Individualized sleep promotion in acute care hospitals: Identifying factors that affect patient sleep

An assessment of a sleep aid and sleep promotion practices in hospitalized medical patients

BACKGROUND

Half of patients admitted to medicine units report sleep disruption, which increases the risk of sleep deprivation. Non-pharmacological interventions are the first step to improving sleep. However, utilization of sleep aids continues to be prevalent. Limited data are available on sleep aid prescribing practices across transitions of care.

OBJECTIVES

The aim of this study was to describe the current practices for assessing sleep and prescribing pharmacologic agents to promote sleep in the adult medicine population.

METHODS

This study was designed as a single-center, retrospective, observational cohort study of all patients discharged by the general medicine teams over a 3-month period (September 2019- November 2019). Prior to admission, inpatient and discharge prescriptions for sleep aids were recorded, and documentation of sleep assessments and non-pharmacological interventions were evaluated.

RESULTS

Of 754 patients included, 211 (28%) were prescribed a sleep aid while inpatient. During hospitalization, 124 (16%) patients had at least one documented sleep assessment, and only 22 (3%) were ordered the institutional non-pharmacological sleep promotion order set. The most prescribed sleep aid in inpatients was melatonin (50%), as well as prior to admission (35%) and at discharge (25%). Overall, the relative reduction in sleep aid prescriptions between admission and discharge was 67%.

CONCLUSION

Inpatient sleep aid prescribing is common in medical patients. Despite this, sleep assessments and the standard of care of non-pharmacological interventions are rarely utilized. Future efforts should focus on implementation of strategies to make sleep assessments and non-pharmacological sleep promotion routine and consistent in the inpatient setting.

Actigraphy-based sleep and activity measurements in intensive care unit patients randomized to ramelteon or placebo for delirium prevention

Patients in the ICU often sleep poorly for various reasons, which may predispose to delirium. We previously conducted a clinical trial in which we tested the efficacy of ramelteon, a melatonin-receptor agonist used to treat insomnia, versus placebo, in preventing ICU delirium in patients who underwent elective pulmonary thromboendarterectomy (PTE) surgery. Here we examine sleep, activity, and circadian patterns, measured with actigraphy, to understand changes in these metrics with our intervention and in those with and without delirium. Participants wore wrist actigraphy devices while recovering post-operatively in the ICU. For sleep analysis, we extracted total sleep time and sleep fragmentation metrics over the 22:00 to 06:00 period nightly, and daytime nap duration from the daytime period (0:600 to 22:00) for each participant. For activity analyses, we extracted the following metrics: total daytime activity count (AC), maximum daytime AC, total nighttime AC, and maximum nighttime AC. Next, we performed a nonparametric circadian analysis on ACs over each 24-h day and extracted the following: interdaily stability (IS), intra-daily variability (IV), relative amplitude (RA), and low and high periods of activity (L5 and M10) as well as their start times. These metrics were compared between patients who received ramelteon versus placebo, and between patients who became delirious versus those who did not develop delirium. We additionally made comparisons between groups for daytime and nighttime light levels. No differences in sleep, activity, circadian metrics or light levels were found between drug groups. Delirious patients, when compared to those who were never delirious, had a lower IS (0.35 ± 0.16 vs. 0.47 ± 0.23; P = 0.006). Otherewise, no differences in IV, L5, M10, or RA were found between groups. L5 and M10 activity values increased significantly over the post-extubation for the whole cohort. No differences were found for daytime or nighttime light levels between groups. Overall, ramelteon did not impact sleep or circadian metrics in this cohort. Consistent with clinical experience, delirious patients had less inter-daily stability in their rest-activity rhythms. These data suggest that actigraphy might have value for individual assessment of sleep in the ICU, and for determining and detecting the impact of interventions directed at improving sleep and circadian activity rhythms in the ICU.Trial registration: REGISTERED at CLINICALTRIALS.GOV: NCT02691013. Registered on February 24, 2016 by principal investigator, Dr. Robert L. Owens.

Evaluation of Preoperative Sleep Quality and Factors Affecting Pain Intensity of Patients Hospitalized in Surgical Services

PURPOSE

The aim of this study was to determine the preoperative sleep quality and pain intensity of patients hospitalized in the surgical services of a university hospital, and to evaluate the relationship between sleep quality and pain intensity and the factors affecting it.

DESIGN

The study was a descriptive cross-sectional study.

METHODS

The study was conducted on 139 patients over the age of 18 who were hospitalized in the surgical services of Eskişehir Osmangazi University Health Practice and Research Hospital between March 1, 2019 and July 31, 2019, and agreed to participate in the study. The "Visual Analog Scale for Pain (VASP)" was used to evaluate the pain intensity of the patients, and the "Visual Analog Sleep Scale (VASS)" to determine the quality of sleep.

FINDINGS

The sleep quality of women, those who had sleep problems before hospitalization and those who had sleep problems in the preoperative period was worse (P <.001). Patients who had a companion and had sleep problems in the preoperative period had higher pain levels (P <.001 for each). As the pain levels of the patients increased, their sleep quality deteriorated (P <.001). Multiple linear regression analysis revealed that for each unit increase in the variable of having sleep problems in the preoperative period increases the VASS score by 180.422 points and the VASP score by 1.788. Being a woman increased the VASS score by 91.469 points, and the presence of a companion increased the VASP score by 1.644 points.

CONCLUSIONS

The preopertive sleep quality and pain intensity of surgery patients were interrelated. Having sleep problems in the preoperative period affected both the sleep quality and pain intensity of the patients. While female gender affected the sleep quality of the patients hospitalized in surgical services, the presence of a companion was found to affect the severity of pain.

Effects of nursing interventions to improve inpatients' sleep in intensive and non-intensive care units: Findings from an umbrella review

AIM

This review aimed to synthesise the available reviews on the effects of nursing interventions on sleep quality among patients hospitalised in intensive care and non-intensive care units.

BACKGROUND

Poor sleep quality is a common fact in hospitalised patients. Nurses can contribute to the improvement of patients' sleep quality and duration.

DESIGN

A review of intervention reviews was carried out and reported following the PRISMA guidelines and checklist.

METHODS

We systematically searched for reviews published from January 2009 to December 2019 in PubMed, CINAHL Plus, Scopus, Institute for Scientific Information Web of Science, Joanna Briggs Database of Systematic Reviews and Cochrane Central Register of Controlled Trials databases. Searches were repeated at 24 November 2020 to include the most recent evidence. A narrative synthesis of the results was conducted.

RESULTS

Nine reviews (representing 109 original papers) met the selection criteria and were included for critical appraisal. Overall, nursing interventions and sleep quality were poorly defined. We grouped the interventions into 3 categories (environmental, barrier and internal interventions) to provide a more comprehensive overview and examine effects of nursing interventions on inpatients sleep quality. Inconsistent results were obtained and low quality of the original articles was reported, making it difficult to establish absolute conclusions.

CONCLUSION

The impact of environmental changes on patients' sleep was positive but inconclusive, while use of earplugs and eye masks, music and acupuncture generally showed positive results with moderate quality of evidence, and no harmful effects were reported.

Sleep improvement intervention and its effect on patients' sleep on the ward

AIM AND OBJECTIVE

The aim of the study was to investigate how the sleep improvement interventions developed for the wards were associated with patients' sleep. The objective was to promote patients' sleep.

BACKGROUND

The quality of sleep is vital for patients' health and recovery from illness. However, patients generally sleep poorly during hospitalisation. Sleep-disturbing factors are connected to the hospital environment, patients' physical illness, emotional state and the activities of the staff. Many sleep-disturbing factors can be influenced by appropriate nursing interventions.

DESIGN

A two-group intervention study including the development of nursing interventions aimed at supporting patients' sleep. One group received a sleep promotion intervention and the other received standard care. Both groups evaluated their sleep in the morning.

METHODS

A survey of participants' sleep evaluations was collected with the five-item Richards-Campbell Sleep Questionnaire. The data were analysed statistically. The STROBE checklist was used to report the study.

RESULTS

From the participants' perspective, sleep was better in the intervention group, even though statistically significantly only among men. The pain intensity correlated with sleep quality. The number of patients in the room or whether participants had had an operation had no effect on their sleep evaluations.

CONCLUSIONS

Interventions targeted at supporting and promoting the sleep quality of hospital inpatients may be effective. They should be developed in collaboration with patients and nurses. Several nursing interventions can be proposed to promote better sleep among patients; however, more research is needed to confirm the results. Sleep promotion should include both standardised protocols and individualised sleep support.

RELEVANCE TO CLINICAL PRACTICE

Investing in nursing interventions to promote patients' sleep is important. Patients' individual sleep-related needs should be part of their care plan. Training programmes that support nurses' knowledge and skills of patients' sleep promotion should be part of nursing education in healthcare organisations.

Individualized sleep promotion in acute care hospitals: managing specific factors that affect patient sleep

BACKGROUND

Improving sleep for hospitalized patients is an essential clinical need. Compared to the traditional "one-size-fits-all" interventions designed by clinicians for all patients, an individualized strategy engaging patients to identify salient sleep disruptors and seek their input how to address these disruptors are more likely to succeed. Followed by our work of developing the Factors Affecting Inpatient Sleep (FAIS) scale, in this report we developed a set of icons illustrating 14 common sleep disruptors on the FAIS scale, and proposed behavioral sleep promotion tips addressing each sleep disruptor. The set of icons and sleep promotion tips were built into the mobile health (mHealth) tool SLEEPKit, which was the start of our endeavor using mHealth technology to support individualized sleep promotion.

METHODS

A participatory iterative approach including feedbacks from patients, family members, and clinicians was used to develop and refine the icons and sleep promotion tips. Focus groups were used to inform the initial development and to brainstorm for the refinement of the icons. Individual interviews with patients and clinicians were conducted to validate each version of the icons using a standardized Content Validity Index (CVI) on a 4-point Likert scale, and offered comments and suggestions for improvement. Strategies of sleep promotion were first identified by the literature review, and then enriched by the summary of data from our previous work. Focus groups were conducted in order to learn empirically if the sleep promotion tips on the current version were acceptable to both patients and clinicians, and how they could be improved.

RESULTS

Six focus groups were conducted and achieved saturation in suggestions for improvement. A total of 5 patients and 3 family members who served on the Patient/ Family Advisory Council, and 42 nurses who served on the interdisciplinary professional practice committees participated in the focus groups. A total of 75 patients and 50 clinicians offered individual feedback and the CVI test for the icons. Successive two or four phases of iterative icon evaluation and refinement were carried out until the average CVI ratings for each icon achieved 3 and above. The sleep promotion tips were created to demonstrate a collaborative effort between patients and clinicians. To empower patients for bedside communication related to their sleep, examples of communication starters ("Try saying") were included in the tips for patients.

CONCLUSIONS

By using the participatory iterative approach, these icons for common sleep disturbing factors were understandable by both patients and clinicians, and the sleep promotion tips were perceived to be feasible and effective in the acute care hospital setting. This work moved the individualized sleep promotion forward, and supported the development of a novel mHealth tool for inpatient sleep promotion tailored to individual patient's needs.

The efficacy of nursing interventions on sleep quality in hospitalized patients: A systematic review of randomized controlled trials

OBJECTIVE

To determine the effect of interventions that could be performed by nurses to improve the sleep quality of hospitalized patients in acute and semi-acute units.

DESIGN

A systematic review of randomized controlled trials and narrative synthesis.

DATA SOURCES

Seven electronic databases (PubMed, CINAHL Plus, Scopus, ISI WoS, CENTRAL, PsycInfo, and Embase) were accessed on 20 May 2019 with a temporal limit of 10 years prior.

REVIEW METHODS

Original research studies of interventions that could be delivered by nurses to improve sleep quality during hospitalization in acute and semi-acute units were included. Study selection, data extraction, and risk of bias assessment were performed by two independent reviewers.

RESULTS

Seventeen studies met the inclusion criteria and were included in this review. The interventions carried out in the trials were classified into four categories of measurement: environmental, physical, behavioural, and combined. Fourteen studies obtained statistically significant improvements; two showed a blend of significant and non-significant improvements; and one reported non-significant results. However, only four trials of the seventeen were judged as having a low risk of bias.

CONCLUSIONS

Overall evidence about interventions that could be performed by nurses to improve perceived sleep quality in hospitalized patients was found to be positive, and no negative effects were reported. However, higher quality research using both subjective and objective measures is needed, in order to strengthen the evidence.

Objectively measured sleep fragmentation is associated with incident delirium in older hospitalized patients: Analysis of data collected from an randomized controlled trial

Delirium may lead to poor outcomes in hospitalized older adults, and sleep deprivation may contribute to its pathogenesis. Thus, we sought to measure sleep duration and fragmentation using wrist-worn actigraphy in older, hospitalized patients with and without delirium, and to determine if actigraphy-based parameters could be used to predict delirium prior to clinical recognition. We conducted a secondary analysis of data from a recent, randomized clinical trial aimed at preventing inpatient delirium. Participants (n = 70) were aged ≥ 65 years admitted to an internal medicine service. Delirium was defined by the Confusion Assessment Method, or altered mental status identified by a clinician. Sleep measurements were actigraphy-based, and included total sleep time, median sleep bout duration and other measures of sleep fragmentation. We found that total sleep duration was similar between patients with (n = 17) and without (n = 53) delirium (mean 384.9 ± SD 162.7 versus mean 456.6 ± SD 135.8 min; p = .081). Mean sleep bout times were shorter in delirious versus never-delirious patients (median 6.1 [interquartile range 4.3-8.9] versus 7.9 [interquartile range 5.7-11.3] min, p = .048). Patients with delirium had more short sleep bouts (< 10 min) and fewer longer sleep bouts (> 30 min) compared with those without delirium. Increased sleep fragmentation was present prior to the clinical recognition of delirium. Overall, delirium was associated with increased sleep fragmentation detected by actigraphy, and sleep fragmentation might be useful as a biomarker for delirium prediction in the future.