Sleep heals

Learn why and how to improve inpatient sleep.

Despite the well-established connection between good rest and better overall health, hospitalists may overlook sleep's supportive role in their patients' outcomes, according to experts.

Image by Getty Images
Image by Getty Images

“Even short-term sleep loss during hospitalization is associated with a host of adverse health effects, including delirium, high blood pressure, hyperglycemia, and also posthospital syndrome—the increased vulnerability to readmission after hospitalization,” said Vineet Arora, MD, MAPP, FACP, a professor of medicine at the University of Chicago's Pritzker School of Medicine.

Several recent studies offer insight into how the hospital environment can affect inpatient sleep quality and patient outcomes, as well as highlighting actions hospitalists can take to ensure patients get the rest they need.

Lingering effects

Dr. Arora and her colleagues studied sleep duration and efficiency in 212 general medicine patients and published results in the February 2017 Diabetes Care. They found that shorter sleep duration and worse sleep efficiency were associated with hyperglycemia and impaired fasting glucose levels in patients with and without diabetes.

Such sleep problems are common in the hospital, according to a study published in PLoS ONE in June 2016. Using a validated sleep quality scale, researchers found that 93 patients admitted across four Canadian general medicine wards reported they slept an average of 1.5 hours less while in the hospital than they did at home. They also rated their sleep quality as significantly worse in the hospital than at home.

Among the most frequently reported inpatient sleep disturbances were noise (59%), nursing interruptions (30%), uncomfortable beds (18%), and bright lights (16%), many of which can often be mitigated by staff.

“Hospitalists can consider timing of medications, vital signs, and patient moves, all of which may interrupt sleep. Allied health teams and hospital administration can consider policies on lighting, toileting schedules, and modifiable noise at night,” said Jennifer Ringrose, MD, FACP, the study's corresponding author and an associate professor of general internal medicine at the University of Alberta in Canada.

Nurses in particular can play a key role in elevating the restfulness of the unit, according to Catherine Auriemma, MD, a pulmonary and critical care medicine fellow at the University of Pennsylvania in Philadelphia. “They spend the most time with patients, so in many ways, they are the frontline providers to witness how care can impede patients' sleep,” she said.

Dr. Arora agreed. “It's important to partner with nurses, who are natural champions for this work, to get these practices to stick at the unit level,” she said.

Empowering nurses

A prospective analysis of a sleep quality intervention developed by Dr. Arora and her colleagues showed that even after an initiative to change physician nighttime order behaviors proved successful, it wasn't until nurses were educated about the importance of good inpatient sleep quality and subsequently empowered to advocate for it on behalf of patients that nighttime room entries dropped significantly.

The six-month pre- and postintervention analysis of results from this single-site quality improvement initiative, called Sleep for Inpatients: Empowering Staff to Act (SIESTA), was published in the January Journal of Hospital Medicine.

Although physicians on both SIESTA-enhanced and standard units were given “nudges” in the electronic medical record (EMR) to issue sleep-friendly orders such as forgoing nocturnal vital sign checks and administering prophylactic heparin every eight to 12 hours instead of every four, only nurses in the study group incorporated enhanced SIESTA protocols into their huddles and dayshift handoffs. Nurses on the study unit were also instructed to advocate for patients to have fewer nocturnal interruptions when appropriate.

While there was a dramatic rise across both units in the number of sleep-friendly orders issued, the difference between the two units was not statistically significant. However, in the SIESTA-enhanced unit, nighttime room entries dropped by 44%. Additionally, there were about 40% fewer reports of nocturnal vital sign check disruptions from patients on the study unit compared with the standard unit, and about a third fewer reports of disruptions for medication on the study unit compared with the other unit (70% vs. 41% and 84% vs. 57%, respectively).

Patient experience was also improved on the SIESTA-enhanced unit, reflected in the 7% and 9% increases, respectively, in the number of HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) top-box scores for “quiet at night” and “pain well controlled.” Meanwhile, there were no major changes in the standard unit's scores.

An important lesson learned from the study, according to Dr. Arora, is not to be held hostage by electronic records' default settings. “I think the EMR can automate bad processes, so it's important to think about what the actual outcome and workflow is that you want and figure out how to automate that,” she said.

Dr. Arora and her team are currently evaluating an additional SIESTA study nudge that reminds hospitalists and other clinical staff to order sleep-friendly labs, rather than the typical labs that are ordered for 4 a.m., which can be painful and disruptive to patients.

Balancing risks

Sometimes, disrupting a patient's sleep is unavoidable, such as when urgent care or time-sensitive medications are needed. However, stratifying patients by risk and thinking ahead can mitigate some concerns about routinely forgoing nocturnal interruptions, according to Dr. Arora.

“The key is to consider this care on a continuum,” she said. “As patients get better, their sleep should be prioritized. This requires some thought, but our EMR interventions can make it easier to remind clinicians to do the right thing. When someone is acutely ill and hospitalized for the first time, they may need to be woken up . . . but as they get better and their vitals have stabilized, there is likely no benefit to waking them up.”

Emerging technology could eliminate the need to disturb some sleeping patients entirely, according to an editorial accompanying the SIESTA results, coauthored by Dr. Auriemma and S. Ryan Greysen, MD, MHS, the University of Pennsylvania's hospital medicine section chief.

“The technology now exists to measure vitals passively and continuously via low-impact wearable devices,” they wrote. The editorialists cited another recent study, published in the August 2018 American Journal of Medicine, which employed such devices, red-enriched light, and noise sensors and found an association with decreased length of stay and readmissions.

Another trial tested a set of sleep enhancements, including an eye mask, ear plugs, and a white noise machine, along with education for some patients. The randomized trial of 86 cardiac patients at a single center, published in the December 2016 American Journal of Medicine, found that the educated patients had significantly improved fatigue levels over baseline three days after instruction, compared with controls who were given the sleep aids but not instruction on how to use them. A significantly higher number of patients in the study group used the sleep aids at least once in the three-day study, compared with controls (69.2% vs. 41.2%).

The study also looked at the use of pain medication relative to sleep quality and found that across the study arms, any patient who used the sleep aids also used fewer analgesics during the hospital stay, although this did not reach statistical significance. The study's authors concluded that less self-reported patient fatigue could positively correlate with improved overall patient care experience.

“It seems like the presence of a sleep aid kit would force a discussion with patients who might think they need to have their vitals checked, but could be getting sleep instead,” Dr. Arora said.

The role of medication

As for the use of sleep medications in patients experiencing poor sleep, Dr. Ringrose urged caution. “We should make every effort to advocate for nonpharmacologic solutions for sleep,” she said.

In fact, the FDA recently issued added boxed warnings for the sleep medications zolpidem, eszopiclone, and zaleplon after an analysis of the literature and adverse events reported to the agency showed potentially fatal complex sleep behavior risks, including attempted suicide, associated with their use in some patients.

“Our older patients are particularly vulnerable to the sedating and impairing effects of these medications, which predispose them to falls and delirium,” Dr. Ringrose said.

Dr. Arora said that while some patients might require medication to ease pain or anxiety, sleep medications should only be used as a second-line treatment after environmental modifications. “In my personal practice, I have seen that often the medication is not as important as really providing a sleep-friendly environment and reducing disruptions,” she said.

This approach to improving inpatient sleep quality is part of a growing shift in what “do no harm” looks like today, noted Dr. Auriemma. “It is exciting to begin one's career in medicine during this time when we are challenged to reexamine the ways we deliver care to hospitalized patients and to use common sense as well as technology to make our systems smarter, more efficient, and more restorative for patients,” she said.