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Weve done several columns discussing the problems inpatients encounter in achieving near-normal sleep patterns and ways for you to avoid use of sleep medications (see, for example, our Patient Safety Tips of the Week for August 6, 2013 Let Me Sleep!, May 15, 2018 Helping Inpatients Sleep, and November 6, 2018 More on Promoting Sleep in Inpatients).
There have been two recent good resources to help you avoid these in your inpatients.
Soong and colleagues published an implementation guide to promote sleep and reduce sedative-hypnotic initiation for noncritically ill inpatients (Soong 2019). They conducted a review summarizing effective interventions aimed at promoting sleep and reducing inappropriate sedative-hypnotic initiation. They then proposed an implementation strategy to guide quality improvement teams.
Many studies had described implementation of sleep hygiene protocols to reduce sedative-hypnotic use. Such have addressed modifiable factors associated with sleep disruption, reinforced premorbid healthy sleep habits and circadian rhythms, and promoted relaxation without pharmacologic means (examples: reduction of noise and light, modifying clinical monitoring and medication administration schedules where appropriate to maximize uninterrupted sleep time, and assisting patients with bedtime routines and relaxation techniques).
A second common approach involved structured medication reviews conducted by pharmacists. Soong et al. note studies showing successful reduction of sedative/hypnotic drugs when these programs are employed in acute care or long-term care settings.
Simple audit and feedback has been successful in reducing ordering of sleep meds in several studies. Computer-based interventions, like alerts and reminders have also been successful in a few studies. These work best not only when combined with educational information but also when they include suggestions for alternative non-pharmacologic interventions to promote natural sleep.
They did also include educational interventions, including counter-detailing, but results have been mixed. While we dont discourage such educational endeavors, we recognize that education is one of the weakest interventions we do for almost any patient safety problem.
The authors go on to suggest several strategies to guide quality improvement initiatives to actively de-adopt sedative-hypnotic use for sleep use among inpatients.
Strategy 1: Create a Sleep-Promoting Inpatient Environment
A multidisciplinary team needs to help create such an environment using concepts like designated overnight periods of reduced noise, lighting, and interruptions for unnecessary clinical monitoring or nonessential medication administration. See our November 6, 2018 Patient Safety Tip of the Week More on Promoting Sleep in Inpatients for multiple examples of such programs.
Strategy 2: Interventions Targeting Prescribers
These include pharmacist-enabled medication reviews to flag new prescriptions, computer-based interventions, performance data feedback, and education. They also stress the role that nurses and nurse practitioners may have in promoting non-pharmacologic interventions.
Strategy 3: Rigorous Evaluation of Interventions
Like any good quality improvement program, these programs need to employ measurement to ensure that the goals of the programs are being met. These should include evaluation of not only sedative/hypnotic use but also clinical and patient-reported outcomes such as falls, delirium, and sleep quality.
The second recent contribution was publication of results of a sedative reduction bundle implemented among medical and cardiology inpatients (Fan-Lun 2019). They had analyzed data at their institution and found that over 15% of hospitalized older adults were prescribed sedative-hypnotics inappropriately. Of those prescriptions, 87% occurred at night to treat insomnia and almost 20% came from standard admission order sets. So, they implemented a multi-modal bundle to address the problem.
The bundle consisted of education, removal of benzodiazepines and sedative hypnotics from available admission order sets, and use of non-pharmacological strategies to improve sleep. From the mean baseline benzodiazepine and sedative/hypnotic prescription rate of 15.8%, the postintervention period saw an absolute reduction of 8.0%. Adjusted for temporal trends, the intervention produced a 5.3% absolute reduction in the proportion of patients newly prescribed benzodiazepines and sedative hypnotics. Prescription rates on the control ward remained stable. There was no change in the patient-reported measure of sleep quality, falls, and use of other sedating medications throughout the study duration.
Some of our previous columns on safety issues associated with sleep meds and promoting sleep in inpatients:
August 2009 Bold Experiment: Hospitals Saying No to Sleep Meds
March 23, 2010 ISMP Guidelines for Standard Order Sets
May 2012 Safety of Hypnotic Drugs
November 2012 More on Safety of Sleep Meds
March 2013 Sedative/Hypnotics and Falls
June 2013 Zolpidem and Emergency Room Visits
August 6, 2013 Let Me Sleep!
June 3, 2014 More on the Risk of Sedative/Hypnotics
May 15, 2018 Helping Inpatients Sleep
June 2018 Deprescribing Benzodiazepine Receptor Agonists
November 6, 2018 More on Promoting Sleep in Inpatients
June 2019 FDA Boxed Warning on Sleep Meds
Soong C, Burry L, Cho HJ, et al. An Implementation Guide to Promote Sleep and Reduce Sedative-Hypnotic Initiation for Noncritically Ill Inpatients. JAMA Intern Med 2019; 179(7): 965-972 Published online June 03, 2019
Fan-Lun C, Chung C, Lee EHG, et al. Reducing unnecessary sedative-hypnotic use among hospitalised older adults. BMJ Quality & Safety 2019; Published Online First: 03 July 2019