UPJ Insight: Routine Overnight Vital Signs Are Rarely Associated with Major Clinical Events in Patients Undergoing Radical Cystectomy: A Retrospective Cohort Study

By: Jeffrey M. Howard, MD, PhD; Thomas Gerald, MD; Akshat Patel, BS; Brandon Crook, MBA; Bailor Hardman; Vitaly Margulis, MD | Posted on: 01 Apr 2022

Howard JM, Gerald T, Patel A et al: Routine overnight vital signs are rarely associated with major clinical events in patients under going radical cystectomy: a retrospective cohort study. Urol Pract 2021; https://doi.org/10.1097/UPJ.0000000000000289.

Study Need and Importance

Overnight vital signs are routinely checked at midnight and 4:00 a.m. in postoperative hospitalized patients. This nonevidence-based practice is inherited from the earliest days of nursing. While seemingly innocuous, routine overnight vital signs are associated with disruption of patients’ sleep, which in turn has been associated with a variety of adverse clinical outcomes. We performed a single-institution retrospective analysis to determine how frequently routine (as opposed to for-cause) overnight vital signs were associated with new-onset major clinical events among stable patients following radical cystectomy for bladder cancer.

What We Found

After appropriate exclusions, a total of 546 patients underwent radical cystectomy over a recent 5-year period, representing 2,589 patient-nights in the hospital. Abnormal vital signs (by prespecified criteria) were noted in 116/2,589 patient-nights (4.5%), but of these a moderate or major intervention (corresponding to concern for a Clavien-Dindo grade ≥II complication) was present in only 17/2,589 cases (0.65%; see table). Thus, a total of 152 patient-nights of routine vital sign checks were required to identify a single moderate or major clinical event. Conversely, of a total of 23 Clavien-Dindo grade ≥II complications with initial onset overnight, a majority (15/23, 65%) were manifested only by clinical symptoms or laboratory abnormalities without associated vital sign derangements. Thus, routine overnight vital sign checks only rarely identified clinically significant events and additionally failed to capture the majority of overnight-onset complications.

Table. Outcomes of patients with abnormal routine overnight vital signs. Denominator for all values is the total of 2,589 patient-nights in the hospital. Inter-rater reliability for the primary outcome (degree of intervention) is a Cohen’s kappa statistic with quadratic weights

No. total pt-nights	2,589
No. pt-nights with abnormal vital signs (%)	116 (4.5)
No. degree of intervention (%):
No intervention, vital signs not abnormal on recheck, or clinical status already known	88 (3.4)
Minor intervention (concern for Clavien I)	11 (0.4)
Moderate intervention (concern for Clavien II–IIIa)	11 (0.4)
Major intervention (concern for Clavien IIIb–V)	6 (0.2)
No. intensive care unit transfer (%)	5 (0.2)
No. reoperation (%)	1 (0.04)
Inter-rater reliability (weighted Cohen’s kappa)	0.734

Limitations

This was a retrospective analysis with a subjective outcome and was thus subject to bias. The outcome could potentially have been altered by selecting more or less stringent criteria for abnormal vital signs. We could not determine the safety of reducing frequency of overnight vital sign checks, which would have required a prospective trial. Our findings should not be interpreted to justify discontinuing all overnight monitoring of postoperative patients or of reduced intensity of vital sign checks in unstable patients.

Interpretation for Patient Care

In carefully selected patients, a reduced intensity of overnight vital sign checks may be safe and, in combination with other targeted practice changes, may reduce patient sleep disturbance. Further research is warranted into ways to optimize patient sleep following elective surgery.