Hospital care practically guarantees that we won’t get good sleep

The importance of sleep is perhaps most realized when we become sick. When we are hospitalized and most in need of every ounce of health, though, hospital care practically guarantees that we won’t get good sleep. Fortunately, two approaches hold promise to improve sleep for patients: one organizational, and the other a common trick of the trade among those of us working in behavioral economics.

Recently I was all-too-miserably reminded of the challenges of hospital sleep when I spent a fitful night recovering from surgery to remove a small kidney tumor. Unlike some patients in that situation, my sleep was not disturbed by pain or nausea; I was lucky to avoid both of those postoperative complications. Instead, my sleep was interrupted, hourly, by clinicians taking care of me. There were vital sign checks every four hours, a frequency that makes sense given that I had just had part of my left kidney removed. Sometimes sleep interruptions are necessary in order to monitor patient conditions. But those vital sign checks, at midnight and 4 a.m., were not the only interruptions I experienced that night. At 3 a.m., if my very foggy memory serves me correctly, someone came into my room to draw blood for follow-up laboratory tests. Several other times that evening, the machine hovering near my left ear beeped to tell me that one of my IV medications had run out; I would push the nursing button and tell the person at the desk about the beeping, and eventually someone would come in and either replace the empty IV bag or turn the alarm off.

Between 10 p.m. and 6 a.m., I did not go more than an hour without some kind of interruption.

As I have already suggested, some of these interruptions are necessary. But many are not. And the consequence of too many sleep interruptions is that patients do not heal as quickly as they would otherwise, thereby not only reducing their quality of life but also driving up medical costs. Indeed, as I have written elsewhere: sleep disturbance is a leading cause of hospital complications, such as falls and delirium. Poor sleep has also been linked to reduced immune function,worsening blood pressure control and mood disorders. All of these problems potentially impair the ability of patients to recover from the acute illnesses that caused them to be hospitalized.

How do we improve hospital sleep?

First, hospitals could make simple organizational changes. During my recent hospital stay, for example, a major contributor to my interrupted sleeping was the specialization of tasks across different hospital personnel. When the IV machine beeped, it was the nurse who helped out, her training being necessary to monitor the IV lines and medications. When it came to measuring my vital signs, though, a nurse’s aide was sent to accomplish the task. And a phlebotomist came to draw my blood. Specialization matters. The doling out of these duties to different people — with different skills and different pay grades — makes great economic sense, and in many ways improves hospital quality of care. But such specialization interferes with sleep, because the different people performing each of these duties enter patient rooms at different times of the night.

There is a better way to coordinate these various clinicians to reduce sleep interruptions. For example, phlebotomists could coordinate their work with nursing aides. Imagine that instead of coming into patient rooms one hour apart from each other, the two came in together: “We are here to check your blood pressure and draw some blood,” they would say (maybe even in unison!). That little change would eliminate one interruption. A second change could also improve patient sleep: more flexibility in the timing of vital sign measures. If, for example, a patient’s IV machine beeps at 11 p.m. and the next check of her vital signs is due at midnight, the nurse could bump up the vital sign measures by an hour, since the patient is already awake.

Indeed, it was an 11 p.m. vital signs wake-up call that led to research that proves the value of my second approach to improving patient sleep: increasing the use ofsleep protocols designed to minimize unnecessary interruptions. More on sleep protocols in a bit, but first let me tell you about that 11 p.m. wake-up call.

Melissa Bartick is a hospitalist in the Harvard medical system, a physician who focuses mainly on inpatient rather than outpatient care, treating patients who have been hospitalized with acute or chronic illnesses. Spending as much time in hospitals as she does, Bartick has long recognized the problems created when patients have difficulty sleeping. But it took her own hospitalization to convince her how fixable this problem is.

Bartick had spent an exhausting evening being evaluated for an acute illness in her hospital’s emergency department. She finally made it up to a hospital bed around 10 p.m., where the nurse checked her vital signs and made sure she was receiving appropriate treatments. Finally allowed to rest, Bartick quickly fell asleep only to be awoken at 11 p.m. for … another vital sign check! She was not awoken because her illness was so acute that she needed hourly assessments. Instead, she was awoken because hospital protocol required nurses to check vital signs each shift, and the night shift began at 11 p.m.

“By the time I left the next morning, I had half of my research design worked out,” Bartick told me. When Bartick was healthy again, she conducted the clinical trial she had begun designing that night. In the trial, some patients, at random, were cared for under a sleep protocol, an order that alerts nursing staff to eliminate all unnecessary middle of the night intrusions — eight hours of quiet time for patients, with darkening of the room and avoidance of waking patients for nonurgent matters. The protocol reduced sleep disturbances by 38 percent.

How do we make sleep protocols the norm among stable hospitalized patients? We change hospital practice so that minimization of sleep disturbances becomes the default condition for how to care for non-critically ill patients, with more frequent sleep interruptions only occurring when physicians actively indicate that such interruptions are clinically necessary. Research in behavioral economics has demonstrated that people are strongly influenced by default options when making decisions. Employees are more likely to contribute to retirement funds when such contributions are automatic. People are more likely to donate their loved ones’ organs in countries where such donations are default policy.

Currently, the default setting in most hospitals is to prioritize testing over patient sleep. While patients in intensive care usually do need to have their vital signs monitored closely, and often need multiple blood draws each day to monitor rapidly changing clinical circumstances, many hospitalized patients do not change enough in their clinical course to require routine middle-of-the-night interruptions. Patient sleep would be improved overnight, literally, if hospitals established new default procedures — for instance: “all patients in non-ICU settings will be cared for under sleep protocols after 36 hours in the hospital, unless the physician indicates otherwise.”

There is one problem with making sleep protocols into default procedures — such protocols cut against tradition. “Hospital cultures are very difficult to change,” Bartick told me, “especially when there is so little incentive for hospitals to make those changes.” She explained that the problem is aggravated by low patient expectations: “We are trying to make hospital care more patient-centric, even looking closely at things like patient satisfaction measures. But sleep interruptions do not reduce patient satisfaction, because patients assume that all of those interruptions are medically necessary.” When Bartick and I were each hospitalized, it was not sleep interruptions per se that disturbed us. It was the fact that as physicians, weknew that those morning labs and middle of the night vital signs were not medically urgent.

The irony is that because of increased emphasis on “patient centric care,” hospitals sometimes act more concerned about patient satisfaction than patient health. Perhaps hospitals will change their practices when patients realize that hospitalization and sleep are not always mutually exclusive.

Peter Ubel is a physician and behavioral scientist who blogs at his self-titled site, Peter Ubel and can be reached on Twitter @PeterUbel.  He is the author of Critical Decisions: How You and Your Doctor Can Make the Right Medical Choices Together. This article originally appeared in The Atlantic.

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  • penguin50

    I would gratefully welcome any of these suggested methods for reducing the number of sleep-interrupting interventions caused by the need for direct patient care. But please also consider that a patient’s sleep is equally disrupted by things such as staff loudly discussing their vacations and retirement plans, noisy carts clattering down the hallways all through the night, fierce arguments among staff, frequent failures to completely close privacy curtains and room doors that could block hallway lights after staff dealt with a patient, etc. These are not rare occurrences—they happened every night I was hospitalized.

    There were also often perhaps demented patients who shouted every few minutes from a few rooms down the hall. I really don’t know what can be done about that, but it is part of the problem too. Thank you for considering this issue. I’ve often been puzzled why sleep is treated as an optional luxury for patients. During my weeks in the hospital, I resorted to taking brief catnaps whenever I could throughout the day and night. The odd benefit of this is that I was always awake at 4 am, which proved to be a great time for me to take walks around the uncrowded ward hallways without feeling I was getting in the way of others.

  • Suzi Q 38

    This is why I try to get out of the hospital ASAP.
    MRSA and Cdifficle are other reasons.

  • Chiked

    During my first and God willing last hospitalization I lost all respect for doctors and medicine. I was admitted at 11pm for a hypertensive emergency. Scared enough by the ER doctor, I understood that they needed to check my blood pressure every 15 mins.

    But by 3am, I was getting very crabby, so I asked if the frequency of blood pressure checks could be reduced…..”No” said the nurse. Thinking I just needed to speak to the doctor, I was shocked at what she told me…..”protocol states that we….blah, blah, blah”.

    By now (5am) I was angry and ready to leave against medical advice. Of course my BP is now 200/120, higher than before. But I was so tired I could care less. I had been up for about 24 hours and I was ready to punch anyone if they stopped me.

    By 7am it was shift change and a much nicer (hmmm….maybe she got some sleep) doctor came on and agreed to let me sleep a few hours without interruption. What do you know my blood pressure came down on its own. I still left the hospital with a bag of BP pills which I stopped taking once I started losing weight and exercising.

    My point is that if doctors cannot understand the basic importance of sleep, please stay away from my body.

  • Karin

    Add loud floor cleaning machine at 4 a.m. to the list of offenders. I couldn’t wait to get home to get some real rest.

  • Michelle Maertz

    I had a vaginal hysterectomy in 2009. I only had to stay over one night, but between the “helpful” compression machines on my legs that woke me up every 10 minutes and the vitals check every hour, I couldn’t wait to get the hell out of there. They insisted that I eat solid food before I could be released. I flushed it. Satisfied, they discharged me. I only wanted my bed, my bathroom, my shower and a minimal amount of pain meds. 3 days later I was off the pain meds and 4 days later I was watching football and shooting pool at a bar. Ever since, whenever a doctor has told me what’s good for me, I respond with, “I’ve lived in this body for 44 years. You’ve known me for 3 minutes. Either listen to me or you’re fired.”

  • meyati

    My grandson has the bedroom next to me-loud music, moving furniture, kicking the wall-they learned that one from me, screaming on the phone at their girlfriends at one am. The grandsons rotate through my life and home. Then I sleep with 2 snoring coonhounds, that jump up bawling and baying when a cat crosses the front yard, or a grandson sneaks somebody in. Nothing like hearing- “Run Stephanie, run.” while the hounds are opening the door to get to Stephanie. Yes they turn door handles and and open sliding patio doors.
    I was aware of every IV pack being changed in May. I was aware of when and how many antibiotic packs were attached to the IV, as whoever did it, said- hi, I need to change— I was aware of the staff that stepped in to check me, the surgeon examining my arm in the wee hours- and popping pus pockets out of my arm. Somebody came in and tried to turn the TV off. I immediately spoke up.
    Somehow-it was so peaceful and quiet.

  • leslie fay

    AMEN! AMEN! I have harped on this for decades. I was a respiratory therapist for almost 40 years, and a patient briefly once, and I always said that the two things patients need as much as the meds are a period of uninterrupted sleep and decent nutrition-neither of which are available in a hospital

  • penguin50

    I have one more observation on this topic. I spent a week each in the ICU of two different hospitals. One maintained an atmosphere of reverential silence. I felt as though I were being cared for in a church! The only “extraneous” noise I can recall was a harpist who played outside of patient rooms now and then. The other one felt like being at a party in a noisy bowling alley—the staff had a great sense of camaraderie and loved to talk and joke constantly. They had a policy of dimming the nursing station lights from 2 am to 4 am every night specifically to remind staff to be quiet. Alas, this resulted in quiet only from 2:00 to 2:08 am.

    Now, the church-like one was headed by a doctor who had a very quiet, serious, and dignified demeanor. The party one was headed by a doctor with a wild sense of humor; he was always popping into my room with a joke or a witty observation. Both doctors were terrific—I have no complaints about the actual care. But it made me wonder if the enforcement of peace and quiet might not be somewhat dependent on the temperament of the person in charge of each department. It’s hard to figure these things out from a patient’s point of view. But it was clear that at least one department valued quiet and found ways to implement it. (Other wards in that same hospital were the typically noisy sort.)

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