Clinical Utility of Routine Overnight Vital Signs in Patients Undergoing Cystectomy
Jeffrey M. Howard, M.D., Ph.D., Solomon L. Woldu, M.D., Vitaly Margulis, M.D..
University of Texas Southwestern Medical Center, Dallas, TX, USA.
INTRODUCTION: Obtaining vital signs every four hours, including the overnight period, is routine practice in patients hospitalized after major surgery. However, increasing attention has been drawn to patient sleep disruption as a potential contributor to impaired recovery, hospital delirium, and patient dissatisfaction. We sought to assess whether routine overnight vital signs (as opposed to those obtained for a clinical indication) led to the diagnosis of serious conditions that would otherwise have been missed.
MATERIALS AND METHODS: Using the electronic medical record, we obtained all vital signs obtained on postoperative days (POD) 0 through 6 of all patients undergoing cystectomy at our institution between January 2016 and December 2020 (a period of five years). The data were filtered to identify complete sets of vital signs obtained between the hours of 22:00 and 05:30, inclusive. Sets of vital signs were then flagged as “abnormal” based on parameters that would generally have prompted a call to the patient’s responding clinician (temperature ≥ 101.0°F or < 95.0°F, pulse < 50 or > 120 bpm, systolic blood pressure < 85 or ≥ 190 mm Hg, respirations ≤ 8 or ≥ 22/min, oxygen saturation < 90%). The primary outcome was the degree of intervention, if any, prompted by the abnormal vital signs as determined by chart review. Interventions were categorized as none (event judged clinically insignificant, or intervention was already under way), minor (administration of IV fluids, antipyretics, reordering a patient’s home medications, etc.), moderate (antibiotics, blood/urine cultures, imaging studies), or major (ICU transfer or reoperation).
RESULTS: Our search criteria captured a total of 754 patients with 22,382 complete sets of vital signs representing 4,701 patient-nights in the hospital. Of the complete sets of vital signs, 6,920 were obtained between the hours of 22:00 and 05:30. Of these, we identified a total of 47 unique cases of abnormal vital signs reflecting a new change in the patient’s status during the overnight period. Most of these cases (24 / 47, 51%) were deemed clinically insignificant, while 11 / 47 (23%) prompted a minor intervention, 7 / 47 (15%) a moderate intervention, and 5 / 47 (11%) a major intervention. Thus, a total of 12 new-onset clinical events prompting a moderate or major intervention occurred over a total of 4,701 patient-nights in the hospital, a rate of 0.26%. Subjectively, most adverse events reviewed were associated with additional signs or symptoms that would likely have prompted evaluation independently of the abnormal vital signs.
CONCLUSIONS: The rate at which routine overnight vital signs (as opposed to those obtained for a specific clinical indication) leads to the diagnosis of a new adverse clinical event is very low. Consideration should be given to omitting routine overnight vitals in stable, uncomplicated patients undergoing cystectomy. We are currently undertaking additional analyses to identify low- and high-risk groups for adverse events and to quantify the costs and benefits of omitting routine overnight vital signs.
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