Introduction
Ringing phones, blinding lights turning on and off constantly, and loud conversations going on in the background or even right in front of you, this does not sound like the ideal environment for a patient to get a peaceful night’s sleep. Unfortunately for a patient that has been admitted to the hospital, this is most likely what they will experience. Being aware of sleep health in the hospital setting can go a long way in a patient’s recovery time and overall stay. In 1974, the United States Environmental Protection Agency encouraged hospitals to have a standard sound level of 45 decibels (dB).
In reality, studies show that Critical Care Units on average have sound levels around 56 dB, with a maximum of 84 dB (Topf, Bookman, & Arand, 1996, p. 158). These increased sound levels introduce a variety of issues for patients in the hospital. The increased sound level, along with many other wide range contributing factors maybe the cause to the lack of sleep for hospitalized patients. This research paper is a meta-analysis compiled to see the importance of sleep health and the affects it has on patients staying in the hospital. There are many different contributors to sleep deprivation and many different ways to improve sleep deprivation for our patients.
Implementation of using clustering care and single patient rooms to decrease the length of hospital stays, hospital acquired delirium, increased hospital costs, reducing noise along with the amount of times the patient is woken up, and the risk of developing a nosocomial disease or infections. The importance of this meta-analysis research paper is to see if there is enough evidence to support these findings to implement a clustering care policy and provide single patient rooms to decrease sleep deprivation.
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Background
Sleep deprivation is a threat to patient’s safety and can be a result in the development of mental and physiological processes that delays healing time which can result in an increase of setbacks often leading to a longer length of stay in the hospital. The length of stay can be increased due to delirium that is brought on by lack of sleep. Collaborating with staff to set times to care for and decrease efforts of loud noises and light during sleeping hours can improve recovery time and patient care. We have all been contributors to these sleep deprivation factors on our patients.
We need to acknowledge that it is a huge deal to decrease these factors contributing to sleep deprivation on our patients and develop a policy or guidelines in order to achieve this, as well as, the importance of having single patient rooms available. This research paper will help show evidence of why sleep deprivation is a big deal and why clustering care or having single patient rooms can help change how we care for our patients when it comes to how much sleep they get in the hospital and the affects of sleep deprivation has on patients.
Literature Review
In a study done at the University of Alberta, 15% of enrolled patients developed hospital-acquired delirium (Alagiakrishnan, 2009, p e44). One of the biggest factors involved was sleep deprivation. Hospital-acquired delirium was associated with longer hospital stays by 13 days (Alagiakrishnan, 2009, p e45). This puts the patient at risk for falls and other hospital-acquired infections. With the longer length of stay, healthcare costs are significantly higher for patients who develop delirium (Ubel, n.d., p 2). Sleep deprivation is induced by hospital staff, ambient noise, nuisance alarms, and noisy patients (Ubel, 2013). By far the most common reason for the loss of sleep in the hospital is staff performing patient care.
Around the clock care is given in the form of obtaining vital signs, lab draws in the middle of the night, alarms going off all the time, timed medication administration, and various other acts of patient care. These acts of care can all contribute to sleep deprivation. Elderly patients are at the highest risk for developing hospital-acquired delirium (Alagiakrishnan, n.d., p. 45). “Delirium in the elderly increases mortality, the length of hospital stay, and increased incidents of institutionalization” (Alagiakrishnan, n.d., p. 45-46).
Sleep deprivation can seriously harm a patient physiologically. Many physiological processes that keep the body healthy, in a state of healing and homeostatic are dependent on adequate REM sleep, “therefore, sleep deprivation has bio-cognitive consequences” (Pilkington, 2013, p. 41). Immune function declines with sleep deprivation, leaving the patient at further risk of developing a nosocomial infection. Increased inflammation due to sleep deprivation can trigger the release of inflammatory markers and increase the immune response and thereby create a stress response (Pilkington, 2013, p. 40). Insulin resistance has been linked to sleep deprivation “with detrimental effects on carbohydrate metabolism” (Pilkington, 2013). Sleep deprivation can be prevented by collaborating with hospital staff and clustering of care.
“Clustering activities can provide extended blocks of uninterrupted time and improve patients’ chances for sleep. The physiological need for sleep must be carefully balanced against the need for frequent assessment of vital signs and other care activities” (Tamburri DiBrienza, Zozula, & Redeker, 2004, p. 103). Health care workers can improve patient’s satisfaction and sleep by grouping their tasks and coordinating their care with other health care workers minimizing interruptions unless there is a clinical need to disrupt the patient’s sleep (Ubel, 2013).
Preventing sleep deprivation delirium might reduce the cause of falls, wandering, unsafe behavior, pressure ulcers, functional decline and death (Alagiakrishnan, 2009). “Nurses should endeavor to ensure that patients in their care receive adequate pain management and reassurance to reduce anxiety and stress. They should also aim to reduce environmental factors such as noise and light, thereby helping to minimize the negative effects of sleep deprivation” (Pilkington, 2013, p. 41). Single rooms can positively impact patients’ hospital experience through increased privacy, better interaction between family and staff, and reduced noise and anxiety (Chaudhury, Valentea, & Mahmood, 2006).
Critical care units have a need to reduce unnecessary noise by replacing equipment alarms and the ring of telephones, offer more spacious rooms, and apply carpet in busy walking areas to absorb more sound and to provide a quieter place to recover by working with hospital administration and the architecture team directly to minimize environmental stressors. Nurses should reduce bedside conversations, talking in the hallways, and should offer earplugs or headphones to help reduce noise in the critical care units (Topf, Bookman & Arand, 1996, p. 550).
“The most frequent types of nurse-patient interactions were direct monitoring (of vital signs, urine output, and weight) indirect monitoring (checking intravenous catheters, oxygen therapy), and measures to promote oxygenation (coughing or suctioning)” (Tamburri DiBrienza, Zozula, & Redeker, 2004, p. 105). Sleep deprivation contributes to increased length of stay, greatly increasing the cost of care. Patients with sleep deprivation do not heal as fast which can lead to increased medical costs for the patient and the hospital. With so many sleep interruptions patients can be more prone to falls, delirium, reduced immune function, mood swings which can further increase the patient’s hospital stay (Ubel, 2013).
In the article, Nocturnal Care Interactions With Patients In Critical Care Units they mentioned, “Routine daily baths were performed on 62% of the study nights between 9 pm and 6 am, 61% occurred between 2 am and 5 am” (Tamburri DiBrienza, Zozula, & Redeker, 2004, p.108). It is not normal for the majority of people to be given baths at these times, and it should not happen in the hospital unless there is a clinical need. Taking out the baths from the night time/early morning routines should be routine for all hospital protocols and should decrease some hospital sleep deprivation.
As a patient in the intensive care unit that does not understand all the medical equipment or the whole situation and environment, it can be super stressful. Just imagine all the alarms going off, people talking, and the equipment attached to you that you can’t make any sense of. All the hospital accommodations cannot even come close to a stress free environment. The best ways to get more sleep in a hospital can be up to the patient, they can call a friend or family member to bring some of their personal items to help make their stay more comfortable, or even stay the night with them. We all know sleep is very important, even when we are not sick.
When we are sick or stressed, we require more sleep as our body works harder to help heal an injury or illness and may be required to stay in a hospital bed, where the patient can be monitored. With that being said, getting a peaceful night’s sleep in the hospital is almost impossible with all the alarms going off, people talking or yelling, and the constant checks that need to happen throughout the night. As a patient, you are in the hospital for a reason and it is not a luxury hotel, but the hospital staff needs to focus on the well being of the patient. So if you or a family member is ever staying in the hospital remember that staying with the patient you can help make the hospital stay more pleasurable so you or your family member can heal faster and avoid the delirium from sleep deprivation.
Here are some tips to help get more quality sleep during your stay in the hospital. Make it dark in your room, have some white noise playing in the background, and get out to see some light during the day, relaxing as much as possible, and make sure to talk to the staff. While many hospitals are making changes to the nighttime policies, it is still a good practice to tell your nurses and doctors that you really want to make sleep a priority. Ask them to disturb you as few times as possible during the night. Most will do what they can to help you get your sleep between medically necessary checks (Stibich, 2018).
Objectives
Care clustering can be a significant task for the hospital to organize. The clustering of care can involve collaborating with the staff on for the night and making sure that when something is needed to be done to the patient where they will be woken up, that all staff that needs to see this patient should all go in at once to utilize the time the patient is awake. Although this task can be difficult, it provides the patient with the best possible environment for healing and should be encouraged despite the extra organizational effort involved. Allowing uninterrupted periods of sleep by clustering care is recommended to improve patient’s sleep (Tamburri DiBrienza, Zozula, & Redeker, 2004, p. 103).
Sleep protocols can be implemented, but is it really going to be beneficial if throughout the hospital a different type of monitoring is necessary. There are different types of patients in one area of the hospital, such as the critical care unit, that would need more detailed monitoring. On the other hand, there are some patients that need less monitoring in the same area. A few protocols would not cover the varying differences among patients in the same area of the hospital (Tamburri DiBrienza, Zozula, & Redeker, 2004, p. 106). “Hourly monitoring of vital signs, have been developed to ensure detection of life-threatening problems in a timely manner” (Tamburri DiBrienza, Zozula, & Redeker, 2004, p. 110).
Although all of these variables may contribute to the poor sleep of these patients, their importance lies in the fact that they are potentially modifiable. As such, interventions to limit these sleep disruptors may serve as the basis for future sleep-promoting protocols in the ICU (Pisani, et al., 2015). Sleep deprivation is not only caused from interruptions in sleep while being hospitalized. Sleep deprivation can result in physical and psychological harm to the hospitalized patient. Many factors are to blame for sleep deprivation. Healthcare workers can work towards better patient outcomes by clustering care and making efforts to keep noise and lights low.
With care coordination and efforts to decrease patient sleep deprivation, the length of stay and healthcare costs decrease, while patient satisfaction overall health improves. Implementation of ICU sleep protocols will require culture change, which will need to be individualized to accommodate the work flows of each institution and critical care setting. This will require education of ICU physicians, nurses, and other ancillary staff along with the measurement of performance and compliance with the protocol (Pisani, et al., 2015). In a study performed between March 1997 and February 1999 at the University of Pennsylvania Medical Center and the Presbyterian Medical Center, all medical ICU patients studied demonstrated sleep–wake cycle abnormalities (Freedman et al., 2001).
To be effective, sleep promotion interventions in the ICU should address multiple aspects of care, such as the ICU organization, staff training, and work environment. At the micro level, staff should be trained to optimize the timing of bedside interventions, as these may disrupt sleep patterns at night. Nighttime staff–patient interactions may cause disrupted sleep and may therefore worsen sleep quality. Background noise due to staff conversation, nighttime illumination, and especially alarms and sounds also contribute to a reduction in sleep. At the meso level, protocols should be implemented to allow for periods of reduced noise and illumination (quiet time).
At the macro level, ICUs should be designed physically to promote proper sleep. For example, single-patient rooms with noise reduction ceilings separated from noisy staff work areas may reduce ambient noise in patient rooms (Giusti, Piergentili, Ceccangoli, Addey, & Ramacciati, 2016). Single rooms have a moderate effect on patient satisfaction with care, noise and quality of sleep, and the experience of privacy and dignity. Conflicting results have been found on hospital infection rates. Some studies did not show significant differences, while others concluded that single rooms decrease the risk of hospital infections. Evidence on recovery rates and patient safety was lacking (van de Glind, de Roode and Goossensen, 2007).
Conclusion
While conducting this research it has led to believe that implementing the use of clustering care and single patient rooms to decrease the length of hospital stays, hospital acquired delirium, increased hospital costs, reducing noise along with the amount of times the patient is woken up, and the risk of developing a nosocomial disease or infections shows positive outcomes. Studies have shown that with implementation of such policies or protocols have contributed to having better outcomes for patients in trying to avoid loss of sleep.
These policies and protocols should be adopted by hospitals to prevent increases in hospital stays resulting in increase hospital costs, hospital acquired delirium, unnecessary waking of patients, and nosocomial infections. Although much more studies need to be done in the research of clustering care and single patient rooms to prevent sleep deprivation and common factors that deprive from that, it is still showing great promise from the research that has already been established and will continue to strive towards resolving issues when it comes to sleep deprivation within the hospital.
References
- Alagiakrishnan, K., Marrie, T., Rolfson, D., Coke, W., Camicioli, R., Duggan, D., Wiens, C. (2009). Gaps in patient care practices to prevent hospital-acquired delirium. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2762300/ (Alagiakrishnan, 2009)
- Chaudhury, H., Valentea, M., & Mahmood, A. (2006, July 28). Nurses’ perception of single-occupancy versus multioccupancy rooms in acute care environments: An exploratory comparative assessment. https://doi.org/10.1016/j.apnr.2005.06.002 https://www.sciencedirect.com/science/article/pii/S0897189706000462 (Chaudhury, Valentea, & Mahmood, 2006)
- Freedman, N., Gazendam, J., Levan, L., Pack, A. and Schwab, R. (2001). Abnormal Sleep/Wake Cycles and the Effect of Environmental Noise on Sleep Disruption in the Intensive Care Unit. [online] Atsjournals.org. https://doi.org/10.1164/ajrccm.163.2.9912128 https://www.atsjournals.org/doi/full/10.1164/ajrccm.163.2.9912128. (Freedman et al., 2001)
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