Nationwide Children’s halts some vitals checks
If you have ever spent a night admitted to the hospital, you know it’s nearly impossible to get a good night’s sleep.
It seems like someone is coming in to take your temperature, check your pulse and blood pressure, and wake you up every five minutes. In reality, it’s every four hours, and the medical abbreviation for this is “Q4H.”
This long-held medical tradition dates back to as early as 1893. And while it seems like a reasonable thing to do in some cases, we don’t have much evidence-based reasoning or research on the practice. Q4H checks are often ordered for everyone — regardless of how sick they are.
Unfortunately, this is also the practice for children. Sleep for hospitalized children is generally shortened and of low quality. In fact, in one analysis of room entry data, researchers found that patient rooms were entered an average of seven times per night.
This is particularly problematic because children need sleep for growth and development, and sick children need it to heal.
For families who are staying with their children in the hospital room, these interruptions also disrupt their sleep, potentially leading to diminished memory and decision-making ability. Having a child in the hospital is difficult enough without the added pressure of disrupted sleep, especially if sleep is disrupted unnecessarily.
An increasing amount of scientific evidence indicates that maybe those sleep disruptions could become a thing of the past — in certain situations and if hospitals and medical staff agree. The scientific literature shows that it can be safe to omit overnight vital sign checks in some patients. And that doing so increases patient satisfaction.
Dr. Hilary Lin, a second-year hospital medicine fellow at Nationwide Children’s Hospital in Columbus, is leading a research project to safely reduce overnight vitals checks between midnight and 6 a.m. in low-risk patients. In this project, low risk is defined as children with hyperbilirubinemia (a condition related to jaundice) and failure to thrive. Her goal: Let children and their caregivers get a good night’s sleep.
She collaborated with hospital faculty, residents, nurses, patient care assistants and the Family Advisory Council. The project began in February 2019, and, to date, has had no adverse patient events. That is, there were no “code blue” events, no transfers for emergencies, and no “near-miss” events.
Changing a common practice such as the Q4H checks requires a lot of teamwork and education. The project team met regularly, created “Quiet at Night” badges for nursing staff and residents, updated the orders for eligible patients when they were admitted to the hospital, and worked with the Family Advisory Council to identify safety concerns and teach them about the initiative.
The team is currently reviewing all of the research data they have collected during this ongoing initiative. They will look for ways to improve the process and the interventions, and will consider whether it is safe to remove Q4H checks for other low-risk patients.
The research work thus far was presented this fall during the Ohio State Resident/fellow QI Symposium. Lin was recognized with the Nina & Roger Post Resident/fellow Quality Award for this work.
Lin, who is from Hartford, Connecticut, earned her undergraduate biology degree at the College of William and Mary and completed her medical school at Penn State University. After graduation, she served her pediatric residency at the University of Rochester before coming to Nationwide Children’s Hospital.