Sleep is essential to healing, but if you’ve ever spent a night in the hospital, you know it’s one of the hardest places to get any. Between hallway noise, alarms, and room entries, rest is regularly interrupted, especially by the routine practice of checking vitals every four hours, regardless of time or patient condition.
A recent quality improvement (QI) initiative sought to challenge that norm by asking: Can we safely reduce unnecessary overnight vital sign measurements to promote better sleep for hospitalized children? They aimed to increase the proportion of patient-nights with one or fewer overnight composite vital sign (VS) checks by 10% and one or fewer blood pressure (BP) checks by 20% within six months.
To get there, the team implemented a multi-pronged strategy: provider and nurse education, electronic health record (EHR) updates using nudge theory, and a new rounding checklist prompt to address sleep interruptions. EHR changes included modifying defaults, requiring providers to actively choose a VS frequency, and making sleep-promoting options easier to select. Broad inclusion criteria allowed application across diverse patient populations and staffing models.
The results were promising. Sleep-promoting BP orders rose from 12% to 63%, with observed reductions in overnight BP and temperature measurements, arguably the most disruptive to a child’s sleep. However, improvements in the primary outcome—composite VS checks—proved more elusive, with gains that regressed over time. Notably, there were no increases in rapid responses or ICU transfers, supporting the safety of these changes.
A major strength of this project was its systems-based approach. By embedding changes into existing workflows through leveraging EHR nudges, modifying default orders, prompting daily rounding discussions, and by engaging broad stakeholders, the team promoted meaningful behavior change.
Like many QI efforts, the path to lasting change wasn’t straightforward. Despite initial improvements in composite VS ordering patterns, only reductions in overnight BP measurements were sustained following the completion of active QI interventions. On the one hand, this represents success given the particularly disruptive nature of BP measurement; however, it also highlights the stubborn challenge of shifting seemingly small everyday behaviors born more from habit (i.e. “routine vitals”) rather than intentional decisions. Furthermore, VS were often collected more frequently than ordered, a disconnect possibly due to nursing workflows or patient acuity. Equity analyses revealed pre-existing and persistent disparities: non-Hispanic white and English-speaking patients were less likely to experience sleep-disrupting VS measurements. Such disparities raise concerns about communication barriers, structural inequities, and clinician biases leading care teams to rely on objective data from the EHR over family input for detecting clinical changes.
Though patient and family feedback wasn’t formally collected, it's likely these changes improved the hospital experience for many. And that matters. Sleep is more than a luxury; it's a fundamental part of healing. This project is a powerful reminder that even small, thoughtful changes to ingrained practices can have a meaningful impact on the quality and humanity of hospital care.
