Improving Hospitalized Patient Sleep: It Is Easier Than It Seems.

Abstract

Adequate sleep is important in healing from illness. Sleep deprivation has been associated with a myriad of negative health effects, including impaired immune function, decreased pain tolerance, and delirium.1–3 Frequent interruptions to sleep additionally impact patient experience, a fact that has been recognized by the Child Hospital Consumer Assessment of Healthcare Providers and Systems, which asks families for feedback on the quietness of the hospital environment at night.4 Perhaps underrecognized is the effect interruptions have on parents and caregivers who remain at bedside overnight.5,6 This becomes important as sleep deprivation, particularly over time, negatively impacts qualities such as optimism, trust, resilience, and ability to concentrate.7While hospitalized, children awaken frequently and receive far fewer hours of sleep than is recommended by the National Sleep Foundation.8,9 Despite the clear importance of sleep in the hospital, health care providers interrupt sleep frequently. In 1 study, the rooms of hospitalized children were entered an average of 10 times per night.9 Other studies in which researchers use actigraphy have revealed a similar (or greater) number of actual patient awakenings.5,8,10 When surveyed, caregivers most frequently identify vital signs and physician and/or nurse presence as disruptive to sleep.11 Other interruptions highlighted include pulse oximetry, medications, and alarms.11,12The article entitled “Improving the Timing of Laboratory Studies in Hospitalized Children: A Quality Improvement Study,”13 in this edition of Hospital Pediatrics, is added to a growing body of quality improvement literature focused on the topic of improving hospitalized pediatric patient sleep. The authors of this study aimed to increase the percentage of laboratory tests ordered for collection after 7 am, with the ultimate goal of not waking children in the early morning hours for routine laboratory draws. After implementing the use of a rounding checklist coupled with educational efforts, the percentage of routine laboratory tests ordered for collection after 7 am increased from 25.8% to 75.0%. Because later laboratory test collection might theoretically delay care plans and discharges, the authors evaluated the number of laboratory tests collected after 11 am as a balancing measure, and there was no increase.Within the past year, there have been additional similar studies, highlighting interventions specifically targeting other interruptions to hospitalized patient sleep. Mozer et al14 modified medication time defaults in their electronic medical record for 4 antibiotics (amoxicillin, amoxicillin clavulanate, cephalexin, and clindamycin) to default to sleep-friendly medication administration times. This intervention, coupled with education efforts, increased the percentage of orders with sleep-friendly administration schedules from 18% to 90%. Cook et al15 modified their electronic vital sign order to more easily allow for deferring the collection of vital signs during sleep. Specifically, with their project, they targeted routine blood pressure monitoring because this was deemed to be the most disruptive to sleep. In this study, the authors were able to demonstrate an increased duration of sleep for children >2 years of age and decreased nighttime disruptions by clinicians. There were no escalations of care or adverse events associated with either of the interventions in these studies.The American Academy of Nursing’s Choosing Wisely campaign specifically notes that nurses should refrain from waking patients for routine care unless required by the patient’s condition.16 When surveyed, 94% of nurses felt that they are doing what they can to improve sleep.11 In stark contrast, in the same study, only 33% of physicians felt similarly.11 In reality, the majority of interruptions to a hospitalized patient’s sleep are in our control as physicians.For example, the practice of obtaining vital signs every 4 hours dates back to the time of Florence Nightingale and is neither an evidence-based nor high-value care practice for the majority of stable patients.17,18 Yet >100 years later, we continue to wake patients in the middle of the night to measure their vital signs. How frequently do we reflect on which patients might not require overnight monitoring? How frequently do we modify our institution’s routine vital sign order once a patient’s condition has stabilized? How often are our patients’ laboratory tests collected before 7 am so that we might have that data for rounds, when, in reality, laboratory tests collected the evening before or later in the morning would have been equally useful? How many of the medications we prescribe actually require exact timing, or is there flexibility in the hours we dose them? How often do we reflect on sleep when starting or discontinuing continuous monitoring or continuous fluids, especially considering the associated devices and pumps are common sources of alarms? These are important questions that we must continue to ask ourselves as we design quality improvement projects at our own institutions.Although the intervention designed by Ramazani et al13 in this edition of Hospital Pediatrics may not be viewed as revolutionary, this is precisely why it warrants our attention. This study, along with the others published within the past year, reveals that, with minimal effort and resources, we can make significant and meaningful improvements to the experience of our hospitalized patients and their families, and we can do so without delaying care or increasing the rate of adverse events.