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Sleepless in the hospital?

July 2012

Published in the July 2012 issue of Today’s Hospitalist

AH, SLEEP! It may be the one proven therapy that hospitals can’t provide on floors that are just as hectic at midnight as at 6p.m.

To boost the number of hours that patients can sleep, neurologists at Johns Hopkins School of Medicine in Baltimore decided to test two different types of what they called sleep rounds.

As part of basic sleep rounds, nurses spent about 20 minutes each night helping their patients get ready for bed. The deluxe model added amenities on top of that basic package, like offering patients a glass of warm milk.

Researchers tested the interventions in several phases from February 2009 to June 2010. Study results were posted online in March by the Journal of Hospital Medicine.

The data provided both good and bad news. The bad news was that patients in neither intervention arm actually got more sleep. But on the plus side, patients who took part in either type of sleep rounds thought that they had slept better and had fallen asleep faster.

For lead author Robert E. Hoesch, MD, however, that good news wasn’t good enough. Dr. Hoesch, who finished his neuro critical care fellowship at Johns Hopkins, has since become the director of the neuro critical care unit (NCCU) at the University of Utah in Salt Lake City.

“Perception isn’t enough,” Dr. Hoesch says. “If your primary outcome is patient satisfaction, the results are good news for people whose job is to care about ratings. But from the standpoint of physiology and medicine, our goal was to actually see changes in the real parameters: time to fall asleep, how long patients stayed asleep and how they rated their sleep the next day.”

White noise and warm blankets
During basic sleep rounds, nurses at 11 p.m. turned off TVs and lights in patients’ rooms, adjusted the room temperature, and offered to help patients to the bathroom to prevent patients waking up during the night.

During the deluxe phase, patients not only received those basic elements, but student volunteers also gave patients a choice of sleep-promoting amenities. In addition to warm milk, patients could opt for aroma spritzers, warm blankets, body lotions or white-noise machines. (A warm blanket was the No. 1 choice.)

Patients the next morning answered the following questions: How many hours did they sleep, how often did they wake up and how long did it take them to fall asleep? During both intervention phases, researchers also put noise recorders in the rooms of some patients to gauge noise levels.

Despite researchers’ best efforts, patients enrolled in both types of sleep rounds reported getting the same amount of sleep “around five hours “as patients during the pre-study baseline period and the washout period between the two interventions.

But when researchers looked at the questionnaires, they were surprised to find that patients in both interventions reported getting a better night’s sleep. And on their Press Ganey scores, patients in both intervention arms gave the hospital higher marks for keeping noise levels down. That’s interesting, Dr. Hoesch notes, because for reasons that weren’t clear, the actual noise levels in patient rooms rose a few decibels over the study period.

Second thoughts
If he could do the study again, Dr. Hoesch knows what he would do differently. For one, he thinks the data would have shown patients getting an hour or two more sleep every night if each intervention phase had lasted more than six months, instead of only four.

He also wishes the study had covered more patients to see how sleep quality and duration varied between patients in private and semi-private rooms. While the study reported the same sleep experience for both sets of patients, “we really weren’t powered to see a difference between room types,” he says.

“I’d be willing to guess that if we did 100 of them, we would see a difference,” he says. (About 65 surveys were collected during each study phase.) The three top problems with sleep that patients reported were pain, staff interruptions and roommates.

That points to another barrier: The study team was not able to reconfigure workflow on the neuro floor where the study was conducted to reduce the number of times that staff woke up patients.

“We tried to come up with ways to get requisite neuro checks timed with blood draws and the beginning of morning rounds,” he says, “but it was just too much to try to do initially.” But subjecting patients to a continuous stream of night-time interruptions is clearly a problem.

“If you want to have a major impact,” says Dr. Hoesch, “try not to interrupt the patient between midnight and 6 a.m.”

But his biggest regret is not making basic sleep rounds the default both before and after the study. It took nurses about a month after each intervention to stop attending to patients’ sleep hygiene at bedtime. But if the team had continued the protocol permanently, Dr. Hoesch notes, “the data from the study would be considered baseline and we could see if other hospital-related complications could have been reduced in further analysis.”

Helping patients to the bathroom at 11 p.m. every night, for instance, may have resulted in fewer nighttime falls. And “patients with brain injury, especially older people in the hospital, tend to become delirious in the middle of the night when they wake up,” Dr. Hoesch explains. “If they’re sleeping more with fewer interruptions, they should be less delirious.”

Sleep hygiene as default
In his new role directing an NCCU, Dr. Hoesch plans to make attending to better sleep hygiene a daily clinical exercise for all patients. Part of that is getting patients up and moving during the day.

“Our immediate plan is to execute a protocol to normalize patients’ days through aggressive mobilization,” he says. “That hopefully will lead to better sleep at night.”

Evaluating how and when to space out interruptions is something else he intends to get off the ground. “We can group interruptions to space them out instead of having them happen randomly every half hour,” he says. “Just like we evaluate whether we can take out IVs or liberate patients from a ventilator, we need to evaluate every day how to move patients toward more normal sleep patterns.”

And paying daily attention to better sleep hygiene has to become the default, he notes.

“For all quality improvement initiatives “DVT prophylaxis, Foley catheter removal, mobility “the secret to success is making the intervention the default,” Dr. Hoesch points out. That includes practices that promote healthier sleep patterns such as quiet time, sleep rounds or just a clear demarcation of the end of the day. “Any time we really want to make an impact, we have to make it the default.”

Phyllis Maguire is Executive Editor of Today’s Hospitalist.