Optimizing Oral Medication Schedules for Inpatient Sleep: A Quality Improvement Intervention

Abstract

Objectives: Hospitalized children experience frequent nighttime awakenings. Oral medications are commonly administered around the clock despite the comparable efficacy of daytime administration schedules, which promote sleep. With this study, we evaluated the effectiveness of a quality improvement initiative to increase the proportion of sleep-friendly antibiotic administration schedules.

Methods: Interprofessional stakeholders modified computerized provider order entry defaults for 4 oral antibiotic medications, from around the clock to administration occurring exclusively during waking hours. Additionally, care-team members received targeted education. Outcome measures included the proportion of sleep-friendly administration schedules and patient caregiver-reported disruptions to sleep. Pre- and posteducation surveys were used to evaluate education effectiveness. Balancing measures were missed antibiotic doses and related escalations of care.

Results: Interrupted time series analysis revealed a 72% increase (intercept_pre: 18%; intercept_post: 90%; 95% confidence interval: 65%-79%; P < .001) in intercept for percentage of orders with sleep-friendly administration schedules (orders: n _pre = 1014 and n _post = 649). Compared with preeducation surveys, care-team members posteducation were more likely to agree that oral medications scheduled around the clock cause sleep disruption (resident: 71% pre, 90% post [P = .01]; nurse: 63% pre, 79% post [P = .03]). Although sleep-friendly orders increased, patient caregivers reported an increase in sleep disruption due to medications (pre 28%, post 46%; P < .001).

Conclusions: A simple, low-cost intervention of computerized provider order entry default modifications and education can increase the proportion of sleep-friendly oral antibiotic administration schedules for hospitalized children. Patient perception of sleep is impacted by multiple factors and often does not align with objective data. An increased focus on improving sleep during hospitalization may result in heightened awareness of disruptions.

FIGURE 1

A, Preintervention CPOE default in the EHR for around-the-clock dosing (q6h, q8h, and q12h). B, Postintervention CPOE default to encourage sleep-friendly oral administration scheduling (QID, TID, and BID) for the targeted medications. Modified order screens included default sleep-friendly dosing schedules with preset daytime administration hours (1), and an “Include Now” option to administer medication immediately and then continue with the sleep-friendly administration schedule (2). G-Tube, gastrostomy tube; J-Tube, jejunostomy tube; NG, nasogastric; OG, orogastric.

FIGURE 2

ITSA graph depicting proportion of orders with sleep-friendly administration schedules for targeted oral antibiotics per week. ITSA is depicted by the dashed line, which reveals an increase in intercept of 72% after the intervention (intercept_pre: 18%, intercept_post: 90%; 95% confidence interval: 65%–79%; P < .001).

FIGURE 3

Resident, nurse, and pharmacist responses to pre- and posteducation surveys regarding (1) the disruptiveness of different medication administration schedules to sleep and (2) if oral medication administration schedules at the hospital are optimized for sleep. * P < .05.