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Patient Safety Tip of the Week
January 3, 2023
Helping Inpatients
Sleep – Failing Grades
Common sense tells us that helping inpatients get restful
sleep is desirable and doing so without using sleep meds makes even more sense.
We’ve done several columns highlighting the poor job we do at allowing patients
to sleep when they are hospital inpatients (see 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”).
Our November 6, 2018 Patient Safety Tip
of the Week “More
on Promoting Sleep in Inpatients”
cited several studies showing inpatients average significantly less sleep in
hospital compared to at home.
We know the many factors contributing to poor sleep in inpatients:
·
excessive noise
·
light exposure
·
other environmental factors like temperature
·
pain
·
stress related to medical conditions
·
psychological stress
·
waking patients to obtain vital signs
·
waking patients for phlebotomy
And we already have lots of tools and programs that can
address many of those factors and make it easier for inpatients to sleep (see
below for details). We want to avoid using sedative/hypnotic medications to
induce sleep in such patients because they are risk factors for falls,
delirium, medication-induced respiratory depression, and other undesirable
complications.
So how are we doing? Pretty poorly, according to a recent
study. Affini et al. (Affini
2022) surveyed and interviewed section chiefs of Hospital Medicine at
the 2020 US News and World Report (USNWR) Honor Roll pediatric and adult
hospitals. Nearly all (96%) hospitalist leaders at those top hospitals rated
patient sleep as important, but fewer than half (43%) were satisfied with their
institution's efforts to improve patient sleep.
Fifty-two percent of the surveyed institutions reported
having no sleep-friendly practices in place. The most common practices in those
that did have some practices included:
·
reducing overnight vital sign monitoring (43%)
·
decreasing ambient ward lights (43%)
·
adjusting lab and medication schedules (35%)
·
implementing quiet hours (30%)
The researchers identified both barriers to adoption of sleep-promoting
practices and factors that helped adoption of such practices. Barriers to
success were related to the hospital environment and culture (e.g.,inflexible workflow, time conflicts, noisy alarms) and
fixed standards of care (not differentiating low-risk and high-risk patients).
A key contributor to successfully improving patient sleep was buy-in from
hospital staff. Examples included providers reducing room entries through
batched care or enforcing quiet hours among peers. External initiatives, such
as patient care initiatives or funded innovation projects were also important
for patient sleep.
Respondents also suggested that grouping tasks and
decreasing interventions, when appropriate, would be opportunities for
improvement.
Affini et al. also asked about
sleep equity and found that only one hospital addressed sleep equity (but did
not reveal how it did so). By sleep health equity the authors meant improving
sleep for racial/ethnic minorities, patients with pre-existing risk factors,
communication barriers, or limited familiarity with hospital services.
The authors conclude that some key reasons for slow progress
are that (1) the culture is such that providers want to improve patient sleep,
but not at the expense of changing standard workflow, and (2) there is a lack
of incentives and programs to support changes. They call upon both clinicians
and hospital leaders to address the issues, develop a culture that promotes
sleep, and adopt best practices for patient sleep.
It's worth reiterating here recommendations from our prior
columns. In our “Let
Me Sleep!” column we noted that the Hospital Elder Life Program
(HELP) program (Inouye
2013) includes a systemic effort to improve sleep in hospitalized patients
by noise reduction, a nonpharmacologic sleep protocol, and coordination of
nighttime care. Inouye points out that besides vital sign monitoring and blood
draws, patients’ sleep is often disrupted by medication administration, IV
changes or IV alarms, intermittent pneumatic compression devices, breathing
treatments, fingersticks for glucose monitoring,
paging systems, room or hallway lights, conversations, cleaning and waxing
floors at night, etc. Moreover, Inouye notes there is often a striking lack of coordination amongst staff that
could minimize these disruptions. Simply having the phlebotomist tag team with
the nurse or aide doing vital signs could avoid one disruption.
Another study (Bartick
2010) implemented the “Somerville Protocol” and documented a 38%
reduction in patients noting sleep disruption due to hospital staff and a 49%
reduction in patients receiving prn sedatives (actually a 62% reduction for
patients aged 65 and older). The protocol consisted of 10 components:
·
“Quiet Time” designated as 10PM to 6AM
·
Timing of “routine” vital signs changed to 6AM,
2PM and 10PM
·
Getting physicians to understand the difference
between daily, BID, TID, QID vs. q24 hours, q12 hours, q8 hours, q6 hours
·
Avoid standing diuretic doses after 4PM
·
Avoid blood transfusions during Quiet Time where
possible
·
Use of a noise detection device in the nursing
station
·
Lullaby over the PA system at 10PM to alert
patients, staff, visitors, etc. to Quiet Time
·
Timer to dim hallway lights automatically at
10PM
·
Nurses perform a bedtime routine before Quiet
Time (vital signs, bedtime meds, toilet patient, ensure IV bag won’t empty at
night, close patient door, etc.)
·
Avoid antecubital IV catheter site where
possible (easier to occlude flow here and set off alarm at night) and even
avoid nighttime IV fluids if possible
A couple of those interventions merit further discussion. At
many (perhaps most) hospitals, the incoming nursing staff gets vital signs when
their shift starts. Hence, many patients get their vital signs checked between
11PM and midnight. Simply changing policy and procedure so that vital signs are
checked by the outgoing staff at 10PM can help avoid one obvious potential
sleep disruption. (Of course, you’d have to look for potential unintended
consequences such as interfering with shift handoffs).
Getting physicians to understand that “three times daily”
and “every 8 hours”, for example, are not the same takes some time and hard
work. If I order a medication today at 10AM and enter it as “every 8 hours” my
patient will be wakened at 2AM to get a dose. On the other hand, if the order
is written for “three times daily” the hospital will have standard times that
such are given to avoid that disruptive nighttime dose. (Note that you have to
be very careful. Today’s CPOE systems often don’t make it clear when the first
dose will be given. We have seen some systems where the first dose or even all
the first day’s doses will not be given when the order is written this way.)
A noise monitoring device for the nursing station doesn’t
need to be expensive. If a teacher can use a free or $0.99 decibel meter for
his/her iPhone to alert him/her to classroom noise exceeding a specified level,
we can certainly find a cheap solution to avoiding excessive noise at the
nursing station or elsewhere. But even Bartick and
colleagues note that reduction in noise and light probably did not
significantly improve patients’ sleep. Rather, a reduction in the physical
disruptions probably played the major role.
There are, of course, several other protocols and programs
for improving sleep in hospital inpatients. See our November 6, 2018 Patient Safety Tip of the Week “More
on Promoting Sleep in Inpatients”
for descriptions of the “Quiet Time”, Sommerville, and “TUCK-in”
protocols, plus the Hospital Elder Life Program (HELP) program.
Promoting natural sleep is also not simply a nocturnal
event. What you do during the daytime is also important in promoting sleep.
Regular exercise is an example of an important contributor to nocturnal sleep.
Reducing ambient light at night is highly recommended. But what about light
levels at other times? In our December 2013 What's New in the Patient Safety
World column “Lighten
Up Your Patient’s Day” we noted a study (Bernhofer
2013) that used light meters and wrist actigraphy to assess
the sleep-waking patterns of hospital inpatients and correlated those
parameters with patients’ pain levels and mood. Light exposure levels were low
and sleep time was poor and fragmented. There was little sleep–wake synchronization
with light. Fatigue and total mood disturbance scores were high and inversely
associated with light. Pain levels were also high and positively associated
with fatigue, but not directly with light exposure. Low light exposure
significantly predicted fatigue and total mood disturbance. They concluded that
inpatients were exposed to light levels insufficient for circadian entrainment.
Nevertheless, higher light exposure was associated with less fatigue and lower
total mood disturbance in participants with pain. Though the study was small
(40 total patients) this research demonstrates the need for further studies to
see if altering light exposure for inpatients would be beneficial in affecting
sleep–wake disturbances, mood and pain.
Our May 15, 2018 Patient
Safety Tip of the Week “Helping
Inpatients Sleep” also noted a
non-pharmacologic multidimensional program at an academic tertiary care
hospital which produced promising results (Herscher
2018). Components of the intervention were:
·
an education and awareness campaign for day and
evening staff through staff meetings and daily huddles, and use of signs and
posters
·
identification of local unit champions from
nursing and patient care advocates (PCA’s)
·
delivery of a sleep package that included an eye
mask, earplugs, lavender scent pad, and non-caffeinated tea
·
the PCA’s asked patients whether they would like
the TV turned off, blinds closed, lights off, or anything else to improve sleep
And see our March
16, 2021 Patient Safety Tip of the Week “Sleep Program Successfully
Reduces Delirium” for a
study by Gode et al. (Gode
2021) that successfully reduced delirium by focusing on a program to
improve non-pharmacologic sleep in inpatients.
Avoiding sleep meds and using non-pharmacologic
interventions to promote sleep is something every hospital should strive for. Don’t
forget that we often have ourselves to blame. It is still common for physicians
to leave orders for prn sleep meds in the admission orders, presumably so no
phone call is needed at night requesting such. In our March 23, 2010 Patient
Safety Tip of the Week “ISMP
Guidelines for Standard Order Sets” we stressed the importance of avoiding
inclusion of “prn” sleep meds in standard order sets. We also refer you back to
our August 2019 What's New in the Patient Safety World column “Tools
for Reducing Sleep Meds in Hospitals” for some interventions to avoid use
of sleep medications in hospitalized patients.
We do have the means to promote non-pharmacologic sleep in
our inpatients. We need to institutionalize the importance of this issue and
foster a culture that is more patient-centered. That means abandoning some of
our old customary practices
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”
August 2019 “Tools
for Reducing Sleep Meds in Hospitals”
March 16, 2021 “Sleep Program Successfully
Reduces Delirium”
January 4, 2022 “Spin or Not: A Useful
Secondary Finding in a Study”
References:
Affini, MI, Arora, VM, Gulati, J,
et al. Defining existing practices to support the sleep of hospitalized
patients: A mixed-methods study of top-ranked hospitals. J Hosp Med. 2022; 17(8):
633-638
https://shmpublications.onlinelibrary.wiley.com/doi/10.1002/jhm.12917
Inouye SK. No Rest for the Weary…or the Sick: Comment on “A
Prospective Study of Nitghtime Vital Sign Monitoring
Frequency and Risk of Clinical Deterioration”. JAMA Intern Med. 2013; (): doi:10.1001/jamainternmed.2013.7809 Published
online July 1, 2013
http://archinte.jamanetwork.com/article.aspx?articleid=1705720
Bartick MC, Thai X, Schmidt T, et
al. Decrease in As-needed Sedative Use by Limiting Nighttime Sleep Disruptions
from Hospital Staff. Journal of Hospital Medicine 2010; 5: E20–E24
Bernhofer EI, Higgins PA, Daly BJ,
et al. Hospital lighting and its association with sleep, mood and pain in
medical inpatients. Journal of Advanced Nursing 2013; Article first published online
: 27 OCT 2013, DOI: 10.1111/jan.12282
http://onlinelibrary.wiley.com/doi/10.1111/jan.12282/abstract
Herscher M, Mikhaylov D, Turakhia P, et al. The Sleep Hygeine
In The Hospital Project: Shh! Society of Hospital Medicine (HM) 2018 Annual
Meeting: Abstract 413905. Presented April 9, 2018
https://www.shmabstracts.com/abstract/the-sleep-hygeine-in-the-hospital-project-shh/
Gode A, Kozub
E, Elizabeth Joerger K, et al. Reducing Delirium in
Hospitalized Adults Through a Structured Sleep Promotion Program. Journal of
Nursing Care Quality 2021; 36(2): 149-154
ISMP (Institute for Safe Medication Practices). ISMP’s
Guidelines for Standard Order Sets. 2010
https://www.ismp.org/guidelines/standard-order-sets
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