Sleepless in the hospital: Our own default

Patients should not be disturbed in the middle of the night unless it is medically necessary.

Sleep is important to health, perhaps no more so than when people become sick. Indeed, it is likely that failure to sleep slows the recovery of patients hospitalized with acute illnesses. Sleep disturbance is a leading cause of hospital complications, such as falls and delirium (“Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem.” Institute of Medicine, 2006; Gerontology. 2009;55(2):162-8). Poor sleep also has been linked to reduced immune function (Arch Intern Med. 2006;166:1756-62), worsening blood pressure control (Sleep. 2003;26(8):986-9) and mood disorders (Sleep Med. 200;8(3):215-21). All of these problems potentially impair the ability of patients to recover from the acute illnesses that caused them to be hospitalized.

Yet hospitals are notoriously difficult places for patients to sleep. Illness symptoms can interfere with sleep, as can noisy roommates. To make matters worse, hospital protocols often lead to further sleep disturbance, with hospital personnel waking patients in the middle of the night to check vital signs or draw blood (J Hosp Med. 2008;3(6):473-82). As a result, just when people need sleep the most, they often don't get it.

Peter Ubel ACP Member
Peter Ubel, ACP Member

Fortunately, there is a simple way to reduce sleep disturbances: a change in policy stating that patients are not to be disturbed in the middle of the night unless it is medically necessary. On many general medicine wards, the default procedure is for nurses and lab techs to wake patients for blood draws and vitals, unless a physician specifically orders a “sleep protocol” to reduce such interruptions (J Hosp Med. 2009;4(1):50-9). I propose that hospital units should consider making “sleep protocol” the default option, so that patients are woken only when physicians specifically indicate such disturbances are required.

Defaults and behavior

Research in behavioral economics has demonstrated that people are strongly influenced by default options when making decisions (“Free Market Madness.” Harvard University Press, 2009). Employees are more likely to contribute to retirement funds when such contributions are automatic (“Nudge: Improving Decisions about Health, Wealth and Happiness. Yale University Press, 2008). People are more likely to donate their loved ones' organs in countries where such donations are default policy (Science. 2003;302:1338-9). In both cases, the actions people take are influenced by framing their choices with a particular default setting. Default options have gained widespread attention because they can influence behavior without unduly restricting freedom (N Engl J Med. 2007;357:1340-4).

Currently in most hospital settings, nursing staff assume physicians want patients awoken for nighttime tests; this is the default. If a physician does not consider a patient's need for sleep, the patient will be interrupted even if it's unnecessary.

While patients in intensive care usually do need to have their vital signs monitored closely, and often need multiple blood draws each day to monitor rapidly changing clinical circumstances, many hospitalized patients do not change enough in their clinical course to require routine middle-of-the-night interruptions. For example, a patient in the third day of his hospital stay, whose clinical situation has been improving and whose vital signs were normal at 10 p.m., may not need vital signs checked again until he wakes up in the morning. Similarly, a person whose hemoglobin and electrolytes have been relatively stable for a couple of days might not need to have these tests checked at 5 a.m. just so the clinician can have the information at morning rounds.

A modest proposal

There are two ways clinicians can use the insights of behavioral economics to improve patients' sleep. First, portions of our hospitals could shift their default procedures so that a “sleep protocol” becomes the standard of care. Bartick et al. developed one such protocol, which establishes eight hours of quiet time for patients, with darkening of the room and avoidance of waking patients for nonurgent matters. The protocol reduced sleep disturbances by 38% (J Hosp Med. 2010;5:E20-4).

The problem with making sleep protocol the default is that some hospital units might choose sleep protocol as the default while others set as their default a protocol calling for middle-of-the-night vital signs. Differing default procedures across hospital units could confuse clinicians who work on multiple units.

This leads to a second approach. Hospitals could require physicians to actively indicate whether they want their patient to receive “standard sleep protocol” or an alternative protocol, such as “interrupt sleep for vitals and blood draws.” In other words, they can eliminate a default, and require physicians to actively contemplate what is best for a given patient. Failure to indicate a protocol would trigger a nursing query. Some hospital units might even require physicians to reconsider their decision in, for instance, 48 hours, a time by which physicians will have a better idea of the need for labs and vitals.

It is time for physicians to think more carefully about how to help their patients sleep better. Sleep is such an important part of health that we need to promote it in our patients. Shifts in our default practices can help reach this goal.