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:
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:
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 () 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”
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
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
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
ISMP (Institute for Safe Medication Practices). ISMP’s Guidelines for Standard Order Sets. 2010