Effectiveness of SIESTA on Objective and Subjective Metrics of Nighttime Hospital Sleep Disruptors
We created Sleep for Inpatients: Empowering Staff to Act (SIESTA), which combines electronic “nudges” to forgo nocturnal vitals and medications with interprofessional education on improving patient sleep. In one “SIESTA-enhanced unit,” nurses received coaching and integrated SIESTA into daily huddles; a standard unit did not. Six months pre- and post-SIESTA, sleep-friendly orders rose in both units (foregoing vital signs: SIESTA unit, 4% to 34%; standard, 3% to 22%, P < .001 both; sleep-promoting VTE prophylaxis: SIESTA, 15% to 42%; standard, 12% to 28%, P < .001 both). In the SIESTA-enhanced unit, nighttime room entries dropped by 44% (−6.3 disruptions/room, P < .001), and patients were more likely to report no disruptions for nighttime vital signs (70% vs 41%, P = .05) or medications (84% vs 57%, P = .031) than those in the standard unit. The standard unit was not changed. Although sleep-friendly orders were adopted in both units, a unit-based nursing empowerment approach was associated with fewer nighttime room entries and improved patient experience.
© 2019 Society of Hospital Medicine
RESULTS
Between March 2015 and March 2016, 1,083 general-medicine patients were admitted to the SIESTA-enhanced and standard units (Table).
Nocturnal Orders
From March 2015 to March 2016, 1,669 EpicTM general medicine orders were reviewed (Figure). In the SIESTA-enhanced unit, the mean percentage of sleep-friendly orders rose for both vital signs (+31% [95% CI = 25%, 36%]; P < .001, npre = 306, npost = 306] and VTE prophylaxis (+28% [95% CI = 18%, 37%]; P < .001, npre = 158, npost = 173]. Similar changes were observed in the standard unit for sleep-friendly vital signs (+20% [95% CI = 14%, 25%]; P < .001, npre = 252, npost = 219) and VTE prophylaxis (+16% [95% CI = 6%, 25%]; P = .002, npre = 130, npost = 125). Differences between the two units were not statistically significant, and no significant change in timing of laboratory orders postintervention was found.
Nighttime Room Entries
Immediately after SIESTA launch, an average decrease of 114 total entries/night were noted in the SIESTA-enhanced unit, ([95% CI = −138, −91]; P < .001), corresponding to a 44% reduction (−6.3 entries/room) from the mean of 14.3 entries per patient room at baseline (Figure). No statistically significant change was seen in the standard unit. After SIESTA was incorporated into nursing huddles, total disruptions/night decreased by 1.31 disruptions/night ([95% CI = −1.64, −0.98]; P < .001) in the SIESTA-enhanced unit; by comparison, no significant changes were observed in the standard unit.
Patient-Reported Nighttime Sleep Disruptions
Between June 2015 and March 2016, 201 patient surveys were collected. A significant interaction was observed between the SIESTA-enhanced unit and post-period, and patients in the SIESTA-enhanced unit were more likely to report not being disrupted by medications (OR 4.08 [95% CI = 1.13–14.07]; P = .031) and vital signs (OR 3.35 [95% CI = 1.00–11.2]; P = .05) than those in the standard unit. HCAHPS top-box scores for the SIESTA unit increased by 7% for the “Quiet at night” category and 9% for the “Pain well controlled” category; by comparison, no major changes (>5%) were observed in the standard unit.
DISCUSSION
The present SIESTA intervention demonstrated that physician education coupled with EHR default changes are associated with a significant reduction in orders for overnight vital signs and medication administration in both units. However, addition of nursing education and empowerment in the SIESTA-enhanced unit was associated with fewer nocturnal room entries and improvements in patient-reported outcomes compared with those in the standard unit.
This study presents several implications for hospital initiatives aiming to improve patient sleep.14 Our study is consistent with other research highlighting the hypothesis that altering the default settings of EHR systems can influence physician behavior in a sustainable manner.15 However, our study also finds that, even when sleep-friendly orders are present, creating a sleep-friendly environment likely depends on the unit-based nurses championing the cause. While the initial decrease in nocturnal room entries post-SIESTA eventually faded, sustainable changes were observed only after SIESTA was added to nursing huddles, which illustrates the importance of using multiple methods to nudge staff.
Our study includes a number of limitations. It is not a randomized controlled trial, we cannot assume causality, and contamination was assumed, as residents and hospitalists worked in both units. Our single-site study may not be generalizable. Low HCAHPS response rates (10%-20%) also prevent demonstration of statistically significant differences. Finally, our convenience sampling strategy means not all inpatients were surveyed, and objective sleep duration was not measured.
In summary, at the University of Chicago, SIESTA could be associated with adoption of sleep-friendly vitals and medication orders, a decrease in nighttime room entries, and improved patient experience.
