Things We Do For No Reason™: Routine Overnight Vital Sign Checks

Inspired by the ABIM Foundation’s Choosing Wisely^® campaign, the “Things We Do for No Reason^™”(TWDFNR) series reviews practices that have become common parts of hospital care but may provide little value to our patients. Practices reviewed in the TWDFNR series do not represent clear-cut conclusions or clinical practice standards but are meant as a starting place for research and active discussions among hospitalists and patients. We invite you to be part of that discussion.

The hospitalist admits a 73-year-old man with non–insulin dependent diabetes and essential hypertension to the general medicine ward for lower extremity cellulitis. The hospitalist uses standard admission orders, encourages him to elevate his leg above his heart, starts intravenous antibiotics, and monitors him throughout the day and night with regular vital signs. On his second day of admission, the patient’s cellulitis clinically improves, and the team prepares for discharge. However, the nurse notes that the patient did not sleep well and has not slept since his 4 am vitals were taken. Now a lethargic and confused patient, the team adds delirium to his problem list.

General medicine floors commonly default frequency for measuring vital signs to every 4 hours (Q4), a practice that dates back more than a century to the time of Florence Nightingale.This custom remains in place to ensure the ability to identify and intervene for those at risk for clinical deterioration and preventable death. Research supports the notion that frequent and consistent vital sign checks can minimize mortality and morbidity in the hospital. In fact, validated scoring systems incorporate vital signs with other clinical findings as a way of quickly identifying a patient with worsening clinical status.¹ Further, trends and trajectories in vital signs may enable us to identify those with impending decompensation.² A 2008 consensus statement made by experts in patient safety encouraged hospitals to use frequent vital sign monitoring of patients when available and affordable.³ These interventions aim to help identify and treat patients with early clinical deterioration to prevent poor outcomes.

The practice of checking vital signs every 4 hours throughout the night dates to long before the modern era of evidence-­based medicine. Research thus far has not focused on the necessity of vital sign checks every 4 hours throughout the night, despite affecting almost every hospitalized patient. Further, patient acuity or need for monitoring does not drive the frequency of overnight vital signs; instead habit and defaults do. We often monitor patients at high risk for clinical deterioration just as frequently as patients at low risk.⁴