How to Make Overnight Hospital Stays Less of a 'Wake-Up Call'

Ricki Lewis, PhD

July 25, 2018

Hospitalized patients reported 83 fewer minutes of sleep at night compared with their sleep at home; earlier final awakening in the morning accounted for a mean 44 minutes of that loss, a study has found.

It is hardly a secret that spending a night in a hospital can be far from relaxing, with lights, sounds, smells, and procedures frequently interrupting slumber. However, no large-scale studies have catalogued the exact causes of sleep disruption.

Hilde M. Wesselius, MD, from VU University Medical Center, Amsterdam, the Netherlands, and colleagues in the Acute Medicine Research Consortium captured the details of one night's sleep on February 22, 2017, with a nationwide, multicenter, cross-sectional, observational study.

The researchers used a "flash mob" (the sudden, planned gathering of many people at a designated location that has been planned in advance) approach to capture evaluations of sleep quality in a hospital for a 1-day period, with findings reported in an article published online July 16 in JAMA Internal Medicine.

Of 39 participating hospitals, 2005 patients who responded to a questionnaire were at least 18 years of age, with a median age of 68 years. Of them, 1427 fully completed the questionnaire. Each had spent at least the previous night in a non-intensive-care hospital ward.

Participants compared the quality of sleep during the previous night in the hospital with a night at home during the month before hospitalization, answering six questions drawn from the Consensus Sleep Diary, the Dutch-Flemish Patient-Reported Outcomes Measurement Information System (PROMIS) Sleep Disturbance item bank, and other queries about whether the factors that disturbed their sleep were personal, disease-related, hospital-related, or environmental.

Specifically, the questions addressed the time of closing the eyes to fall asleep and the time of final awakening, time to fall asleep, number of awakenings, total duration of wakefulness after initially falling sleep, sleep quality using descriptive language ("satisfying and refreshing," "restless," "difficulty falling asleep," and "feeling lousy when waking up"), and sleep quality on a scale of very poor to very good. The researchers used the responses to calculate total sleep time and sleep efficiency (the percentage of time spent asleep, from lights out to final awakening).

Sleep in the hospital was on average 83 minutes (95% confidence interval [CI], 75 - 92 minutes; P < .001) shorter than at home. The mean number of nocturnal awakenings was 3.3 (95% CI, 3.2 - 3.5) during hospitalization compared with 2.0 (95% CI, 1.9 - 2.1) at home. The shorter duration of sleep in the hospital was largely a result of awakening 44 minutes (95% CI, 44 - 45 minutes; P < .001) earlier than at home.

For all six measures of sleep disturbance, the hospital setting fared worse than the home setting. Patients on surgical wards reported more sleep disturbance than others in the hospital, but surgical patients rated the quality of slumber at home the same as nonsurgical patients. Younger patients reported more disturbance in the hospital than did older patients.

Unimportant factors were sex, length of stay, and number of patients sharing a room.

Almost two thirds (64.6%) of 1276 patients reported at least one hospital-related factor that disturbed sleep. The most common disruptive factor was sounds from other patients, which interfered with falling asleep for 473 patients (23.6%).

At least one nighttime awakening plagued 1696 (84.6%) patients, with 65.8% of their reasons hospital-related, including sounds from other patients (453; 22.6%) and being awakened by hospital staff (403; 20.1%). For 434 patients (21.6%), having to urinate disturbed sleep, which the investigators partly attributed to use of extra diuretics and intravenous fluids during the night.

Only 566 patients (28.2%) awakened spontaneously in the morning. Of the remainder, 73.7% reported hospital-related reasons for awakening. For 718 patients (35.8%), a hospital staffer woke them.

"We found that hospitalized patients slept shorter times with more interruptions, woke up earlier, and experienced poorer sleep quality than at home," the researchers conclude, with two thirds of the cases blaming hospital-related factors.

Practical strategies to promote sleep hygiene include:

  • minimizing light and sounds, including providing patients with eye masks and earplugs;

  • Reducing care-related disruptions, such as minimizing early-morning nursing activities and recording vital signs less frequently or remotely; and

  • altering the timing of administering diuretics to minimize the need to urinate during the night.

"Wake-up Call"

The findings serve as a "wake-up call," Matthew E. Growdon, MD, MPH, from the Department of Medicine, Brigham and Women's Hospital, and the Department of Population Medicine, Harvard Medical School, and Sharon K. Inouye, MD, MPH, from the Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, and the Aging Brain Center, Institute for Aging Research, Hebrew Senior Life, all in Boston, Massachusetts write in an invited commentary. They question the trade-off between necessary hospital-level care and the negative effects on sleep quality, pointing out that measures to improve sleep are being taken in the intensive care unit setting and might work in general units as well.

To that end, Inouye has developed the Hospital Elder Life Program (HELP) protocol to improve sleep in the hospital outside of the intensive care unit. This "nonpharmacologic sleep protocol" includes relaxing music, massage, warm beverages, and noise-reduction strategies on wards. Evaluation of the protocol indicates reduced incidence of delirium and falls, lower hospital and 1-year healthcare costs, lowered use of hypnotics, fewer readmissions, and shorter hospital stays. HELP is available for free at any hospital.

"Only with widespread shifts in current practice and consistent implementation of such interventions can we reconfigure the US hospital as a more humanistic, healing, patient-centered environment where the essential human need for sleep is prioritized," Growdon and Inouye write.

A limitation of the study was the subjectivity of the reporting from patients, particularly the perceived difference between recalled sleep at home and sleep quality in the hospital.

The researchers and the commentators have disclosed no relevant financial relationships.

JAMA Intern Med. Published online July 16, 2018. Abstract, Extract

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