Patient Safety Tip
of the Week
May 15, 2018 Helping Inpatients Sleep
Sleep medications
(hypnotics) have many potential adverse effects when given long-term. But they
also have potential adverse effects even when used in the short-term. In
hospitalized patients they increase the risk for falls and delirium. Therefore,
we like to avoid them in hospitalized patients. But, at the same time, the
hospital environment is not conducive to normal sleep-waking cycles.
Way back in 2009 we discussed a hospital’s attempt to improve
patients’ sleep while reducing the use of sleep medications (see our August
2009 What's New in the Patient Safety World column “Bold
Experiment: Hospitals Saying No to Sleep Meds”). But little has been
published about subsequent hospital attempts to go hypnotic-free.
Our August 6, 2013
Patient Safety Tip of the Week “Let
Me Sleep!” described a physician’s own account (Ubel
2013) of problems sleeping
as a hospital inpatient and went on to discuss the numerous interventions we do
that disturb a patient’s sleep (such as vital signs and blood draws). In that
column we discussed the Hospital Elder Life Program (HELP) and the “Somerville
Protocol” interventions to reduce interruptions to sleep and promote more
normal circadian day-night cycles. We discuss these again below.
Now a new non-pharmacologic multidimensional program at an
academic tertiary care hospital 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
The 5-question Richards-Campbell Sleep Questionnaire survey was
given to randomly chosen patients the following morning. As compared to 49
pre-interventions surveys, scores increased on four of the five questions in 56
post-intervention surveys. There was also a 15.3% increase in patients
answering “always” to the HCAHPS question pertaining to quietness at night in
the post-intervention period.
The authors consider the results preliminary and will be
assessing for longer term sustainability. The abstract also did not report
whether the intervention resulted in less use of sleep medications, though we
presume it likely did.
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 reduction in the physical
disruptions probably played the major role.
But promoting natural sleep is 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.
Lastly, 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.
Avoiding sleep meds and using non-pharmacologic
interventions to promote sleep is something every hospital should strive for.
Some of the system changes mentioned in today’s column and our previous columns
to avoid unnecessarily waking patients at night should also be an important
component of your program.
Some of our previous
columns on safety issues associated with sleep meds:
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”
References:
Ubel P. Sleep Deprivation in
Hospitals Is a Real Problem. Simple changes can make recovery more restful, and
better overall. The Atlantic 2013; June 19, 2013
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/
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
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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