Quiet in the Hospital: Improving Patient Care MARK GARWOOD M.D. CLINICAL ASSISTANT PROFESSOR, UNIVERSITY OF MICHIGAN SLEEP DISORDERS CENTER DEPARTMENT OF NEUROLOGY
I found many similar recent articles on the internet from the public regarding hospital sleep. Some of you may have been patients in a hospital before or their with family members and I suspect may not have felt fully rested when you left. Anecdotally, excluding being in the hospital for the birth of my children which I would view as an exception, the other times I have stayed the night with family members at various hospitals none of us slept well.
University of Michigan Health System THE QUIET CAMPAIGN
Quiet Campaign Office of Service Excellence Launched 2011 Increase quietness and improve patient care experience and staff
work conditions Posters, visual displays, noise meters Replaced pillow speakers with headphones and ear buds Patients given eye masks and ear plugs Noisy equipment fixed and replaced (doors, cart wheels) Piloting of sound absorbing materials and noise meters Partnership with University Health System Consortium (HCAHPS
White noise channel on TV (White noise machines tried but difficult to clean) Observation glass some units and more quiet door handles and seals around door frames
Quiet Hours
9 pm to 5 am 1 pm to 3 pm (Units may vary)
Presenter
Presentation Notes
Unified quiet hours began May 2015 Quiet all time in pediatrics
HCAHPS Improvement Collaborative
Hospital Consumer Assessment of Healthcare Providers and Systems Joint project CMS and AHRQ (Agency for Health Care Research
and Quality ) HCAHPS survey since 10/2006- Goal uniformly measure patient
perception of inpatient care 25% of Medicare’s Value Based Purchasing Score using now 9
weighted measures CY15 2 out of 8 HCAHPS domains failed to meet CMS public
thresholds (Cleanliness/Quietness, Communications about meds) During this hospital stay how often was the area around your room
Overall rating of hospital % 9s and 10s Doctors always communicate well Nurses always communicate well Patients always received help as soon as they wanted Staff always explained about medications Pain was always well controlled Patient’s room always kept quiet at night Patient’s room and bathroom always kept clean Patient’s given information about recovery at home Patient’s would definitely recommend this hospital to friends and
These slides are from our internal websites which all of you should have access to and some of which have been presented in our faculty meeting. While all information should be available publicly. Please do not disclose this information externally. I would not want any of us including me to get into trouble. You should all know that there has been some restructuring with integration of the medical school and faculty group practice and I looked at some of the diagrams closely prior to the lecture and I understand if anyone of us should get in trouble we would not report directly to our new leader of our organization, which of course now is Coach Jim Harbaugh and punishments could include but may not be limited to rather intensive conditioning drills. Go Blue.
Patient perception of care surveys Press Ganey Private
All age inpatients and ER
Larger sampling size
Larger survey (HCAHPS and more) Roughly 100 questions
Some open ended
Can obtain unit specific data
Data available immediately
Rescaled, averaged (0-100 index)
Very poor to very good (5 point)
HCAHPS Public
Adult inpatients
Smaller sampling size
Smaller survey 18 rated questions, 9 demographic
No open ended
Hospital data
9-12 month data lag
% top box reporting
Never to always or yes no (4 point)
Presenter
Presentation Notes
Press Ganey is a nationwide patient experience company. We partner with them, but it is an independent company. Press Ganey partners with more than 50% of all U.S. hospitals to help improve clinical and business outcomes. Hospitals can administer HCAPS by themselves but we have Press Ganey do this for us in addition to administering a separate survey that allows us to focus on a greater breadth of and unit specific information
Sleep Quality in the hospital Prolonged sleep latency, increased sleep fragmentation,
early morning awakenings, decreased total sleep time. Association between sleep disturbances and quantity of
chronic diseases, pain, tricyclic antidepressants, duration of hospitalization (Frighetto 2004)
Almost 50% admitted to general hospital medical wards experience insomnia, excessive daytime sleepiness, or both. Few, if any of these sleep problems are ever reported in the medical records (Meissner 1998)
The use of hypnotic medications both prior to admission and during the hospital stay is common
Watson Paula et. al. Best Pract Res Clin Anaesthesiol. 2012 Sep; 26(3): 10.1016/j.bpa.2012.08.005
Presenter
Presentation Notes
So, we’ve talked about how making a hospital more quiet is tied to Medicare reimbursement and some steps UMHS has taken to make our hospital more quiet but I now want to focus more about sleep quality in the hospital setting. Hospitalized patients often have poor quality sleep
Sleep Quality in the ICU TST 7-9 hours but 50% occurring during daytime hours. Increased sleep fragmentation (6.2 awakenings per hour) Prolonged sleep onset, decreased sleep efficiency, decreased REM
sleep Altered sleep wake cycles for up to 3 months after discharge Severity of illness and environmental factors likely contribute to poor
sleep Normal subjects had less sleep disruption than ICU patients at ICU noise level
but normal subjects without intense clinical monitoring
Mechanical ventilation: Endotracheal tube discomfort, level of inspiratory support, inducing central apnea, patient-ventilator asynchronies.
Sleep has been deprioritized in hospital setting and perhaps more so in ICU (intubated, sedated patients)
Delaney et al. Annals of Intensive Care (2015) 5:3
Presenter
Presentation Notes
Intensive care units (ICU) are the hospital setting where the problem of sleep disturbances likely reaches its highest level and represents the source of most relevant data available in the literature.
Cyclical interaction: sleep and common medical illnesses.
Young et al. “Sleep in hospitalized medical patients, Part 1: Factors affecting sleep” Journal of Hospital Medicine (3) 6 473-482
Medical conditions: associated sleep problems
Asthma • Nocturnal symptoms, GER
CHF • Orthopnea, PND, OSA, CSA, Diuresis
COPD • Nocturnal hypoxemia, Early morning airway obstruction
ESRD • Pruritus, nausea, RLS, PLMD
GERD • Heartburn, coughing
OSA • Worsened by some hospital meds
Stroke • Dysphagia, focal deficits, insomnia, OSA, CSA
Young et al. “Sleep in hospitalized medical patients, Part 1: Factors affecting sleep” Journal of Hospital Medicine (3) 6 473-482
Presenter
Presentation Notes
Asthma: Treatment: Inhaled corticosteroids and/or long-acting inhaled beta-adrenergic agents CHF Also increased sympathetic tone: Keep the head of bed elevated ≥30 degrees. Nocturnal O2 to keep O2 saturation >88%. Daytime diuresis. Optimize cardiac function to treat Cheyne-Stokes respiration. Consider CPAP for CHF COPD: Persistent nocturnal hypoxemia with complications (e.g., cor pulmonale, polycythemia) O2 for COPD and persistent hypoxemia (PaO2 55-60 mm Hg) Sporadic nighttime desaturationsPaO2 ≤55 mm Hg monitor O2 saturation by pulse oximetry. If patient desaturates to ≤88% at night consistently, start nocturnal O2. For hypercapnia, adjust O2 to maintain O2 saturation at 88% to 90%. Early-morning airflow obstruction. Consider bedtime tiotropium (Spiriva) long acting anti-cholinergic and inhaled long-acting beta-adrenergic agonist agents. Inhibition of respiratory muscles in REM. Avoid sedative-hypnotics that cause respiratory depression. Decreased functional residual capacity from recumbent position during sleep. Minimize recumbancy by keeping the head of bed up at ≥30 degrees. End-stage renal disease: Ambulation may help with RLS. Consider ropinirole and pramipexole. Correct hyperphosphatemia and uremia. Consider antipruritic and antiemetic agents. Nocturnal GERD: Avoid eating or drinking ≤2 hours before bedtime, especially those that delay gastric emptying, increase acid secretion, or decrease lower esophageal sphincter pressure; e.g., high-fat foods, ethanol, chocolate, peppers, peppermint. Keep head of bed ≥30 degrees. Minimize medications that could worsen nocturnal GER; e.g., theophylline, calcium channel blockers, prostaglandins, bisphosphonates OSA: ethanol ≤2 hours before bedtime. Minimize CNS depressants. Avoid supine position. Consider CPAP, oral mandibular advancement device, and/or surgical correction. Stroke: Regularly suction secretions. Post-stroke patients have an increased risk of hypersomnia, insomnia, and/or OSA Also, Pain, meds, sepsis, liver disease, PD, anxiety and depression
Adverse effects of sleep deprivation Respiratory
Decreased ventilatory response to hypoxia and hypercarbia Decreased FEV1 and FVC by 5% in COPD MIP decrease from 81.5 to 75.9 cm H2O healthy adults Decreased respiratory muscle endurance
Cardiovascular Increased sympathetic response and BP and HR BP elevated 12 mm Hg after one night sleep deprivation healthy adults
(Ogawa) Immunologic
Decrease ability for extravasation of T cells , Decreased NK cells 30% (Irwin)
Delaney et al. Annals of Intensive Care (2015) 5:3
Presenter
Presentation Notes
Maximal Inspiratory Pressure FEV1 Volume exhaled first second FVC Total amount of air exhaled in forced volume test
Adverse effects of sleep deprivation Metabolic
Dysfunction of HPA axis and disrupted cortisol secretion Suppressed release of insulin from pancreas (Hyperglycemia)
Neurocognitive Adverse effects on cognition (Delirium?) (Poor ability of patients
and families to understand instructions?) Adverse effects on balance (falls?) Increased risk for seizures
Delaney et al. Annals of Intensive Care (2015) 5:3
“ ”
When a delirium or raving is appeased by sleep, it is a good sign
-HIPPOCRATES
Disruption of Sleep and the delirium relationship:
Presenter
Presentation Notes
Hippocrates noted that sleep disturbance and delirium were linked. Delirium is common in hospitalized patients and occurs in 11% of elderly emergency department patients,2 in 37% of post operative patients,3 and in as many as 80% of critically ill patients receiving mechanical ventilation.4 Older patients are more susceptible with up to 50% of geriatric patients developing delirium at some point in their hospital course. Delirium is characterized by inattention, fluctuating mental status, disorganized thinking and an altered level of consciousness – findings which are also characteristics of sleep deprivation. Sleep disturbances are common in delirious patients. And, while sleep deprivation is regarded to be a potentially modifiable risk factor for the development of delirium, it is also likely that delirium itself contributes to sleep disturbances. Delirium and poor sleep quality are common and often co-exist in hospitalized patients. A link between these disorders has been hypothesized but whether this link is a cause and effect relationship or simply an association resulting from shared mechanisms is yet to be determined.
Possible common pathophysiological pathways between delirium and sleep disruption
Watson Paula et. al. Best Pract Res Clin Anaesthesiol. 2012 Sep; 26(3): 10.1016/j.bpa.2012.08.005
Presenter
Presentation Notes
The pathogenesis of delirium is poorly understood. Hypotheses regarding contributing etiologies have included neurotransmitter imbalances (including secondary to medication effects), proinflammatory cytokines, tissue hypoxia, and sleep deprivation. Potential shared mechanisms include: abnormalities of neurotransmitters, tissue ischemia, inflammation, and sedative exposure. Increased dopamine, reduced acetylcholine, reduced tryptophan (and subsequently melatonin) Sedatives, while decreasing sleep latency, often cause a decrease in slow wave sleep and stage REM sleep and therefore may not provide the same restorative properties as natural sleep. Sedatives are a known risk factor for delirium. Decreases in SWS and stage REM sleep are also known risk factors for delirium representing a potential for a shared mechanism. In particular, post-operative patients in whom melatonin plasma levels were measured for two days after surgery, showed a correspondence between abnormal melatonin levels and delirium. Patients without postoperative delirium had normal plasma levels, while those who developed delirium had plasma melatonin levels lower than preoperative values if their operative course was uncomplicated or increased melatonin levels if they had further complications like pneumonia or sepsis.30 A possible derangement, not only in melatonin secretion, but also in melatonin metabolism can also be suspected from the observation of Balan, who showed that patients with hypoactive or hyperactive delirium had, respectively, increased or decreased urinary 6-sulfatoxymelatonin levels. Other possible mechanisms believed to contribute to the occurrence of delirium are acute inflammation and ischemia. The anatomical pathway thought to be involved in delirium includes brain areas like the thalamus, prefrontal, posterior parietal and fusiform cortex and the basal ganglia. It has been observed that delirious patients after hip replacement surgery had higher serum levels of C-reactive protein. Another link between sleep disturbances and delirium comes from the observation that delirium, in a population of elderly patients undergoing knee replacement surgery, occurred more frequently among those with obstructive sleep apnea (Hypoxia, Inflammation, Less premorbid reserve from OSA cognitive effects)
Sedation versus sleep
Sedation Decreased response to external
stimuli
Decreased muscle tone
Respiratory depression
Med specific effects
Dose dependent
Changes in sleep architecture
EEG patterns different than sleep
Sleep Decreased response to external
stimuli
Decreased muscle tone
Respiratory depression
Essential biologic function
Spontaneous
Reversible
Circadian rhythm
Cyclical progression through sleep stages
Presenter
Presentation Notes
For years sleep has been used as a metaphor for sedation and they have similarities though also many important differences. Commonly used sedatives cause abnormalities of sleep architecture (decreases in SWS and stage REM sleep) and are also known risk factors for delirium representing a potential for a shared mechanism. Therefore, whenever possible exposure to these medications should be minimized.
“Sleep Quality and its Association with Delirium among Veterans enrolled in Hospice”
Objectives: Describe sleep quality and evaluate the association of sleep quality with delirium onset amongst patients enrolled in hospice.
Design: Prospective, observational, longitudinal study. Setting: Veterans enrolled in hospice Portland Oregon. Cohort: 105 patients, of whom 73% had at least one sleep measurement. Sleep quality was measured with the Pittsburgh Sleep Quality Index (PSQI). Delirium was measured with the Confusion Assessment Method. Of the patients who could be assessed, 44% had poor average sleep quality
and 58% reported at least one episode of poor sleep. Overall, sleep quality did not appear to worsen as patients neared death although an increasing number of patients were unable to report on sleep quality.
Poor sleep quality was associated with an increased risk of developing delirium, with a HR of 2.37 (95% CI 1.50 – 3.74), for every one point worsening in the sleep quality score on a four point scale.
Slatore et. al Am J Geriatr Psychiatry . 2012 April ; 20(4): 317–326
Presenter
Presentation Notes
Patients enrolled in hospice experience many neuropsychiatric symptoms, including problems with sleep. Sleep disturbance is common among patients with advanced cancer ]. Delirium occurs in up to 90% of cancer patients at the end of life Secondary analysis of prospectively collected data from a longitudinal study of neuropsychiatric syndromes among hospice patients which utilized validated instruments to measure sleep quality and delirium. The goals of this report were to characterize sleep quality and disturbances in hospice patients, describe characteristics of patients who reported good versus poor sleep quality, describe the trajectory and prevalence of sleep disturbance as patients neared death and particularly, evaluate the association of sleep quality with delirium Subjects were seen on average 6 days after referral to hospice, for three weekly visits and then every other week until either death, withdrawal from the study, or discharge from hospice because of improved medical or functional status. interviewers attempted to complete multiple measures with the participant and his/her primary caregiver at each visit Sleep quality was assessed with the widely used and validated Pittsburgh Sleep Quality Index (PSQI) (21). The primary measure for this study was sleep quality over the previous month, measured on a four-point integer scale (1–4) from “very good” to “very bad” (indicating worse sleep quality as the score increases). This specific question has been shown to be highly correlated with the global PSQI scores (r=0.79–0.80) (22). The complete PSQI has items regarding typical sleep latency and sleep duration as well as items regarding the frequency of specific symptoms interfering with sleep and how often medications were taken for sleep in the prior month (the list of items are included in Figure 1). The study was designed to record the sleep quality item of the PSQI at every visit and the complete PSQI at every other visit (usually monthly). The interviewers preferentially completed the PSQI with the individual subject and would request the caregiver’s rating on the sleep quality item only if the subject could not complete the instrument. If neither could adequately complete the sleep quality item, it was recorded as missing. If a participant was delirious or had an MMSE score below 18, the complete PSQI was not performed on that particular visit only; if the delirium had resolved or the MMSE was ≥ 18 on a subsequent visit, the complete PSQI was then completed. To measure delirium, interviewers completed the observer-rated Confusion Assessment Method (CAM) (23) at every visit Other Measures—We obtained baseline information on all subjects, regardless of delirium, through interview and electronic medical record review, including the participant’s age, sex, educational attainment, race/ethnicity, marital status, medical reason for hospice referral, past mental illness, and physician-diagnosed dementia. Designation of the subject’s primary caregiver was made at the first study visit (spouse/partner, family, friend, staff, guardian, other). Mental state was evaluated using the MMSE at each visit. Prorated MMSE scores were calculated when the participant was physically unable to complete one or more items. Functional status, based on the interviewer’s observations and participant/caregiver report, was recorded at baseline using the 5-point scaled Eastern Cooperative Oncology Group (ECOG) performance status (fully active to completely disabled) (24). At each visit, subjects were asked to rate suffering (where “I am suffering greatly” equals 0 and “I am not suffering” equals 100), and quality of life (QOL) (where “My quality of life is terrible” equals 0 and “My quality of life is as good as it can be” equals 100). Additional measures were completed at baseline in participants whose CAM was negative and MMSE > 18. A Structured Clinical Interview for DSM-IV (SCID) was conducted at the first visit to document a history of depression and alcohol abuse/dependence. The severity of depression and anxiety was also assessed with the 14-item Hospital Anxiety and Depression Scale (HADS) (25). In order to characterize sleep quality, it was characterized as the mean overall sleep quality rating for the entire study (patients without delirium) or until the first delirium episode. Sleep quality was not assessed in 30 subjects because the patient was delirious, had impaired cognition, and/or was too ill to complete the question.
The Confusion Assessment Method (CAM) Diagnostic Algorithm
Feature 1: Acute Onset and Fluctuating Course Feature 2: Inattention Feature 3: Disorganized thinking Feature 4: Altered Level of consciousness The diagnosis of delirium by CAM requires the
presence of features 1 and 2 and either 3 or 4.
Presenter
Presentation Notes
Feature 1: Acute Onset and Fluctuating Course �This feature is usually obtained from a family member or nurse and is shown by positive responses to the following questions: Is there evidence of an acute change in mental status from the patient's baseline? Did the (abnormal) behavior fluctuate during the day, that is, tend to come and go, or increase and decrease in severity? Feature 2: Inattention �This feature is shown by a positive response to the following question: Did the patient have difficulty focusing attention, for example, being easily distractible, or having difficulty keeping track of what was being said? Feature 3: Disorganized thinking �This feature is shown by a positive response to the following question: Was the patient's thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject? Feature 4: Altered Level of consciousness �This feature is shown by any answer other than "alert" to the following question:: Overall, how would you rate this patient's level of consciousness? (alert [normal]), vigilant [hyperalert], lethargic [drowsy, easily aroused], stupor [difficult to arouse], or coma [unarousable]) The diagnosis of delirium by CAM requires the presence of features 1 and 2 and either 3 or 4.
“Sleep Quality and its Association with Delirium among Veterans enrolled in Hospice”
Histograms of average sleep quality for patients with no delirium and average pre-delirium sleep quality for patients with delirium during hospice care.
Slatore et. al Am J Geriatr Psychiatry . 2012 April ; 20(4): 317–326
Presenter
Presentation Notes
Of the 105 subjects, 54 experienced at least one episode of delirium during the study period and 71 had a sleep quality rating prior to a delirium measure. Average pre-delirium sleep quality was 2.4 (SD 0.7) for those who experienced delirium and 2.1 (SD 0.7) for those without delirium (Wilcoxon rank sum test z 1.97, p=0.049). Figure 2 displays the average pre-delirium sleep quality during the study for patients with and without delirium onset during the study. Pre-delirium sleep quality is the mean overall sleep quality rating for the entire study (patients without delirium) or until the first delirium episode. Poor sleep quality prior to delirium onset was associated with delirium onset, as shown in Table 3. The hazard ratio for developing delirium was 2.37 (95% CI 1.50–3.74) for each one point worsening of sleep quality in the previous 28 days. In sensitivity analyses, this association between worse sleep quality and delirium was similar for sleep quality assessed in the previous 14 days and from the first visit to delirium onset (data not shown). Similarly, this association was similar when individually adjusted for caregiver status (professional caregiver vs. other), history of mental illness (yes vs. no), and hospice diagnosis (cancer vs. other), respectively. We did not collect information on the dose or duration of medications that impact sleep. However, the mode and worst score regarding self-reported sleep medication use were similar, indicating that most patients likely remained on stable doses of these medications throughout the study. Thus, we cannot determine if worsening sleep quality is counterbalanced by increases in these medications though it seems unlikely this possibility is the sole explanation for our finding. Alternatively this finding may reflect that subjects who were becoming delirious could no longer validly complete the sleep scale. In general, subjects with a spouse/partner caregiver had better sleep quality and those without depression tended to have better sleep quality (p=0.042 and 0.062 for caregiver and depression, respectively). Patients with worse baseline QOL scores, but not suffering scores, also reported worse average sleep quality (p=0.049 and 0.730 for QOL and suffering scores, respectively). Patients with dementia more often had missing sleep quality data (50% of patients with dementia were missing sleep quality ratings compared to 9% in patients without dementia Finding that poor sleep quality precedes delirium onset has potentially important clinical ramifications. For example, noting changes in sleep quality may prompt earlier recognition and treatment of other causes of delirium, such as evaluating the patient for other causes of delirium such as dehydration, infection, pain, respiratory insufficiency, or adverse reactions to medications (11, 12), and more attention and intervention for improving sleep quality
Delirium and hospital sleep disruption Hospital Elder Life Program (HELP) tested by Yale Delirium
Prevention trial1 assessed six risk factors (dehydration, sleep deprivation, immobility, visual impairment, cognitive impairment, hearing impairment) at hospital admission.
When a risk factor was present, it was treated with a targeted intervention.
Nonpharmacologic sleep protocol included sips of warm milk, back and shoulder rubs and relaxing music when going to sleep.
Protocol not only reduced sedative and hypnotic drugs, but also reduced incidence of delirium.2
1. McDowell JA et al. A nonpharmacologic sleep protocol for hospitalized older patients. J Am Geriatr Soc. 1998;46:700–705. 2. Inouye SK et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med. 1999;340:669–676.
Presenter
Presentation Notes
Studies conducted mainly in cardiac surgical patients indicate that sleep deprivation can either cause delirium,22 be a result of it,23 or may simply lower the clinical threshold for delirium. Decreased SWS and decreased stage REM sleep have been hypothesized as contributing factors for the development of delirium. While a recent study of ICU patients demonstrated an association between delirium and severe REM sleep reduction (<6% of total sleep time), a cause and effect relationship was not established.15 22. Sveinsson IS. Postoperative psychosis after heart surgery. J Thorac Cardiovasc Surg. 1975;70:717–726. [PubMed] 23. Harrell RG, Othmer E. Postcardiotomy confusion and sleep loss. J Clin Psychiatry. 1987;48:445–446. [PubMed] 15. Trompeo AC, Vidi Y, Locane MD, Braghiroli A, Mascia L, Bosma K, Ranieri VM. Sleep disturbances in the critically ill patients: role of delirium and sedative agents. Minerva Anestesiol. 2011;77:604–612. [PubMed]
Delirium and hospital sleep disruption
Guidelines for prevention of delirium in hospitalized patients by National Institute for Health and Clinical Excellence (NICE).
Recommend efforts to improve sleep quality (i.e. avoiding unnecessary nursing or staff procedures during night-time and reducing environmental noise as much as possible) as mainstay measure to attempt to reduce delirium incidence.
O’Mahony et al. Synopsis of the National Institute for Health and Clinical Excellence Guideline for Prevention of Delirium. Ann Intern Med. 2011;154:746–751
Presenter
Presentation Notes
The association between sleep disturbance and delirium has been studied for many years. At present it is difficult to define the true relationship between them. Perhaps, though, it is possible to view their relationship as part of a shared pathophysiologic pathway.
Improving the hospital sleep environment
Reducing Hospital Sleep Disturbance Establish nocturnal environment Enhance staff awareness of conversation noise Employ night settings in monitoring equipment with backlighting to
reduce light exposure. Judicious use of pharmacological agents that may worsen sleep Monitor, assess, and treat pain Individualized sleep hygiene routines Relaxation techniques in preparation for sleep Decrease environmental stimuli (eye masks, ear plugs) Reduce nocturnal clinical interactions Ventilator support to promote rest overnight Reduce daytime napping in order to reduce circadian desynchrony
Delaney et al. Annals of Intensive Care (2015) 5:3
Clinical interactions and impact on sleep
Walker and Woods reported ICU patients sleep disturbed 1-14 times/hour by staff
50% of ICU patients described being woke up 2-5 times per night (Lee) Tamburri and Celik 40-60 patient staff interactions/night Sleep disruption even worse in ventilated patients 14% of ICU clinical interactions could be safely omitted Le et al. Timing meds or assessments together Future technology may let us collect same data with less sleep disruption Scheduling for patients instead of health care providers
Modified Early Warning Scale
Presenter
Presentation Notes
The routine practice of collecting vital signs every 4 hours in hospitalized ward patients has been perpetuated since as early as 1893, but little evidence supports this tradition.1 Although vital signs can be indicative of impending clinical deterioration, routine nighttime vital sign monitoring adds to the already fragmented sleep of inpatients. Overnight vital sign checks not only are an especially bothersome disrupter but also can deplete crucial health care resources. Track and trigger systems, such as the Modified Early Warning Score (MEWS), have been used to identify high-risk patients for critical interventions.4
From: A Prospective Study of Nighttime Vital Sign Monitoring Frequency and Risk of Clinical Deterioration JAMA Intern Med. 2013;173(16):1554-1555. doi:10.1001/jamainternmed.2013.7791
Adverse Event Rate and Evening Modified Early Warning Score. The bars represent the adverse event rate (per 1000 patient-days). The line represents nighttime vital sign monitoring (per patient median).
Figure Legend:
Presenter
Presentation Notes
The present study investigated whether the MEWS could identify low-risk patients who might forgo overnight vital sign monitoring. In total, 54 096 patients were included in the study, accounting for 182 828 patient-days on the wards and 1699 adverse events. The patient sample was 43.0% male and had a median age of 56 years (interquartile range, 40-68 years). The median evening MEWS was 2 (interquartile range, 1-2). The adverse event rate increased with higher evening MEWS, from a rate of 5.0 per 1000 patient-days (when the MEWS was ≤1) to 157.3 per 1000 patient-days (when the MEWS was ≥7) (P = .003 for trend) (Figure). However, the frequency of vital sign disruptions was unchanged, with a median of 2 vital sign checks per patient per night and at least 1 disruption from vital sign collection 99.3% of the nights regardless of MEWS category. Almost half of all nighttime vital sign disruptions (45.0%) occurred in patients with a MEWS of 1 or less. To our knowledge, this is the first study to critically examine the practice of vital sign collection on medical wards. Our study found that overnight vital signs are collected frequently among ward patients regardless of their risk of clinical deterioration. The evening MEWS identified a low-risk subset of patients who had significantly fewer adverse events but had overnight vital signs taken at a similar rate as high-risk patients. This suggests that the nighttime frequency of vital sign monitoring for low-risk medical inpatients might be reduced. Such a reduction could have dramatic benefits to patient sleep, considering that vital sign checks have been shown to be the environmental factor most disruptive to patient sleep.5 In addition to being linked to negative health outcomes and patient distress during inpatient care, sleep deprivation may be an important factor in the posthospitalization syndrome that has recently been implicated as a cause for 30-day readmissions.6 Given that half of all nighttime vital sign checks are for low-risk patients, this reduction could also have significant health care resource implications. With fewer vital sign collections required for most patients, overnight nurse staffing could be moderated. This would represent a significant cost savings, considering that nursing wages account for one-quarter to one-third of a hospital’s operating budget.7 A tailored approach would also enable a reallocation of resources away from the sleep-deprived, low-risk patients to more careful monitoring of high-risk patients. Evidence suggests that this reallocation could improve patient safety. For example, investigations have shown that adverse events on the medical wards are often closely preceded by vital sign changes, indicating that some of them may be predicted and prevented with individualized increases in monitoring
Post-hospitalization Syndrome
Hospital Readmission
Loss of Strength
Nutritional Deficit
Sleep Deprivation
Adverse drug effects
Dharmarajan. JAMA. 2013;309:355-63.
Generalized vulnerability to
illness
Presenter
Presentation Notes
The broad range of acute conditions responsible for readmission may reflect a posthospitalization syndrome—a generalized vulnerability to illness among recently discharged patients, many of whom have developed new impairments both during and after hospitalization. Inpatients frequently experience loss of strength and mobility and develop new disabilities and difficulties in performing activities of daily living. Hospitalized patients may have nutritional deficits due to reduced appetite and imposed caloric restriction. Sleep deprivation may occur. Delirium often continues even after hospitalization. Adverse effects of commonly used pharmacotherapies started in the hospital and continued at discharge may exacerbate all of these conditions.33-35 This heightened vulnerability to a diversity of illnesses may explain why interventions that are broadly applicable to many conditions with multiple components or are delivered by a multidisciplinary team may be more likely to reduce readmissions.
6. Install a noise detector 7. Play lullaby at 10pm 8. Overhead hallway lights on a
timer, set to turn off at 10pm 9. Nighttime nursing routine: vitals,
bedtime meds, toilet, change IV bag, close patient’s door
10. When possible avoid IV line in antecubital fossa (alarms if occluded). When possible do not run IV at night.
Bartick. Hospital Med 2010;5:E20–E24.
Establishment of the 8 hour Quiet Time
Presenter
Presentation Notes
Hospital routines frequently interrupt nighttime sleep. Sedatives promote sleep, but increase the risk of delirium and falls. Few interventional trials have studied sleep promotion in medical-surgical units and little is known about its impact on sedative use. A 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 so as not to wake patients. OBJECTIVE: To determine causes of sleep disruption, and assess whether decreasing sleep disruptions lowers sedative use in medical-surgical patients. Interventional trial with historical controls on a medical-surgical unit of a community teaching hospital. (Somerville Hospital, Somerville MA) Nurses, physicians, and patients were blinded to the measurement of as-needed sedative use.
What Keeps Patients Awake?
0
10
20
30
40
50
Nothing Discomfort ofIllness
Noise Hospital Staff AttachedEquipment
Worries
Perc
ent R
espo
nse
Pre-Intervention Intervention
Bartick. Hospital Med 2010;5:E20–E24.
39%
Presenter
Presentation Notes
INTERVENTION: Somerville Protocol MEASUREMENTS: As-needed sedative use, responses to a 8 item patient questionnaire, door closing, adherence to protocol, meds on flexible schedule RESULTS: Preintervention, ‘‘hospital staff ‘‘ was the disturbance most likely to keep patients awake. The intervention decreased the proportion of patients reporting it from 42% to 26%, a 38% reduction (P = 0.009; 95% confidence interval [CI]: 0.0452- 0.2765). Specifically, within the category of “hospital staff” (not shown here) Preintervention, 19.2% of patients selected ‘‘voices’’ as the noise most likely to ‘‘bother’’ them at night, and this dropped to 9.9% with the intervention, a 48% decrease (P =0.045; 95% CI: 0.0074-0.1787). No other significant differences were found.
Decreased Use of As-Needed Sedative by Limiting Sleep Disruption
32
38
16 15
05
101520253035404550
All Ages Ages >65 yr
% P
atie
nt R
equi
ring
As-
Nee
ded
Se
dat
ives
Pre-Intervention
InterventionP=0.0054 P=0.0041
49% 61%
Bartick. Hospital Med 2010;5:E20–E24.
Presenter
Presentation Notes
Preintervention, 32% of patients received as-needed sedatives, compared to 16% with the intervention, a 49% reduction (P = 0.0041; 95% CI: 0.056-0.26), with a 62% decrease in patients over age 64 years (P = 0.005). VSH scores were unchanged. CONCLUSIONS: Hospital staff was the factor most responsible for patient sleep disruption, and behavioral interventions on hospital staff can reduce use of as-needed sedatives. Small modifications in hospital routines, especially in the timing of vital signs and routine medication administration, also can significantly reduce sedative use in unselected hospital patients. The authors found a 49 percent drop in the number of patients who were given sedatives. That 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
Noise and impact on hospital sleep
WHO: Noise level should not exceed 30 dB hospital wards ICUs worldwide > 50 dB and often > 70 dB (traffic noise) ICU Noise increasing over last decades (.42 dB/night/year) Noise varies throughout night (Lombard effect) Subjectively and objectively: Main source of sleep disruption ICU Polysomnographic data regarding noise show some impact but not
main impact in ICUs Some studies suggest 6-20% subjective reduction in noise after
behavior modification Studies using noise meters less improvement or results in short term
Delaney et al. Annals of Intensive Care (2015) 5:3
Familiar sounds (dB) Quiet room Soft whisper at 2 m Refrigerator humming Microwave oven Normal conversation at 1 m Daytime acute care hospital floor Alarm clock Hair dryer, blender, lawn mower MP3 player at full volume
∼30 ∼35 ∼45 ∼55 ∼60 ∼60 ∼80 ∼90 ∼100
National Institute on Deafness and Other Communication Disorders, American Academy of Audiology, US Department of Labour (Occupational Safety & Health Administration).
Presenter
Presentation Notes
Decibel system is logarithmic. A 10 fold increase in decibels represents 10 times greater intensity of sound. 30 dB is 100 times louder than 10 dB
This sound acoustic panel is 36×96 inches and thickness measured 3/8 inch with overall depth of 11 inches. Custom panel is matte colour-studded hollow surfaces with an ordered array of half and full-sized cones, which jut from wall surface.
Peter M Farrehi, Brahmajee K Nallamothu, and Mojtaba Navvab BMJ Qual Saf doi:10.1136/bmjqs-2015-004205
Reducing hospital noise with sound acoustic panels and diffusion: a controlled study.
Presenter
Presentation Notes
While eliminating noise would be ideal this may not always be possible. Some industries use sound acoustic panels that diffuse noise rather than attempt to eliminate it. Pilot study here to determine whether strategically placed, sound acoustic panels applied in hospitals would acutely reduce noise in hallways adjacent to patient rooms. If true, this option could serve as an architectural design solution to enhance patient care and experience during hospitalization. The inpatient telemetry unit is organized as two central parallel hallways with architecturally identical patient rooms on both sides. We evaluated noise levels for 3 days after installing sound acoustic panels. Placement of sound acoustic panels was done on vertical walls and ceiling not to interfere with patient flow, hospital codes or building standards to maximize scattered sound. Four custom panels (two large and one small in the hallway and one small in the ceiling) were used for the intervention hallway. Sonic acoustic panels were not placed in patient rooms. Sound pressure levels were recorded in both control and intervention hallways at specified distance (30 feet) from the center station. Digital recordings of 1 s interval (Goldline, Model TEF25, West Redding, Connecticut, USA) were done for 72 h during routine hospital work schedules. Observational, controlled study assessing sound levels on an active inpatient telemetry unit. Due to physical nature of sound acoustic panels, staff not blinded. Dr. Navvab College of Architecture and Urban Planning
A-weighted Leq measured (1 s time intervals) in hospitals hallways with (blue triangle) and without (red circle) the use of sonic panels.
Peter M Farrehi et al. BMJ Qual Saf doi:10.1136/bmjqs-2015-004205
Presenter
Presentation Notes
A-weighted Leq measured (1 s time intervals) in hospitals hallways with (blue triangle) and without (red circle) the use of sonic panels. A delta of 3–4 dB (A) is observed at all hours of the day due to utilisation of the panels. Sound levels from patient rooms on this same unit fell by 5 dBA during nighttime hours when compared with daytime hours. Over the study period, the mean sound level was 60.89±4.36 dBA in the control hallway and 57.55±4.00 dBA in the intervention hallway for a difference of 3.34 dBA (p<0.0001; figure 2). Impact of the sound acoustic panels was primarily on decay or diffusion of mid-frequency and high-frequency sound levels within the space studied. Our novel approach through diffusion reduced background or ambient noise by 3–4 dBA, which is admittedly modest. However, this reduction at a baseline level of 60 dBA (ie, the typical noise level of a normal conversation) is perceptible to the human ear and consistent with a fall in noise generated by a car decreasing from 80 to 60 miles per hour
Light: Impact on hospital sleep
Low levels of artificial light less than 500 Lux for as long as 20 min identified as sufficient to suppress nocturnal melatonin secretion
Light levels within ICUs being highly variable, ranging between a mean of 5 and 1,400 Lux
Subjective studies have reported that ICU survivors perceived light exposure to be minimally disruptive to their ability to sleep
Delaney et al. Annals of Intensive Care (2015) 5:3
Melatonin and ICU Sleep Mundigler (2002): Melatonin secretion suppressed in septic ICU patients
compared to non-septic patients with normalized circadian patterns
Double blind placebo controlled study (n = 8), patients receiving supplemental melatonin demonstrated an improvement in sleep duration and sleep quality (Shilo 2000)
Egi (2006) 32 tracheostomized ICU patients inconclusive regarding benefit of melatonin in promoting sleep. Although melatonin levels increased in the treatment group, no improvement in nocturnal total sleep time.
Bourne (2008) Studied effect of supplemental nocturnal 10 mg melatonin in 27 ICU patients who had undergone trachesotomy insertion to promote ventilator weaning. Sleep in treatment group increased by 1 h along with objective sleep quality improvement by bispectral index (BIS).
Delaney et al. Annals of Intensive Care (2015) 5:3
Assessing patient sleep in the hospital
Presenter
Presentation Notes
We likely currently hear about this if someone is really sleepy or having significant troubles sleeping. Routinely this is not assessed objectively or subjectively Patient’s sleep quality may impact their perception of noise around their room and Medicare reimbursement and overall affect their satisfaction More importantly, by improving sleep quality we may be able to improve hospital outcomes in addition to patient satisfaction
In lab PSG and home sleep testing In lab polysomnogram Home sleep apnea test
Presenter
Presentation Notes
In lab polysomnogram Positive (Sleep architecture, respiratory, cardiovascular, limb EMG parameters) Negative (Cost, more cumbersome) Home sleep apnea test Positive (Less cumbersome, cost). (Identifies primarily sleep apnea and not sleep)
Actigraphy
Presenter
Presentation Notes
Generally use an accelerometer worn on the wrist to detect wrist movements as a surrogate for wakefulness. Positive (cost effective, easy to wear, objective, circadian rhythm disturbances, long trends) Negative (No sleep architecture, less accurate for patient’s with limited mobility)
0-9 Normal 10-14 Mild sleepiness 15-17 Moderate sleepiness >18 Severe sleepiness
Sleep Diary
Future Directions
Improvement of accurate and early detection of hospital sleep impairment
Continued efforts to implement a hospital environment that fosters sleep
Future study to identify links between hospital sleep impairment and health outcomes
Future aims to identify improvement in not only patient satisfaction but also clinical outcomes though improved hospital sleep
Conclusion
Public, insurance providers, and health care systems are beginning to focus on improving sleep in the hospital
Poor sleep quality has been associated with adverse physiological consequences and is common in hospitalized patients and may lead to slowed recovery times from illnesses and predispose to medical comorbidities
Sleep disturbances and delirium frequently coexist and while a cause and effect relationship has not been established, it is likely that both can cause and/or worsen the other.
Steps can be taken to attempt to foster a hospital environment (such as the Quiet Campaign) that best facilitates sleep in addition to identifying medical factors related to patient’s illnesses that could be improved to aid their sleep
