Simple Changes Boost Sleep Quality in Hospital

Liam Davenport

February 25, 2019

HOUSTON — Simple changes could improve how well patients sleep in the hospital, which in turn could have beneficial effects on how quickly they recover. These are the implications from a small study carried out on one specific group of patients — children who have undergone hematopoietic stem cells transplants (HSCT) for blood cancers — who often have a prolonged hospital stay after the procedure.

The study was presented here at the Transplantation and Cellular Therapy (TCT) 2019 Meetings.

Conducted at the Cincinnati Children's Hospital Medical Center, study authors found that these patients and their caregivers had disturbed sleep during their hospital stay. The biggest culprits for nighttime noise on the transplant unit were pump and monitor alarms, and clinical assessments.

However, trash pulls from the rooms, staff talking in the corridor, and noisy doors all featured highly as disturbances, and the team successfully implemented an intervention to improve them, reducing both median nighttime noise and dramatically reducing spikes in noise levels.

Priscila Badia Alonso, MD, Cincinnati Children's Hospital Medical Center in Ohio, presented the study and said that the researchers' findings show that "we can modify some of the factors contributing to nocturnal awakening."

 "The most important change, and I think it's one of the drivers of all of this, was the trash pulls," she added.

"Sometimes we even had some families putting a sign on the door saying 'please, no trash pulls after midnight' or 'no trash pulls overnight.' "

 "Talking to families, they have been very happy, and even the nurses feel like now there's more of a routine to everything," Alonso added.

Session co-chair Christine Duncan, MD, Dana-Farber Cancer Institute, Boston, Massachusetts, told Medscape Medical News that "what's so impressive about that study is that it was a quality improvement project that used scientific method and design to address a very practical, very real problem."

"I'm excited to see what's next; if it actually helps people to improve sleep, I think it's an excellent start," said Duncan, who was not involved with the current study.

Her co-chair, Linda Burns, MD, National Marrow Donor Program/Be The Match, Minneapolis, Minnesota, added that "to make any type of quality improvement effort succeed in a hospital, we need to engage multidisciplinary care teams, but most important [is] to engage the patients and the caregivers".

"They are our best resources in saying ‘This is what's keeping us awake at night.' We might not even be aware of that," she said.

They [patients] are our best resources in saying, 'This is what's keeping us awake at night.' We might not even be aware of that. Dr Linda Burns

Burns added: "Christine and I are both advocates of patient and caregiver engagement to drag patient-centered research forward, and this is a really delightful study."

Study Details

Alonso began the presentation by highlighting that sleep is essential for human well-being, with effects on psychological, mental, immunologic, metabolic, and endocrine functioning.

However, juvenile patients with HSCT and their caregivers often experience sleep disruption during prolonged hospital stays that can persist for months after discharge.

This can be due to repeated interruptions from room entries, medications, monitor alarms, cleaning services, and clinical staff.

Noting the lack of data evaluating sleep improvement interventions during hospitalization, the researchers initially looked at sleep quantity and quality in eight patients and 26 caregivers.

Actigraphy showed that patients in particular had poor sleep efficiency, defined as the percentage of time asleep vs time spent trying to sleep.

Against a threshold for normal sleep of 90%, the patients were found to have a sleep efficiency of just 77% in the first 28 days following stem cell transplant, while the caregivers had a sleep efficiency of 88%.

Using the Pittsburgh Sleep Quality Index, the researchers found that patients, despite wide variability, had a sleep quality in the first 6 months post-transplant that centered around the published mean scores for healthy controls.

However, caregivers had very poor quality sleep, exceeding the threshold score of 5 on the index in the week before the transplant, in the first 100 days afterward, and again at 6 months post-transplant.

A cross-sectional focus group revealed that 82% of patients found staff assessments/vital signs and pump alarms to be the greatest source of sleep disturbance, while 76% identified monitor alarms, and 71% cited the room door opening and closing.

In addition, 53% mentioned the noise from trash pulls and talking in the hallway at night as sources of sleep disturbance; 36% pointed to the staff using the nurse server storage cabinets; and 12% said sounds in the hallway.

Alonso said that the World Health Organization recommends that hospitals should not exceed 35 decibels (dB) overnight, with 40 dB recommended for the general population.

To illustrate what this means, she said that people whispering registers at 30 dB, whereas standard office noise is 40 dB and a vacuum cleaner emits 70 dB.

Changes in Nighttime Noise

To try to decrease nighttime noise on their transplant unit from an average of 47.8 dB to 38.0 dB over a 6-month period, the researchers initially built up a team involving the unit charge nurses, nighttime nurses, the nighttime hospitalist, unit coordinators, patients, and caregivers.

They identified that the sources of nighttime noise arose primarily from trash pulls, people entering and leaving rooms, noisy doors, and nurses gathering to talk.

To tackle these, the team modified the trash pull and cleaning schedules so that there were no pulls after 9 PM, adapted the doors to reduce the noise they make, and trained nurses to be 'BMT Night Ninjas' — functioning efficiently but quietly — to raise awareness among staff.

The measures led to an 8% reduction in median nighttime noise levels, from 47.8 dB to 43.9 dB.

There was also a marked decrease in the variability in nighttime noise, with a 44% reduction in the number of spikes above 60 dB, from a median of 271 to 151 spikes.

In the future, Alonso and colleagues would like to work on sustaining the changes they achieved, generalize their noise-reduction practices to other units in their institution, and look further into nursing care to identify other sources of noise.

Acknowledging that they missed the target of getting nighttime noise levels down to 38.0 dB, Alonso said that it was, in hindsight, not achievable.

"I even went to the unit at midnight, when it was super quiet, with a decibel meter," she said, "and I think it's the background noise and the filtration system of the unit, and that won't let get us down [to the target].

Alonso, Duncan, and Burns have disclosed no relevant financial relationships.

Transplantation and Cellular Therapy (TCT) 2019 Meetings: Abstract 86. Presented February 24, 2019.

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