Impaired sleep in hospitalized patients may have detrimental impacts on both outcomes and patient satisfaction. There are multiple reasons for sleep disruption in inpatients (see our Patient Safety Tip of the Week for August 6, 2013 “Let Me Sleep!”). And we, of course, 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.
We’ve done several columns discussing the problems inpatients encounter in achieving near-normal sleep patterns (see, for example, our Patient Safety Tips of the Week for August 6, 2013 “Let Me Sleep!” and May 15, 2018 “”). But we’ve relied primarily on anecdotal or intuitive data to tell us we need to do something more to help promote sleep in inpatients. Now, 2 new studies actually quantify the problem.
In a study from the Netherlands (ter Maaten 2018), researchers found that the total sleep time in the hospital was 83 minutes shorter than the patients’ habitual sleep at home. The mean number of nocturnal awakenings was 2.0 times at home vs 3.3 times during hospitalization. Patients also woke up 44 minutes earlier than their habitual wake-up time at home. Moreover, all aspects of sleep quality, as measured using PROMIS (the Dutch-Flemish Patient-Reported Outcomes Measurement Information System) questions, were rated worse during hospitalization than at home.
70.4% reported having been awakened by external causes and 35.8% concerned hospital staff. Sleep-disturbing factors reported most often by inpatients were noise of other patients, medical devices, pain, and toilet visits.
Another recent study used actigraphy to study sleep quality in 40 children and their co-sleeping mothers both when hospitalized and when at home (Bevan 2018). The researchers found that children had on average 62.9 min, and parents 72.8 min, per night less sleep in hospital than at home. Both children and parents had poorer sleep quality in hospital than at home: mean sleep efficiency 77.0% vs 83.2% for children and 77.1% vs 88.9% for parents, respectively. They also measured sound levels and found median sound levels in hospital measured in children averaged 48.6 dBA compared with 34.7 dBA at home (World Health Organization recommends a maximum of 30 dB.). They suggest that a reduction in the level of noise might lead to an improvement in sleep, affecting the quality of stay of both parent and child.
A couple recent publications have focused on noise reduction as a strategy to improve inpatients’ sleep.
McGough et al. (McGough 2018) reported on implementation of an evidence-based practice project conducted in 4 progressive care units in a community hospital. The Quiet Time Bundle implementation improved patient satisfaction and patient and nurse perceptions of noise even though the decrease in noise levels may not be discernible.
Goeren et al. (Goeren 2018) used a decibel meter to collect noise data in 4 locations of a neurosurgical intensive care unit every 30 minutes during chosen times for 8 days. Then, quiet time was implemented 1 week after staff, patient, and family education was completed. During quiet time, limiting conversations, eliminating environmental noise, and dimming the lights as a reminder to be quiet were 3 simple strategies used to lessen noise. There were statistically significant reductions in noise levels at two locations. Noise levels were lower, but not significantly so, for the other two locations. Noise levels during quiet time decreased to an average of 10 to 15 decibels lower than baseline data.
However, a randomized controlled trial of a non-pharmacologic multidisciplinary protocol failed to show any significant differences in any of the outcomes between intervention and control patients (Dobing 2017). Researchers used the “TUCK-in” protocol (timed lights-off periods, minimizing night-time noise, distribution of earplugs at bedtime, cued toileting before bedtime, and identification and reduction of modifiable interruptions). The protocol was randomized to two of five identical medicine wards. Self-reported duration of night-time sleep (median 5.0 vs. 5.0 hours) and daytime sleep (1.0 versus 0.5 hours) did not differ between the 40 intervention patients and the 41 control patients. There was also no difference in the cumulative Verran–Snyder-Halpern (VSH) Sleep Score or inpatient sleep pharmaceutical use. The researchers felt that lack of true blinding and overcapacity (they sometimes had 3 patients in rooms designed for two) may have contributed to the lack of statistical improvement. They were encouraged that nursing and other staff felt that the intervention was beneficial to patient care.
In the Dobing study, patient reasons for poor sleep were (in intervention and control patients, respectively):
Noise (48% vs. 44%)
Care interruptions (20% vs 22%)
Uncomfortable beds (20% vs. 17%)
Lighting (7.5% vs. 12%)
Unfamiliarity of surroundings (18% vs. 17%)
Disease-related factors were infrequently cited (<10%) and included pain, anxiety, and cough. Other infrequently cited factors included intravenous lines, temperature, odors, and decreased daytime activity.
One quality improvement project undertaken by UNC Healthcare provides some insight into facilitators and barriers to implementing a Quiet Time program (Hedges 2017). They had found that decibel levels on some units were as high as 90 decibels (equivalent to highway truck traffic!). Implementing "Quiet Time" was shown to improve both patient and staff satisfaction in several units at UNCH. Quiet Time was designated as 2-4 in the afternoon & 12-5am at nighttime. During quiet time lights are dimmed, doors to patients' rooms are closed, overhead paging is reduced in both number and volume (texting was used for messaging), ringer volumes on phones are decreased and patients are cared for but minimally disturbed. They even paid attention to everyday things we tend to overlook, such as replacing the wheels on rolling carts/equipment with wheels that produce less noise. Patients were presented with a “sleep menu” and were given eye masks and ear plugs, if requested.
There was also an attempt to cluster care and provide it more quietly. Patient rooms were prepared in advance (eg. remove dirty trays, check IV pumps, and perform toileting). To minimize interruptions, non-urgent procedures (eg. phlebotomy, radiology studies, PT/OT, etc.) and patient rounds were timed to be undertaken during non-Quiet Time hours.
But they emphasize that quiet time is not “no care time”. Rather staff focus on performing patient care in a quieter and less disruptive manner during these hours.
They identified the following strategies as things that worked:
But the biggest challenges were in:
Most of the protocols that have been used to promote more natural sleep patterns in inpatients (HELP, TUCK-in, Somerville, and Quiet Time) share features in common with Quiet Time.
The “TUCK-in” protocol is as follows:
T Toileting assistance offered prior to 22:00
U Unnecessary interruptions (vital signs, meds, etc.) reviewed
C Cue the lights (minimize lights 22:00 to 06:00)
K Keep it down! (reduce noise, offer earplugs, turn off TV/radio)
The Somerville protocol, which resulted in a 38% reduction in patients noting sleep disruption due to hospital staff and a 49% reduction in patients receiving prn sedatives in one study (Bartick 2010), consists of 10 components:
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.
In an editorial accompanying the ter Maaten study, Growdon and Inouye (Growdon 2018) point out some of the limitations of the study, including the considerable data gaps in the methodology. But they support the overall message of the study – that we need to do a better job of promoting good sleep in inpatients without negatively impacting their other medical needs. Sharon Inouye, of course, is the architect of the Hospital Elder Life Program (HELP) program (Inouye 2013) mentioned above. 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.
Bartick and colleagues (Bartick 2010) also felt that the reduction in noise and light probably did not significantly improve patients’ sleep. Rather reduction in the physical disruptions probably played the major role.
In our May 15, 2018 Patient Safety Tip of the Week “” we noted that 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).
We also mentioned how physicians may inadvertently cause some of those disruptions. 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.) And we often reflexly order vital signs to be taken “every 4 hours” or “every 6 hours” when they really don’t need to be taken during the wee hours of the morning (being careful not to overlook times when vital signs really do need to be taken so frequently).
It's certainly logical to focus on noise reduction as one strategy to promote more natural sleep in your inpatients. But your program needs to be a multiple component one and we think the primary focus needs to be on coordinating care so that interruptions are kept to a minimum.
Lastly, don’t forget one of our goals is to minimize use of sedative/hypnotic drugs and their detrimental side effects. 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 and promoting sleep in hospitalized patients :
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 “”
June 2018 “”
ter Maaten C, van den Ende ES, Alsma J, et al. for the “Onderzoeks Consortium Acute Geneeskunde” Acute Medicine Research Consortium. Quality and Quantity of Sleep and Factors Associated With Sleep Disturbance in Hospitalized Patients. JAMA Intern Med 2018; Published online July 16, 2018
Bevan R, Grantham-Hill S, Bowen R, et al. Sleep quality and noise: comparisons between hospital and home settings. Archives of Disease in Childhood Published Online First: 17 July 2018
McGough NNH, Keane T, Uppal A, et al. Noise Reduction in Progressive Care Units
Journal of Nursing Care Quality 2018; 33(2): 166-172
Goeren D, John S, Meskill K, et al. CE Article: Quiet Time: A Noise Reduction Initiative in a Neurosurgical Intensive Care Unit Crit Care Nurse 2018; 38: 38-44
Dobing S, Dey A, McAlister F, Ringrose J. Non-pharmacologic interventions to improve sleep of medicine inpatients: a controlled study. Journal of Community Hospital Internal Medicine Perspectives 2017; 7(5) 287-295
Hedges C, Hunt C. Implementing “Quiet Time” to Improve Patient Sleep and Decrease Noise. UNC Institute for Healthcare Quality Improvement 2017
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
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; 173(16): 1555-1556
Growdon ME, Inouye SK. Minimizing Sleep Disruption for Hospitalized Patients. A Wake-up Call. JAMA Intern Med 2018; 178(9): 1208-1209