(This article appeared previously on KaiserHealthNews.)
It’s a common complaint: If you spend a night in the hospital, you probably won’t get much sleep.
There’s the noise. There’s the bright fluorescent hallway light. And there’s the unending barrage of nighttime interruptions — vitals checks, medication administration, blood draws and the rest.
Peter Ubel, a physician and a professor at Duke University’s business school, has studied the rational and irrational forces that affect health. But he was surprised, when hospitalized at Duke in 2013 to get a small tumor removed, by how difficult it was to sleep.
“There was no coordination,” he said. “One person would be in charge of measuring my blood pressure. Another would come in when the alarm went off, and they never thought, ‘Gee if the alarm goes off, I should also do blood pressure.’”
“From a patient perspective,” Ubel added, “you’re sitting there going, ‘What the heck?’”
The reality for many, many patients is they’re woken up multiple times … for the convenience of staff.
— Susan Frampton, President of Planetree
Taking a Second Look
As hospitals chase better patient ratings and health outcomes, an increasing number are rethinking how they function at night — in some cases reducing nighttime check-ins or trying to better coordinate medicines — so more patients can sleep relatively uninterrupted.
The American Hospital Association (AHA) doesn’t formally track how many hospitals are reviewing their patient-sleep policies, though it’s aware a number are trying to do better, said Jennifer Schleman, an AHA spokeswoman.
And, though few studies specifically link quality of shut-eye and patient outcomes, doctors interviewed said the connection is obvious: Patients need sleep. If they get more of it, they’re likely to recover faster.
Heavy Activity at Night
Traditionally, hospitals have scheduled a number of nighttime activities around health professionals’ needs — aligning them with shift changes or updating patient’s vital signs so the information is available when doctors make early morning rounds. Both the sickest patients and those in less serious condition might get the same number of check-ins.
In some cases, that can mean patients are being disturbed almost every hour, whether medically necessary or not.
“The reality for many, many patients is they’re woken up multiple times for things that are not strictly medically necessary, or … multiple times for the convenience of staff,” said Susan Frampton, President of Planetree, a nonprofit that encourages health systems to consider patient needs when designing care.
Changing that “seems like kind of easy, low-hanging fruit,” said Margaret Pisani, an associate professor at Yale School of Medicine. She is working with other staff at the Yale hospital to reduce unnecessary wake-ups, using strategies like letting nurses re-time when they give medicines to better match patient sleep schedules, changing when floors are washed or giving nurses checklists of things that can, and should, be taken care of before 11 p.m.
Part of ‘Patient-Centered Care’
Not only is the push for better patient sleep part of a larger drive to improve how hospitals take care of their patients, but it is fueled in part by measures in the 2010 health law tying some Medicare payments to patient approval scores. As more hospitals try to improve those numbers, experts said, more will likely home in on improving chances for a good night’s sleep.
“There’s a movement toward patient-centered care, and this is definitely a part of it,” said Melissa Bartick, an assistant professor at Harvard Medical School.
That focus makes sense, since federal patient approval surveys specifically ask about nighttime noise levels. A number of hospitals initially struggled to get good scores on that, said Richard Evans, Chief Experience Officer at Boston-based Massachusetts General Hospital.
His hospital instituted quiet hours — a couple of hours in the afternoon and between six and eight hours at night, depending on the hospital unit, in which lights are turned low and staffers are encouraged to reduce their noise levels. It also encourages hospital workers to consider whether patients really need particular care at night before waking them.
“We’re trying to [increase awareness] that patients need to rest, and we need to structure our care as much as possible to allow that to happen,” said Evans.
It’s hard to delineate the degree to which such efforts have affected patient approval scores, he said, but anecdotally, patients have expressed appreciation.
It’s Not the Noise, It’s the Interruptions
The Department of Veterans Affairs New Jersey Health Care System is taking this concern even further. In addition to quiet-time restrictions, where it tries to reduce the use of noisy equipment, staff chatter and things like phone volume, patients can opt to have lavender oil sprayed in their rooms or an evening cup of herbal tea to facilitate sleep.
All of these kinds of changes can help, said Planetree’s Frampton. But they don’t get at the real problem for most patients.
“Low scores on quiet-at-night [questions on patient surveys] are not because it’s overly noisy … but because patients are woken up repeatedly,” she said. “Their sleep is disturbed so they’re lying awake.”
To address that, hospitals may need to look at less obvious questions.
At New York’s Mount Sinai Hospital, doctors are rethinking when they prescribe medicines as well as which kind, said Rosanne Leipzig, a professor of geriatrics and palliative medicine and who practices at the hospital. For instance, some antibiotics can be given at six-hour intervals rather than four-hour intervals, reducing the need for nighttime interruptions. And some drugs usually given every six hours can instead be given four times a day during the hours patients are usually awake.
The hospital is also working to develop a system to classify patients who need repeated checks from the medical staff, such as those who might face imminent health threats or are at risk for serious infections such as sepsis. For those patients, frequently checking vitals is important, even if patients sleep less, Leipzig said.
But not every patient’s condition requires that they be roused every four hours, she added.
Too Many Vitals Checks, Study Shows
About half of all patients woken up for vitals checks probably don’t need to be, according to a 2013 study published in JAMA Internal Medicine. The study said waking them may contribute to bad patient results and dissatisfaction and could increase the odds of patients having to come back to the hospital.
Another study, published in 2010 in the Journal of Hospital Medicine, looked at efforts to encourage patient sleep — particularly by rescheduling activities, nighttime checks and overnight medication doses to avoid waking patients. That paper, co-written by Bartick, found a 49 percent drop in the number of patients who were given sedatives. That change can have the added benefit of improving patient outcomes, since sedatives are associated with dangerous side effects such as falling or hospital delirium or confusion.
“Sleep disruptions are actually not benign as far as patients are concerned,” said Dana Edelson, an assistant professor of medicine at the University of Chicago and an author on the 2013 study. “We’re putting them at unnecessary risk when we’re waking them up in the middle of the night when they don’t need to be.”
And possibly making the recovery a bit more difficult.
“Patients will tell you, ‘I was so exhausted, I couldn’t wait to get home and go sleep,’” said Yale’s Pisani.
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