Getting a good night’s sleep may be just what the doctor ordered. But getting it in a hospital setting can be challenging. Patients are routinely bombarded by hallway noises, lights, overhead paging systems and electronic alarms. Add to that middle-of-the-night blood draws, blood pressure checks and medication administration, and a patient may suffer the result of sleep deprivation on top of a primary medical diagnosis.
Recent studies give heft to the notion that improved patient outcomes can be a by-product of better in-hospital sleep. Moreover, they point to the fact that the implementation of some common-sense practices around sleep issues can make a big difference in the quality of patient care.
Intentional Noise Exposure
Researchers from Cambridge Health Alliance, Brigham and Women’s Hospital and Massachusetts General Hospital recruited 12 healthy volunteers to participate in a three-day study which took place in a sleep lab. On the first night participants slept without disruptions; on the successive two nights they were exposed to 14 pre-recorded sounds common in hospitals. These included an intravenous alarm, ice machine, voices in the hall, a telephone, outside traffic and a helicopter.
The research protocol provided for the presentation of sounds at increasing decibel levels during specific sleep stages. While it was anticipated that louder sounds would create more sleep disruption, the researchers also discovered important differences in sleep disruption based solely on the type of sound; electronic sounds proved to be most problematic, even at a volume just above a whisper.
“We think this study [published by Annals of Internal Medicine in June 2012] was a landmark effort,” said Jo M. Solet, PhD, of Cambridge Alliance Health, senior study author. “There has been a lot of previous documentation of subjective complaints about noise from patients, but no one had brought the real hospital noise environment into a lab and exposed sleeping individuals to the sounds. It adds some perspective to recognize that such research requires approval from research ethics review boards before subjecting the participants to the very same noises that patients experience all the time in hospitals.”
Dr. Solet pointed out that while the participants were young and healthy, similar sleep disruption could be far worse for people suffering with additional stresses brought on by illness. The tested sleepers were subjected to 10-second exposures to the various sounds. “But in a real hospital, patients would likely have longer exposures, and to more than one stimulus simultaneously,” said Solet. “And because many patients are older than our study participants, their sleep architecture is different; the amount of time they spend in the lighter sleep stages that are much more vulnerable to disruption is greater. For example, non-REM2 sleep is easily disrupted by noise, deep sleep is more protected. How much time do most patients spend in deep restorative sleep? Not much.”
A Conduit to Change
Solet, who serves on the national committee charged with writing hospital construction guidelines through the Facilities Guidelines Institute, noted that prepublication findings of the research helped inform acoustic performance standards included in the 2010 Guidelines. “Standards continue to evolve,” said Solet, “as new Guidelines will be published in 2014.”
While broad conclusions of the study were anticipated by clinicians via quality of care surveys offered up by sleepy patients, the research offers a conduit to meaningful change. “We now have the required evidence for translation into brick-and-mortar change,” explained Solet. “Actually quantifying the problem means, for example, that we can write code requiring noisy ice machines to be isolated away from patient rooms.”
While new facilities can build according to the latest guidelines, making noise-reducing adjustments in existing facilities can prove more challenging. Solet said enhancing surface materials and reconfiguring hospital units can certainly help. “But honestly — along with design, materials, construction and configuration – other important efforts can be made to improve sleep environment in terms of noise,” she noted. “Consider possible night care routines: Have a lullaby play at 10 p.m. as a cue for visitors to leave. Turn off TVs. Alter when medication is given. Make sure no one gets awakened for a blood sample in the middle of the night unnecessarily. All these things have been routine and we keep doing them because that’s how we’ve always done them. We must rethink all of this from the perspective of patient care.” Prior research undertaken with hospitalist Melissa Bartick, MD, demonstrated the success of altered night-care routines in decreasing sedative use on a medical-surgical unit (2009, Journal of Hospital Medicine).
Common Sense Approach
A very recent initiative, from Johns Hopkins Hospital, Baltimore, proves that Solet is right on target. Clinicians in the ICU implemented a project to see if simple steps to reduce nighttime noise, light and staff interruptions could reduce delirium.
Some relatively simple steps produced some very impressive results. “Without interventions, we were able to improve a patient’s odds of being free of delirium in the ICU by 54%, even after taking into account the diagnosis, need for medical ventilation, age and other factors,” said Brian Kamdar, MD, MBA, MHS, a Johns Hopkins pulmonary and critical care fellow who led the effort. Findings of the project were published in March by Critical Care Medicine.
According to information supplied by Johns Hopkins Medicine, three sets of interventions were employed in progressive stages:
First, a 10-item checklist included turning off televisions, room and hallway lights, consolidating the number of nighttime staff visits to patient rooms for blood draws and medication, reducing overhead pages and minimizing unnecessary equipment alarms.
Second, patients were offered eye masks, ear plugs and tranquil music.
Third, new administration guidelines were introduced to discourage giving patients commonly prescribed drugs for sleep that are known to cause delirium.
“We put together a common-sense approach to change how care is provided to see if by improving sleep we could reduce patients’ confused thinking, and it was effective,” said Dale M. Needham, MD, PhD, associate professor of pulmonary and critical care medicine at Johns Hopkins and senior author of the study article, noting that delirium is often a marker for the health of the brain. He also said, via a Johns Hopkins news release, that physical rehabilitation is important for the recovery of intensive care patients, and if they’re sleepy or delirious during the day, they cannot appropriately participate in therapy. “Up to 80 percent of ICU patients may experience delirium,” said Needham. “The longer they have it, the higher their risk of long-lasting problems with memory and other cognitive functions.”
Solet advised that there is still another problematic layer to remediating noise within hospitals, related to technology. “Approximately 80 percent of alarms that go off have no clinical relevance,” she noted. “Imagine that. Here you have patients being aroused by these sounds that they cannot interpret – so that raises anxiety along with waking them. But the other interesting point is that nurses have so many stimuli that they are required to respond to, that over time they become desensitized. They don’t necessarily know which signals to prioritize because the alarms are not standardized — you just can’t tell which alarm signal is more urgent across the devices.” This desensitizing, which can lead to failed responses, is called “alarm fatigue.”
Solet said it takes a team approach within a hospital to limit noise pollution – clinicians, researchers, designers, and engineers are all recognizing that hospitals have gotten noisier over the decades.
“We have an aging population of baby boomers who will be flooding our hospitals and we have to be prepared to do a better job,” she admonished. “The more sleep patients get, the less pain they will experience, the fewer the sedatives they will take, the lower the readmission rates, the lower the infection rates, the shorter the hospital stays. This all translates into better care and lower costs.”
Valerie Neff Newitt is on staff at ADVANCE. Contact: firstname.lastname@example.org.