Nursing Protocol Helps Sick Kids Sleep

Categories: Medical Center News
Nurses develop new protocol for taking vitals.
The nurses who developed the new protocol presented their work at a Grand Rounds session for Connecticut Children’s as a whole last year ago. Here, at that event, are (from left to right), Sonal Fisco, RN; Molly Ray, RN; Christine Baldi, RN; and Nicole Mendelson, RN.

When a child needs to be in the hospital, he or she needs lots of rest. But that child also needs to be monitored regularly. And taking a child’s vital signs requires waking the child up. At Connecticut Children’s, the standard protocol is to check vital signs every four hours, around the clock. So no child can get a full, uninterrupted night’s sleep.

That tension between the benefits of sleep and the need to monitor got Connecticut Children’s nurses wondering: Might there be some children whose condition is stable enough to skip the vital signs check while still providing complete care? Might there be room for a new protocol? This is the question that a group of nurses on the 6th floor of Connecticut Children’s Hartford facility set out to answer.

But how would you know for sure which children could safely skip the vital signs check? What was needed was some kind of algorithm—a set of rules for analyzing a large amount of data and reaching the best decision. Once you have a strong algorithm, a nurse or doctor would only have to enter all the needed information about a particularly child, and the algorithm would sort through it and tell you whether or not the child could safely skip the overnight vitals check.

Nurses let children sleep soundly.
One-year-old Rashad Lucas, Jr, sleeps soundly despite being in a hospital. Nurses at Connecticut Children’s are hoping to find ways to let children like Rashad continue sleeping soundly.

Testing the Idea

Before proceeding, the algorithm itself had to be based on hard data and tested, so the nurses started a research project called “Rest is Best” to figure it all out. They started by sending out a survey to doctors and clinicians. The nurses asked them if there were certain conditions that suggest vital signs could be skipped or situations in which they definitely could not be skipped. For example, the doctors said that children who were transferred from the ICU or the Emergency Department were among those would need vital signs to be regularly checked. On the other hand, skipping vital signs checks might work for patients who consistently had a low pediatric-early-warning score, a system for gauging a child’s medical stability.

With responses from clinicians, the nurses put together the first version of a protocol for determining which kids could have reduced vital sign frequency. The next stage was to test it. But they couldn’t just stop taking vital signs on some patients and see what happened. So, the nurses did the next best thing: They went back through old patient files, applied the algorithm to them and then compared the algorithm’s predicted outcome to the patients’ actual outcomes. In other words, they looked at what the algorithm said would be the outcome if the vital signs checks were skipped and then looked to see if that prediction turned out to be right.

Do not disturb
If further testing proves the protocol to be safe, this may become the norm for some patients.

The Final Test

“From our retrospective study,” says Christine Baldi, RN, one of the project nurses, “there were no adverse outcomes that we could find. It was all good news. So, we went to the third phase and applied to test the algorithm on actual patients. We asked parents and guardians if they would be OK with our doing this first, of course. And we just finished that third phase.”

Baldi is quick to point out that skipping vital signs checks does not mean that the child is ignored. Nurses still regularly go into the room and observe the child to be sure there are no problems. But those observations do not necessarily require waking the child.

The research team sent out a second survey to those parents and guardians and asked them if they felt skipping the vital signs checks made a difference in their child. They also asked the children themselves. The parents felt there was improvement with the increased rest, and the children’s responses are still being evaluated.

The next phase will be more testing and more education of staff and, eventually, the publication of a research paper.

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