductions in LUSO (approximately 40 min), followed by bed changes (-33.79 min).

CONCLUSION

This study demonstrates the utility of LUSO and interruptive episodes as EHR-based measures to link PSIs to sleep opportunities. While vital signs and medications were the most frequent PSIs, neurological checks and off-unit testing were associated with the largest impact on reducing LUSO. The predominance of single-PSI interruptive episodes underscores that the bundling of PSIs is not occurring. These findings highlight that PSIs impact sleep opportunities in distinct ways, supporting the use of this methodology to evaluate and address EHR-linked disruptions to patient sleep.

Nudging towards Sleep-Friendly Health Care: A Multifaceted Approach on Reducing Unnecessary Overnight Interventions

BACKGROUND

 Choice architecture refers to the design of decision environments, which can influence decision-making in health care. Nudges are subtle adjustments in these environments that guide decisions toward desired outcomes. For example, computerized provider order entry within electronic health records (EHRs) recommends frequencies for interventions such as nursing assessments and medication administrations, but these can link to around-the-clock schedules without clinical necessity.

OBJECTIVES

 This study aimed to evaluate an intervention to promote sleep-friendly practices by optimizing choice architecture and employing targeted nudges on inpatient order frequencies.

METHODS

 We employed a quasi-experimental interrupted time series analysis of a multifaceted, multiphase intervention to reduce overnight interventions in a hospital system. Our intervention featured EHR modifications to optimize the scheduling of vital sign checks, neurological checks, and medication administrations. Additionally, we used targeted secure messaging reminders and education on an inpatient neurology unit (INU) to supplement the initiative.

RESULTS

 Significant increases in sleep-friendly medication orders were observed at the academic medical center (AMC) and community hospital affiliate (CHA), particularly for acetaminophen and heparin at the AMC. This led to a reduction in overnight medication administrations, with the most substantial impact observed with heparin at all locations (CHA: 18%, AMC: 10%, INU: 10%, p < 0.05). Sleep-friendly vital sign orders increased significantly at all sites (AMC: 6.7%, CHA: 4.3%, INU: 14%, p < 0.05), and sleep-friendly neuro check orders increased significantly at the AMC (8.1%, p < 0.05). There was also a significant immediate reduction in overnight neurological checks performed at the AMC.

DISCUSSION

 Tailoring EHR modifications and employing multifaceted nudging strategies emerged as promising approaches for reducing unnecessary overnight interventions. The observed shifts in sleep-friendly ordering translated into decreases in overnight interventions.

CONCLUSION

 Multifaceted nudges can effectively influence clinician decision-making and patient care. The varied impacts across nudge types and settings emphasizes the importance of thoughtful nudge design and understanding local workflows.

Sleeping with one cerebrum open: patient and staff perceptions of sleep quality and quantity on an inpatient neurology unit

STUDY OBJECTIVES

This study sought to investigate perceptions of sleep disruptions among patients and staff in the inpatient neurology setting. The objectives were to explore the differences between these groups regarding factors that impact sleep, identify the most significant sleep disruptions, and examine the barriers and opportunities suggested to improve inpatient sleep.

METHODS

A survey-based observational study was conducted on a 25-bed inpatient neurology unit at an academic medical center. Staff and patients completed the Potential Hospital Sleep Disruptions and Noises Questionnaire, and focus groups were held to gather qualitative data. Patient-reported sleep measures were collected for additional assessment. Responses were dichotomized for comparison. Regression models were used to assess associations between disruptors and patient-reported sleep measures. Qualitative thematic analyses were performed.

RESULTS

Forty-nine inpatient staff and 247 patients completed sleep surveys. Top primary patient diagnoses included stroke, epilepsy, autoimmune diseases, and psychogenic nonepileptic attacks. Medical interventions, environmental factors, patient-related factors, and unit workflows emerged as key themes related to sleep disruptions. Patient-reported sleep efficiency was significantly reduced when pain, anxiety, stress, temperature, and medication administration disrupted sleep. Staff perspectives highlighted medical interventions as most disruptive to sleep, while patients did not find them as disruptive as expected.

CONCLUSIONS

Differing perspectives on sleep disruption exist between staff and patients in the inpatient neurology setting. Medical interventions may be overstated in staff perceptions and inpatient sleep research, as pain, anxiety, and stress had the most significant impact on patient-reported sleep efficiency.

CITATION

Kadura S, Poulakis A, Roberts DE, et al. Sleeping with one cerebrum open: patient and staff perceptions of sleep quality and quantity on an inpatient neurology unit. J Clin Sleep Med. 2024;20(4):619-629.