Department of Medicine 2016 Tech Challenge

New Uses of Information Technology to Advance the Missions of the Department of Medicine

Bed Rec: A Simple Order Reconciliation Tool for Better Patient Sleep

Idea Status: 

The problem: Hospitalized patients get fewer than five hours of sleep a night.[1]

Poor sleep leads to increased rates of delirium, falls and hypertension, and to lower patient satisfaction scores and longer hospital stays. [2], [3], [4] Nighttime disruptions – including vital signs, lab draws and medication administration – are a major contributor to poor sleep. These clinical activities can often be shifted to waking hours without compromising patient care.

However, Apex is not currently able to show physicians the orders that will occur at night, or to give physicians the option to easily change them to waking hours.

That’s where Bed Rec comes in.

How it works: Prior to signing out for the day, a provider opens the Bed Rec tab. Under this tab, Apex will list the active orders that will take place during “sleeping hours” from 10pm to 6am.  Providers will then have the option, if clinically appropriate, to cancel these orders or shift them to waking hours.

Examples of Bed Rec in use:

Vital signs

  • Bed Rec shows vitals are scheduled for Q4 hours, taking place at 8pm, 12am and 4am.
  • This patient’s vitals have been stable and suspicion for clinical deterioration is low, so the provider can change vitals to 10pm and 6am

Medications (switch to PRN)

  • Bed Rec shows Zofran is a q6 hour “standing” order and is scheduled at 8pm, 2am, 8am
  • The provider can change the 2am dose to “PRN” while keeping the daytime doses “standing"

Medications (switch to TID)

  • Bed Rec shows amoxicillin is written for Q8 hours and the patient will be woken to receive a dose at 4am
  • This medication can safely be given three times a day during waking hours rather than strictly every 8 hours, so the provider can change it to TID and schedule a 6am dose.


  • Bed Rec shows that the patient is scheduled for a 4am BMP and CBC.
  • The provider can change the labs to 6am.

Obstacles and Concerns:

1. Patient Safety

If we monitor patients less closely at night, will this compromise our ability to recognize clinical deterioration? To address this concern, the Bed Rec tool will have validated decision support built in. The Modified Early Warning Score (MEWS) uses recent vital signs to identify patients who are at high risk for an adverse event or clinical deterioration.[5] Patients with MEWS scores of one or less have adverse event rates of just 5.0 per 1000 patient-days, compared to patients with MEWS of seven or greater, who have adverse event rates of 157.3 per 1000 patient days.[6]

On the page where nighttime vitals are listed, the MEWS score will also be listed in green, yellow or red, and labeled low-, medium- or high-risk for clinical deterioration. Providers will be advised not to forego vitals for the ~50% of patients with a MEWS of greater than one.


2. Will busy residents and attendings really take the time to use this tool?

One of the most common complaints we hear when rounding on patients is that they slept terribly. If the interface is user-friendly and intelligently built to allow for changes with the fewest number of clicks, residents will view this as a “high-yield” use of time. They will be able to give patients eight hours of uninterrupted sleep (a treasured commodity in the medical field) in a minute or less.

Proposed by Timothy Judson, MD, MPH, and Michelle Mourad, MD

[1] Beveridge C, Knutson K, Spampinato L, et al. Daytime Physical Activity and Sleep in Hospitalized Older Adults: Association with Demographic Characteristics and Disease Severity. J Am Geriatr Soc. 2015;63(7):1391-400.

[2] Figueroa-ramos MI, Arroyo-novoa CM, Lee KA, Padilla G, Puntillo KA. Sleep and delirium in ICU patients: a review of mechanisms and manifestations. Intensive Care Med. 2009;35(5):781-95.

[3] Gangwisch JE, Heymsfield SB, Boden-albala B, et al. Short sleep duration as a risk factor for hypertension: analyses of the first National Health and Nutrition Examination Survey. Hypertension. 2006;47(5):833-9.

[4] Young JS, Bourgeois JA, Hilty DM, Hardin KA. Sleep in hospitalized medical patients, part 1: factors affecting sleep. J Hosp Med. 2008;3(6):473-82.

[5] Subbe CP, Kruger M, Rutherford P, Gemmel L. Validation of a modified Early Warning Score in medical admissions. QJM. 2001;94(10):521-6.

[6] Yoder JC, Yuen TC, Churpek MM, Arora VM, Edelson DP. A prospective study of nighttime vital sign monitoring frequency and risk of clinical deterioration. JAMA Intern Med. 2013;173(16):1554-5.


Tim, this is a great idea. We piloted something similar at the VA. We used the MEWS and patients with a score of 1 or 0 we wrote an order for no overnight vitals. The number of patients was small but we did not have any adverse events. Now, this is an informal practice. The data collection and implementation were time-consuming.

This could be greatly improved with technology as you propose. Perhaps for patients with a low MEWS vitals are automatically discontinued overnight and it is an 'opt in' practice. I would love to see this expanded - we just did not have the resources. Send me an email if you'd like to know more of what we experienced.

Tim, Congrats on an innovative and thoughtful proposal. Anyone who has spent a night in the hospital knows that sleep is a precious commodity, and your unique approach takes a systems approach to sleep preservation. I look forward to helping you make this a reality funding or not! 

Tim this is awesome. Im for it!

Great idea - I think the culture of our residency is such that we actively think about these issues but it has been extremely challenging for me to manually navigate Apex to ensure our patients sleep better and get disturbed less. Bed rec will make this a lot easier!

This is a great idea and I think that it will be truly appreciated by patients. One additional idea for promoting sleep is to add melatonin PRN to the bed rec (or automatically for all patients). As a crosscover I received many "patient requesting something to help them sleep" pages and would always start with melatonin. We can empower RNs treat hospital-acquired insomnia independently with melatonin since there are no significant adverse effects at the doses we use in the hospital.

PRN low dose melatonin would be a great addition for many patients. This sounds like something that could easily be a "check-box" item on the Bed Rec tool. Thanks for the idea Scott!

Great idea Tim! Really like the idea of being able to change the PM orders, but still be able to leave the daytime orders as is!

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