Nudging Towards Sleep-Friendly Hospitalizations: A Multifaceted Approach on Reducing Unnecessary Overnight Interventions.

BACKGROUND: Choice architecture refers to the design of decision environments, which can influence healthcare decision-making. Nudges are subtle adjustments in these environments that guide decisions toward desired outcomes. For example, Computerized Provider Order Entry (CPOE) within Electronic Health Records (EHR) recommends frequencies for interventions such as nursing assessments and medication administrations, but these can link to around-the-clock schedules without clinical necessity. OBJECTIVE: 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 decrease 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 reduction in overnight neurological checks 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 emphasize 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.

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

Inpatient sleep loss can worsen health outcomes, including delirium and falls. Sleep disruptions in the hospital often originate from provider-patient interactions ordered electronically through computerized provider order entry. These orders contain clinical decision support systems with default schedules. These defaults are often around-the-clock, may not align with patients' needs, and cause iatrogenic sleep loss. Optimizing clinical decision support in the electronic health record can decrease unnecessary sleep disruptions and influence sleep-friendly decision-making. CITATION: Kadura S, Siala T, Arora VM. Perspective: Leveraging the electronic health record to improve sleep in the hospital. J Clin Sleep Med. 2023;19(2):421-423.