Sick and tired: How can hospitals help patients get the sleep they need?
While pregnant, Cindy MacDougall suffered from hyperemesis, a severe form of nausea. She vomited so much that she couldn’t keep food or water down, and at one point, had to be hospitalized.
“Sleep was really necessary because it was one of the few times I didn’t feel nauseous,” she says.
But the alarm of a malfunctioning IV drip machine kept her awake.
“There I am to rest and rehydrate and we’re having to restart the IV pump every 20 minutes,” she says.
The result was a sleepless night.
Poor sleep can have a host of harmful effects on a patient’s recovery. A 2013 review found multiple studies highlighting poor memory recall, slower wound healing, less vitality and strength, along with more vulnerability to feeling pain. A 2009 study also found reduced sleep could leave people more susceptible to catching colds.
“Lack of sleep can cause physiological stress,” says Nadia Gosselin, a scientist at the Center for Advanced Research in Sleep Medicine at the Hôpital du Sacré-Coeur de Montréal Research Center. “It can increase cortisol, cause inflammation in the body, reduce the immune system. There are a lot of consequences.”
So what can hospitals do to help patients get the sleep they need?
Lights, Code Calls & Squeaky Wheels
Good sleep is defined by two factors: depth and duration.
Last year, the National Sleep Foundation updated its sleep recommendations, saying adults need between seven and nine hours of sleep to be able to go from the lightest stage of sleep, when a person is most easily wakened, to a second stage in which brainwaves slow, and then into the final stage, considered the deepest and most restful, when muscles relax and breathing becomes slow and rhythmic.
Hospital staff administering medication or transferring patients for tests or procedures often bear the blame for disturbing sleeping patients, but a 2016 Canadian review of research around sleep in the intensive care unit (ICU) shows there’s a lot keeping patients awake.
The review found some patients complain of bright lights, others of the noise made by alarms, announcements, squeaky laundry carts, food delivery, roommates, visitors and conversation around the nursing station.
“At night it’s quieter, but patients then have the opportunity to think about what’s happening,” says Debra Bournes, the Chief Nursing Executive and Vice-President of Clinical Programs at The Ottawa Hospital. (She’s also an editor at Healthy Debate.) “They stay awake not only because of noise but also because of what’s happening with them. It can be a daunting, scary thing.”
Patients in geriatric units are also prone to sleeplessness, often fueled by confusion at being in hospital, as are newborns in the neo-natal unit, who are hyper-sensitive to sound and yet reliant on sleep to help brain development.
Gosselin’s team studies sleep patterns in orthopaedic patients with traumatic brain injuries. Using equipment to monitor their brain waves, they found many of these patients got less than five hours sleep over a 24-hour period.
“There’s no problem to sleep only five hours per night for a couple nights, but when you have an injury or when you’re sick, then sleeping only five hours per night for many consecutive nights is a problem,” Gosselin says.
Taking sleeplessness home from the hospital
Patrick Hanly, a professor of medicine at the University of Calgary and the medical director of the sleep clinic at the Foothills Medical Centre, spent years studying sleep disruptions in the ICU and says, simply: “The reality of hospitals is, it’s a horrible place to sleep.”
In a small study involving both critically ill patients and healthy subjects, Hanly found that alarms and staff disruptions were most frequently to blame for waking both groups. Even in private rooms, staff activities and the opening and closing of the ward’s main doors kept patients awake.
“You see the same thing on the ward, just less extreme than the ICU,” Hanly says, noting that patients tend to compensate by dozing during the day. This can disrupt sleep patterns at night, leading to a kind of sleeplessness that can sometimes follow a patient home, ingraining a pattern of insomnia that can be difficult to break.
It can make sleeping pills seem alluring – but that creates additional problems. Choosing Wisely Canada recommends against sedatives in geriatric patients because they can produce a “hangover effect” of mental fog and excessive drowsiness, which has been shown to lead to debilitating falls and hip fractures.
“Sedatives can put patients into the stages of sleep, but not necessarily restful sleep,” says Christine Soong, an assistant professor at the University of Toronto and a hospitalist at Mount Sinai. “And some of these drugs have a lot of downsides and side effects.” Choosing Wisely Canada says twice as many people are harmed by sedatives than helped.
“We had to educate patients and families to make them aware that sleeping pills are not what they seem to be, and there’s more harm than benefit in many studies,” she says.
Potential sleep solutions abound, but evidence scarce
A 2013 systemic review of non-drug interventions to promote better sleep found “insufficient to low strength” evidence that relaxation techniques such as aromatherapy or massage made any difference to the quality of a patient’s sleep.
Even with a range of interventions – decreased noise and light, cooler room temperatures, clustering nursing activities, fewer unnecessary interruptions and practicing relaxation techniques – sleep quality improved only by seven percent.
The most promising intervention seemed to be soft white noise – ocean sounds played throughout the night that help mask intermittent noise – which produced a 38 percent improvement in sleep scores in surgical patients compared to a control group.
“It’s hard to study this kind of thing in isolation,” Soong says. “Often you need many different types of approaches, and there’s a lot of variability within the research population, from the severity of illness to different diagnoses requiring different treatments or interventions.”
Still, hospitals should be motivated to put solutions to sleeplessness on their priority lists, Bourne says.
“There’s enough research out there that shows that people in the hospital need their sleep. When they’re able to get a better night’s sleep, first their satisfaction goes up, they spend less time in hospital, they heal faster, and experience less anxiety. Overall it’s better for patient care.”
Some hospitals track patient-reported experiences of sleeplessness using surveys and phone calls conducted after a patient has returned home. Since May 2014, the Canadian Institute for Health Information has also offered hospitals a patient experience survey that asks a single question about night time noise, but the data are not publicly reported.
The Ottawa Hospital has installed a “sound ear” to help minimize noise. The machine features the silhouette of an ear, which turns green, yellow or red depending on noise levels.
“It’s a visual warning cue to staff and patients and family in the area that, hey, it’s getting a bit noisy in here,” Bournes says.
When The Ottawa Hospital first began using the sound ear, noise levels were equivalent to that of city traffic, roughly 25 percent higher than the World Health Organization recommends, Bournes says.
Now they aim for a nighttime average of 45 decibels – about the same level as what’s found in the home – or a maximum of 60 decibels, which is the range of a normal conversation. The ear started off in the neonatal unit – where noise and interrupted sleep can be harmful to the continued development of the patients – and moves around different units in the hospital.
“The reality is that we have patients who are confused, people who snore, emergencies happen at night and they can all increase noise,” Bournes says. “But all else being equal, there are things we can do to minimize that noise and help patients get a better sleep.”
That includes a staff awareness campaign to lower the ring volume on phones, dim the lights, use a flashlight instead of overhead lights, wear soft-soled shoes, use break rooms for night-time conversation, fix squeaky doors and carts, and avoid use of the public address system.
For patients and their families, there are earplugs and eye masks and headphones to wear when watching TV. While visiting hours are now 24 hours, Bournes said they haven’t really seen an increase in noise complaints.
Of course, medical care will still trump sleep.
“When good care requires a patient to be woken up, they need to be woken up,” Bournes said. “We try to minimize that, but there is a reason why they’re in the hospital, right?”
The hierarchy of hospital logistics also means patients who have managed to get to sleep may be woken for tests and blood work that needs to be available in time for rounds, which can determine the course of further treatment or whether they’re well enough to continue their recovery at home.
MacDougall says she learned to be more vocal, asking nursing staff to time their visits to the sounds of activity in her room.
“It’s easy to forget as a patient – the system is there for you. It exists to get you better. If you look at yourself as a partner in your own healthcare rather than somebody who’s worked upon, if you’re an active team member, it can really change the way you interact with staff and really help solve these problems.”