Sleep assessment of hospitalised patients: a literature review

Reprint of: 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.

Psychometric properties and structural validity of traditional Chinese version of the Richards-Campbell Sleep Questionnaire in intensive care unit patients without physical restraint

BACKGROUND

Sleep assessment in the intensive care unit (ICU) is difficult and often unreliable. The most commonly used questionnaire for assessing ICU sleep, the Richards-Campbell Sleep Scale (RCSQ), has not been tested for reliability and construct validity in the Mandarin-Taiwanese speaking population.

OBJECTIVE

The objective of this study was to test the construct validity and criterion validity of the traditional Chinese version of RCSQ (TC-RCSQ) in critically ill patients without physical restraint.

METHODS

We adopted a cross-sectional study design. Adults aged 20 years and above were recruited from a plastic surgery ICU of a medical center. The Cronbach's alpha was used to test internal consistency; the validity testing included content validity, criterion validity, and construct validity. Criterion validity was analysed by testing the association of TC-RCSQ with the Chinese version of Verran and Snyder-Halpern Sleep Questionnaire and sleep parameter of actigraphy using the Pearson correlation coefficient; construct validity was analysed using exploratory factor analysis.

RESULTS

A total of 100 patients were included with a mean age of 49.78 years. Internal consistency reliability suggested Cronbach's alpha of 0.93. Moderate to strong correlations of TC-RCSQ with Verran-Snyder-Halpern Sleep Questionnaire were identified (r = 0.36 to 0.80, P < 0.05). We found significant correlations of actigraphic sleep efficiency with difficulty of falling sleep, awakening times, sleep quality, and total score of the TC-RCSQ (r = 0.23, 0.23, 0.20, and 0.23, P < 0.05). One factor (named as overall sleep quality) was extracted by exploratory factor analysis with a total variance explained of 78.40 %, which had good construction validity.

CONCLUSIONS

The TC-RCSQ yields satisfactory reliability and validity in critically ill patients. Actigraphic sleep efficiency may be a single index for objectively sleep assessment of sleep quality in patients without physical restraint. Both the TC-RCSQ and actigraphy can aid nurses to evaluate the sleep quality in critically ill patients without physical restraint.

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.

Medical clowns improve sleep and shorten hospitalization duration in hospitalized children

Intervention by medical clowns was proven to have a positive effect in reducing stress and anxiety, increasing cooperation and improving the child's experience prior to a medical procedure and during the various stages of hospitalization. Sleep has long been known to be essential for recovery from injury and sickness, improving immune functions, and there is an emerging understanding of the restorative role quality sleep has on health and diseases. Hospitalized children are more exposed to sleep disorders and sleep deprivation due to the hospitalized environment, anxiety, and illness. Different behavioral interventions to promote sleep were previously studied in hospitalized children, some showing potential benefits. In this study, we sought to examine the ability of medical clowns to positively impact the child's sleep during hospitalization. The study is an observational matching (case-control) interventional study which took place at the department of pediatrics in Carmel Medical Center. Forty-two hospitalized children ages 2-17 were included in two equal groups of intervention or control. Children in the control group were recruited based on a method of matching the chief complaint plus the medical diagnosis and age of the children in the intervention group in a 1:1 matching. The children's sleep parameters were objectively evaluated for two consecutive nights using an Actigraph device and subjectively by parent's questionnaire. Additional factors such as hospital length of stay and demographics were also monitored. The study group had an encounter with a medical clown (15-30 min) before bedtime on either the first or the second night, and the control group was not exposed to a medical clown at all. We then compared the data from both groups using unpaired t-tests. Hospitalized children exposed to a medical clown prior to bedtime (n = 21) and children not exposed to a medical clown (n = 21) were comparable in age and clinical characteristics. The study group had a significantly delayed wake-up time compared to the control group (06:59 ± 46 min vs. 07:26 ± 42 min, p < 0.05) (mean difference of 27 min). Night's duration (from bedtime to wake-up) was significantly longer in the study versus the control group (570 ± 76 vs. 500 ± 66.1 min, p < 0.05), a total mean increase of 70 min, and sleep efficiency were significantly increased (92.3 ± 4.6% vs. 87.9 ± 8.7%, p < 0.05). Within the clown group, when comparing nights with and without exposure to a medical clown, total sleep time was prolonged by a mean of 54 min on the night of the intervention (518 ± 74 min vs. 464 ± 59 min, p < 0.01), and the total wake time during the night were reduced (52 ± 27 min vs. 77 ± 61 min, P < 0.05), mean difference of 25 min), mainly by reduction of wake period after sleep onset (WASO) (42 ± 25 min vs. 66 ± 58 min, p < 0.05), mean difference of 24 min). Regarding general medical outcomes, hospital stay was significantly shorter in the clown group vs. control (104 ± 42 h vs. 128 ± 42 h, p < 0.05), a mean reduction of 23 h-nearly an entire day. An encounter with a medical clown before bedtime in hospitalized children positively affects sleep parameters, which may be of great importance for healing in general. The clown intervention was also shown to shorten the hospital stay. Larger scale studies are warranted to establish these findings.

Standardized Extract of Valeriana officinalis Improves Overall Sleep Quality in Human Subjects with Sleep Complaints: A Randomized, Double-Blind, Placebo-Controlled, Clinical Study

INTRODUCTION

Sleep deficit or poor sleep leads to ill-health, whereas sleep deprivation for longer periods of time increases the risk of developing adverse conditions associated with poor quality of life, and high socioeconomic impact. The treatments for sleep disturbances include melatonin and over-the-counter medicines like diphenhydramine and doxylamine, all of which have negative side effects. Valerian (Valeriana officinalis L.) is a traditional herb and the most preferred alternate sleep solution to manage sleep complaints.

METHODS

Eighty adult subjects with sleep complaints were randomized in 1:1 ratio to receive either V. officinalis extract (VE) or placebo for 8 weeks in a double-blind, placebo-controlled, parallel, clinical study. Primary efficacy endpoints included the Pittsburgh Sleep Quality Index (PSQI) and sleep latency using wrist actigraphy (WA), as well as a number of secondary endpoints, including sleep parameters such as actual sleep time and sleep efficiency using WA, the Epworth Sleepiness Scale (ESS), the Beck Anxiety Inventory (BAI), the Visual Analogue Scale (VAS) for the feeling of waking up refreshed, and a tertiary endpoint of sleep parameters using polysomnography (PSG) in a subset of 20 subjects per group. Safety parameters included physical examination, vital sign measurements, hematology, and clinical chemistry tests. Adverse events and serious adverse events were monitored throughout the study period.

RESULTS

Seventy-two subjects (35 and 37 subjects in the placebo and VE groups, respectively) completed the study and were included in the efficacy assessments. On Days 14, 28, and 56, the PSQI Total Score in the VE group decreased significantly (p < 0.05) compared to the placebo group. Further, the VE group showed significant improvements (p < 0.05) in sleep latency and actual sleep time on Days 3, 14, 28, and 56, and sleep efficiency on Days 14, 28, and 56, as evaluated by WA. There was a decrease (p < 0.05) in anxiety (BAI) on Days 14, 28, and 56, daytime drowsiness (ESS) on Days 28 and 56, and an increased feeling of waking up refreshed (VAS) on Days 28 and 56 compared to placebo. PSG results carried out in subset of subjects revealed significant improvements (p < 0.05) in total sleep time, sleep latency, and sleep efficiency on Day 56 in the VE group compared to the placebo group. No safety concerns were observed throughout the study.

CONCLUSION

VE supplementation significantly improved various subjective and objective parameters of sleep in young subjects with mild insomnia symptoms, such as overall sleep quality, sleep latency, sleep efficiency, and total sleep time. We also observed decreased anxiety and daytime sleepiness, and improved feeling of being refreshed after waking up with VE supplementation. VE was found to be safe and well tolerated throughout the study.

TRIAL REGISTRATION

Clinical Trials Registry of India: CTRI/2022/05/042818.

Evaluation of the sensory environment in a large tertiary ICU

BACKGROUND

ICU survival is improving. However, many patients leave ICU with ongoing cognitive, physical, and/or psychological impairments and reduced quality of life. Many of the reasons for these ongoing problems are unmodifiable; however, some are linked with the ICU environment. Suboptimal lighting and excessive noise contribute to a loss of circadian rhythms and sleep disruptions, leading to increased mortality and morbidity. Despite long-standing awareness of these problems, meaningful ICU redesign is yet to be realised, and the 'ideal' ICU design is likely to be unique to local context and patient cohorts. To inform the co-design of an improved ICU environment, this study completed a detailed evaluation of the ICU environment, focussing on acoustics, sound, and light.

METHODS

This was an observational study of the lighting and acoustic environment using sensors and formal evaluations. Selected bedspaces, chosen to represent different types of bedspaces in the ICU, were monitored during prolonged study periods. Data were analysed descriptively using Microsoft Excel.

RESULTS

Two of the three monitored bedspaces showed a limited difference in lighting levels across the day, with average daytime light intensity not exceeding 300 Lux. In bedspaces with a window, the spectral power distribution (but not intensity) of the light was similar to natural light when all ceiling lights were off. However, when the ceiling lights were on, the spectral power distribution was similar between bedspaces with and without windows. Average sound levels in the study bedspaces were 63.75, 56.80, and 59.71 dBA, with the single room being noisier than the two open-plan bedspaces. There were multiple occasions of peak sound levels > 80 dBA recorded, with the maximum sound level recorded being > 105 dBA. We recorded one new monitor or ventilator alarm commencing every 69 s in each bedspace, with only 5% of alarms actioned. Acoustic testing showed poor sound absorption and blocking.

CONCLUSIONS

This study corroborates other studies confirming that the lighting and acoustic environments in the study ICU were suboptimal, potentially contributing to adverse patient outcomes. This manuscript discusses potential solutions to identified problems. Future studies are required to evaluate whether an optimised ICU environment positively impacts patient outcomes.

The Role of Wearable Sensors to Monitor Physical Activity and Sleep Patterns in Older Adult Inpatients: A Structured Review

Low levels of physical activity (PA) and sleep disruption are commonly seen in older adult inpatients and are associated with poor health outcomes. Wearable sensors allow for objective continuous monitoring; however, there is no consensus as to how wearable sensors should be implemented. This review aimed to provide an overview of the use of wearable sensors in older adult inpatient populations, including models used, body placement and outcome measures. Five databases were searched; 89 articles met inclusion criteria. We found that studies used heterogenous methods, including a variety of sensor models, placement and outcome measures. Most studies reported the use of only one sensor, with either the wrist or thigh being the preferred location in PA studies and the wrist for sleep outcomes. The reported PA measures can be mostly characterised as the frequency and duration of PA (Volume) with fewer measures relating to intensity (rate of magnitude) and pattern of activity (distribution per day/week). Sleep and circadian rhythm measures were reported less frequently with a limited number of studies providing both physical activity and sleep/circadian rhythm outcomes concurrently. This review provides recommendations for future research in older adult inpatient populations. With protocols of best practice, wearable sensors could facilitate the monitoring of inpatient recovery and provide measures to inform participant stratification and establish common objective endpoints across clinical trials.

Society of Anesthesia and Sleep Medicine Position Paper on Patient Sleep During Hospitalization

This article addresses the issue of patient sleep during hospitalization, which the Society of Anesthesia and Sleep Medicine believes merits wider consideration by health authorities than it has received to date. Adequate sleep is fundamental to health and well-being, and insufficiencies in its duration, quality, or timing have adverse effects that are acutely evident. These include cardiovascular dysfunction, impaired ventilatory function, cognitive impairment, increased pain perception, psychomotor disturbance (including increased fall risk), psychological disturbance (including anxiety and depression), metabolic dysfunction (including increased insulin resistance and catabolic propensity), and immune dysfunction and proinflammatory effects (increasing infection risk and pain generation). All these changes negatively impact health status and are counterproductive to recovery from illness and operation. Hospitalization challenges sleep in a variety of ways. These challenges include environmental factors such as noise, bright light, and overnight awakenings for observations, interventions, and transfers; physiological factors such as pain, dyspnea, bowel or urinary dysfunction, or discomfort from therapeutic devices; psychological factors such as stress and anxiety; care-related factors including medications or medication withdrawal; and preexisting sleep disorders that may not be recognized or adequately managed. Many of these challenges appear readily addressable. The key to doing so is to give sleep greater priority, with attention directed at ensuring that patients' sleep needs are recognized and met, both within the hospital and beyond. Requirements include staff education, creation of protocols to enhance the prospect of sleep needs being addressed, and improvement in hospital design to mitigate environmental disturbances. Hospitals and health care providers have a duty to provide, to the greatest extent possible, appropriate preconditions for healing. Accumulating evidence suggests that these preconditions include adequate patient sleep duration and quality. The Society of Anesthesia and Sleep Medicine calls for systematic changes in the approach of hospital leadership and staff to this issue. Measures required include incorporation of optimization of patient sleep into the objectives of perioperative and general patient care guidelines. These steps should be complemented by further research into the impact of hospitalization on sleep, the effects of poor sleep on health outcomes after hospitalization, and assessment of interventions to improve it.

Effect of mini-dose dexmedetomidine supplemented intravenous analgesia on sleep structure in older patients after major noncardiac surgery: A randomized trial

STUDY OBJECTIVES

In previous studies, low-dose dexmedetomidine supplemented opioid analgesia improved sleep architecture but increased sedation level. Herein we tested the hypothesis that mini-dose dexmedetomidine supplemented analgesia improves sleep structure without increasing sedation.

METHODS

In this randomized trial, 118 older patients (≥65 years) following major noncardiac surgery were randomized to receive patient-controlled intravenous analgesia supplemented with either placebo or dexmedetomidine (median 0.02 μg kg^-1 h^-1) for up to 3 days. Polysomnogram was monitored from 9:00 p.m. on the day of surgery until 6:00 a.m. on the first day after surgery. Our primary outcome was the percentage of non-rapid eye movement stage 2 (N2) sleep. Secondary outcomes included other sleep structure parameters during the night of surgery and the sedation score during the first five postoperative days.

RESULTS

All 118 patients completed the study; of these, 85 were included in sleep structure analysis. Dexmedetomidine supplemented analgesia increased the percentage of N2 sleep (median difference, 10%; 95% CI, 1%-20%; P = 0.03). It also prolonged total sleep time (median difference, 78 min; 95% CI, 21 to 143; P = 0.01), increased sleep efficiency (median difference, 14%; 95% CI, 4%-26%; P = 0.01), decreased percentage of N1 sleep (median difference, -10%; 95% CI, -20% to -1%; P = 0.04), and lowered sleep fragmentation index (median difference, -1.6 times⋅h^-1; 95% CI, -3.7 to 0.1; P = 0.04). Sedation score within 5 days did not differ between the two groups.

CONCLUSIONS

Supplementing intravenous analgesia with mini-dose dexmedetomidine improved sleep structure without increasing sedation in older patients recovering from major surgery.

CLINICAL TRIALS

www.

CLINICALTRIALS

gov (NCT03117790), registered 2 April 2017.

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.

Consumer Wearables for Patient Monitoring in Otolaryngology: A State of the Art Review

OBJECTIVE

Consumer wearables, such as the Apple Watch or Fitbit devices, have become increasingly commonplace over the past decade. The application of these devices to health care remains an area of significant yet ill-defined promise. This review aims to identify the potential role of consumer wearables for the monitoring of otolaryngology patients.

DATA SOURCES

PubMed.

REVIEW METHODS

A PubMed search was conducted to identify the use of consumer wearables for the assessment of clinical outcomes relevant to otolaryngology. Articles were included if they described the use of wearables that were designed for continuous wear and were available for consumer purchase in the United States. Articles meeting inclusion criteria were synthesized into a final narrative review.

CONCLUSIONS

In the perioperative setting, consumer wearables could facilitate prehabilitation before major surgery and prediction of clinical outcomes. The use of consumer wearables in the inpatient setting could allow for early recognition of parameters suggestive of poor or declining health. The real-time feedback provided by these devices in the remote setting could be incorporated into behavioral interventions to promote patients' engagement with healthy behaviors. Various concerns surrounding the privacy, ownership, and validity of wearable-derived data must be addressed before their widespread adoption in health care.

IMPLICATIONS FOR PRACTICE

Understanding how to leverage the wealth of biometric data collected by consumer wearables to improve health outcomes will become a high-impact area of research and clinical care. Well-designed comparative studies that elucidate the value and clinical applicability of these data are needed.

Landscape of biomedical informatics standards and terminologies for clinical sleep medicine research: A systematic review

A systematic literature review was conducted to understand the current landscape of standards and terminologies used in clinical sleep medicine. Literature search on PubMed, EMBASE, Medline and Web of Science was performed in March 2021 using terms related to sleep, terminologies, standards, harmonization, semantics, ontology, and electronic health records (EHR). Systematic review was carried out according to PRISMA. Among 128 included studies, 35 were eligible for review. Articles were broadly classified into six topics: standard terminology efforts, reporting standards, databases and resources, data integration efforts, EHR abstraction and standards for automated sleep scoring. This review highlights the progress and challenges related to establishing computable terminologies in sleep medicine, and identifies gaps, limitations and research opportunities related to data integration that could improve adoption of clinical research informatics in this field. There is a need for the systematic adoption of standardized terminologies in all areas of sleep medicine. Existing data aggregation resources could be leveraged to support the development of an integrated infrastructure and subsequent deployment in EHR systems within sleep centers. Ultimately, the adoption of standardized practices for documenting sleep disorders and related traits facilitates data sharing, thus accelerating discovery and clinical translation of informatics approaches applied to sleep medicine.

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.

Investigating the construct and concurrent validity of the Richards-Campbell Sleep Questionnaire with intensive care unit patients and home sleepers

BACKGROUND

Sleep is vital to our wellbeing. Critically ill patients are vulnerable with effects of sleep deprivation including weakened immune function, decreased glucose tolerance, and increased sympathetic activity. Intensive care unit (ICU) patients' sleep evaluation is difficult and often not reliable. The most commonly used instrument for assessing ICU patients' perspective of their sleep, Richards-Campbell Sleep Questionnaire (RCSQ), has not been reported to have undergone known-group construct validity testing or concurrent validity testing with the criterion measure of feeling refreshed.

OBJECTIVES

The aim of the study was to explore the construct validity of the RCSQ with known-groups technique and concurrent validity with the criterion measure of feeling refreshed on awakening.

METHODS

A cross-sectional descriptive survey study using the RCSQ was conducted on people sleeping at home (n = 114) over seven nights. The results were compared with the RCSQ sleep scores of nonintubated alert oriented adult ICU patients (n = 114). Home sleepers were also asked to rate how refreshed they felt on awakening. The study was executed and reported in accordance with the STROBE checklist for observational studies.

FINDINGS

RCSQ construct validity was supported because home sleepers' and ICU sleepers' sleep evaluations differed significantly. Home sleepers rated their sleep significantly better than ICU patients in all five sleep domains of the RCSQ. Concurrent validity was supported because the item "feeling refreshed on awakening" correlated strongly with all sleep domains.

CONCLUSIONS

Sleep quality may be accurately measured using the RCSQ in alert people both in the ICU and at home. This study has added to the validity discussion around the RCSQ. The RCSQ can be used for sleep evaluation in ICUs to promote wellbeing and recovery.

Music intervention for sleep quality in critically ill and surgical patients: a meta-analysis

OBJECTIVE

Sleep disruption occurs frequently in hospitalised patients. Given the potential of music intervention as a non-pharmacological measure to improve sleep quality, we aimed to assess and quantify current literature on the effect of recorded music interventions on sleep quality and quantity in the adult critical care and surgical populations.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Embase, MEDLINE Ovid, Cochrane Central, Web of Science and Google Scholar.

ELIGIBILITY CRITERIA FOR STUDIES

Randomised controlled trials assessing the effect of music on sleep quality in critically ill and surgical patients.

METHODS

The electronic databases were systematically searched from 1 January 1981 to 27 January 2020. Data were screened, extracted and appraised by two independent reviewers. Primary outcomes were sleep quality and quantity, assessed with validated tools. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Random effects meta-analysis was performed, and pooled standardised mean differences (SMDs) with 95% CIs were reported.

RESULTS

Five studies (259 patients) were included in qualitative (risk of bias) and quantitative analysis (meta-analysis). Pooled data showed a significant effect of recorded music on subjective sleep quality in the critical care and surgical population (SMD=1.21 (95% CI 0.50 to 1.91), p<0.01, excluding one non-English study; SMD=0.87 (95% CI 0.45 to 1.29), p<0.01). The SMD of 1.21 corresponded to a 27.1% (95% CI 11.2 to 42.8) increase in subjective sleep quality using validated questionnaires. A significant increase in subjective sleep quantity of 36 min was found in one study. Objective measurements of sleep assessed in one study using polysomnography showed significant increase in deeper sleep stage in the music group.

CONCLUSIONS

Recorded music showed a significant improvement in subjective sleep quality in some critical care and surgical populations. Therefore, its use may be relevant to improve sleep, but given the moderate potential for bias, further research is needed.

PROSPERO REGISTRATION NUMBER

CRD42020167783.

Sleep quality assessment in intensive care: actigraphy vs. Richards-Campbell sleep questionnaire

Introduction

It has been repeatedly shown that sleep of intensive care unit (ICU) patients is fragmented and its architecture is impaired. As sleep disorders have numerous negative effects on the organism, there have been efforts to implement sleep-promoting strategies into practice. When comparing the effectiveness of such measures, sleep quality assessment itself is a considerable problem.

Objective

The study aimed to assess the quality and quantity of night sleep in ICU patients simultaneously with actigraphy (ACT) and the Richards-Campbell Sleep Questionnaire (RCSQ). The secondary goals were to test the performance and effectiveness of the above methods and to verify correlations between selected RCSQ items and actigraph parameters.

Methods

A single-center prospective observational study (20 patients staying in a Interdisciplinary Intensive Care Unit). The quality of sleep was assessed using a Czech version of the RCSQ and ACT. The obtained data were analyzed and their dependence or correlations were verified by selected statistical tests.

Results

The mean RCSQ score was 47.6 (SD 24.4). The worst results were found for sleep latency (44.4; SD 31.2); the best results were for sleep quality (50.2; SD 29.4). The mean sleep effciency measured with ACT reached 86.6% (SD 9.2); the mean number of awakenings per night was 17.1 (SD 8.5). The RCSQ total parameter with a cutoff of 50 (RCSQ total = 50 good sleep / RCSQ total < 50 poor sleep) was shown to be suitable for discrimination of subjectively perceived sleep quality in ICU patients. However, the study failed to show statistically significant relations between subjectively perceived sleep quality (RCSQ) and ACT measurements.

Conclusion

The RCSQ appears to be a suitable instrument for assessing night sleep quality in ICU patients. On the other hand, the study showed a very low level of agreement between subjective sleep quality assessment and objective ACT measurements. The main drawback of ACT is low reliability of obtained data. Further research is needed to determine its role in sleep quality assessment in the ICU setting.

Measuring Subjective Sleep Quality: A Review

Sleep quality is an important clinical construct since it is increasingly common for people to complain about poor sleep quality and its impact on daytime functioning. Moreover, poor sleep quality can be an important symptom of many sleep and medical disorders. However, objective measures of sleep quality, such as polysomnography, are not readily available to most clinicians in their daily routine, and are expensive, time-consuming, and impractical for epidemiological and research studies., Several self-report questionnaires have, however, been developed. The present review aims to address their psychometric properties, construct validity, and factorial structure while presenting, comparing, and discussing the measurement properties of these sleep quality questionnaires. A systematic literature search, from 2008 to 2020, was performed using the electronic databases PubMed and Scopus, with predefined search terms. In total, 49 articles were analyzed from the 5734 articles found. The psychometric properties and factor structure of the following are reported: Pittsburgh Sleep Quality Index (PSQI), Athens Insomnia Scale (AIS), Insomnia Severity Index (ISI), Mini-Sleep Questionnaire (MSQ), Jenkins Sleep Scale (JSS), Leeds Sleep Evaluation Questionnaire (LSEQ), SLEEP-50 Questionnaire, and Epworth Sleepiness Scale (ESS). As the most frequently used subjective measurement of sleep quality, the PSQI reported good internal reliability and validity; however, different factorial structures were found in a variety of samples, casting doubt on the usefulness of total score in detecting poor and good sleepers. The sleep disorder scales (AIS, ISI, MSQ, JSS, LSEQ and SLEEP-50) reported good psychometric properties; nevertheless, AIS and ISI reported a variety of factorial models whereas LSEQ and SLEEP-50 appeared to be less useful for epidemiological and research settings due to the length of the questionnaires and their scoring. The MSQ and JSS seemed to be inexpensive and easy to administer, complete, and score, but further validation studies are needed. Finally, the ESS had good internal consistency and construct validity, while the main challenges were in its factorial structure, known-group difference and estimation of reliable cut-offs. Overall, the self-report questionnaires assessing sleep quality from different perspectives have good psychometric properties, with high internal consistency and test-retest reliability, as well as convergent/divergent validity with sleep, psychological, and socio-demographic variables. However, a clear definition of the factor model underlying the tools is recommended and reliable cut-off values should be indicated in order for clinicians to discriminate poor and good sleepers.

Patient Reports of Night Noise in Hospitals Are Associated With Unplanned Readmissions Among Older Adults

Objective:

Sleep disturbance is a key contributor to posthospital syndrome; a transient period of vulnerability following discharge from hospital. We sought to examine the relationship between patient-reported hospital quietness at night, via a validated survey, and unplanned hospital readmissions among hospitalized seniors (ages 65 and older) in Alberta, Canada.

Design:

Retrospective, cross-sectional analysis of survey responses, linked with administrative inpatient records.

Setting:

Using the Canadian Patient Experiences Survey—Inpatient Care and Discharge Abstract Database, patients aged 65 and older, and living with one or more chronic conditions were identified.

Participants:

Of all, 25 674 respondents discharged from hospital between April 2014 and December 2017.

Main Outcome Measure:

All-cause, unplanned readmission within 30 or 90 days (yes vs no).

Results:

Approximately half (50.5%) of the respondents reported that the area around their room was always quiet at night. Eight (8.1%) percent of respondents (2066) were readmitted within 30 days (2241 total readmissions), while 15.6% (4000) were readmitted within 90 days (5070 total readmissions). When controlling for a variety of demographic and clinical factors, patients not reporting “always” to the survey question regarding hospital quietness at night had slightly greater odds of readmission within 30 (adjusted odds ratio [aOR] = 1.32, 95% confidence interval [CI]: 1.20-1.45) and 90 days (aOR = 1.14, 95% CI: 1.06-1.23).

Conclusion:

Our results demonstrate a clear association between patient-reported hospital quietness at night and subsequent readmission within the first 30 and 90 days following discharge. Efforts to minimize hospital noise, particularly at night, may help promote a restful environment, while reducing readmissions among older patients living with chronic conditions.

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.

Providing Evidence-Based Care, Day and Night: A Quality Improvement Initiative to Improve Intensive Care Unit Patient Sleep Quality

OBJECTIVE

Evidence-based guidelines recommend promoting sleep in the Intensive Care Unit (ICU), yet many patients experience poor sleep quality. We sought to engage allied health staff and patient families to determine barriers to sleep promotion, to measure sleep quality for ICU patients, and to evaluate the improvement in sleep quality after implementation of nursing morning report protocol and a doorway poster.

DESIGN

The study followed an interrupted time-series framework of quality improvement. Qualitative diagnostics included focus groups and interviews with patients, families, and allied health care workers, analyzed by qualitative descriptive analysis. Quantitative diagnostics included direct observation of nurses and patients overnight. Analysis of primary outcome data used statistical process control methodology.

PATIENTS

Patients included were >18 years old, admitted overnight to a Canadian tertiary academic ICU, with a Richards Agitation Sedation Scale (RASS) ≥-2.

INTERVENTIONS

Sleep quality was measured using the Richards Campbell Sleep Questionnaire (RCSQ). Two interventions were developed: sleep quality in morning nursing report, and a doorway poster.

MAIN RESULTS

A total of 2332 patient nights across 7 consecutive months were included for analysis. Baseline sleep in the ICU was poor (mean RCSQ 53.7/100). Root cause-analysis identified the most prominent sleep barriers as nurse stigma associated with less active management of patients and lack of physician engagement. No significant improvement occurred over the sleep quality improvement initiative (mean RCSQ 59.5/100). Sleep quality was better among non-delirious patients compared with delirious patients (mean RCSQ 62.7 vs 53.3).

CONCLUSION

The intervention of a nursing morning report protocol and sleep posters did not improve the quality of ICU patient sleep in this study. Structured interviews revealed potential sleep barriers to be addressed such as nursing stigma and inappropriate awakenings. Nursing stigma has not been previously linked to sleep quality.

An Arabic Translation, Reliability, Validity, and Feasibility of the Richards-Campbell Sleep Questionnaire for Sleep Quality Assessment in ICU: Prospective-Repeated Assessments

BACKGROUND AND PURPOSE

To translate Richards-Campbell Sleep Questionnaire (RCSQ) into the Arabic language (RCSQ-A), to assess content validity of the translated tool, to analyze the internal consistency, and to evaluate its feasibility.

METHODS

A rigorous translation was completed using the process of translation by World Health Organization. Cognitive debriefing interviews were performed. Repeated assessments using RCSQ-A was conducted in critical care patients in Saudi Arabia.

RESULT

Cronbach's alpha of .89 was seen in the RCSQ-A. The cognitive interviews showed that the RCSQ-A well understood and interpreted correctly and consistently. Fifty-seven participants reported their sleep using RCSQ-A a total of 110 times.

CONCLUSION

RCSQ-A has adequate translation validity, provided good internal consistency and content validity, making it suitable for use as a measurement tool in practice and research in Arabic-speaking countries.

Sleep quality among orthopaedic patients in Denmark - A nationwide cross-sectional study

BACKGROUND

Hospitalised patients sleep less and have a lower quality of sleep compared to patients who recover in their own home. Low sleep quality is associated with complications such as increased pain sensation, delirium and reduced rehabilitation capacity.

PURPOSE

To investigate patients' self-reported sleep quality and factors related to sleep quality during admission to a department of Orthopaedic Surgery.

METHODS

The Richard-Campbell Sleep Questionnaire was used to assess patients' sleep quality, measured using a VAS 0-100 scale, (a higher score indicating good sleep quality). The moderated Pittsburgh Sleep Quality Index assessed the most severe and frequent barriers to high sleep quality.

RESULTS

A total of 533 patients undergoing orthopaedic surgery participated. There was an overall mean sleep quality score of 54. The most common and severe factors impacting sleep quality were; waking during the night, difficulties falling asleep, waking early, waking for toileting or pain. The intensity of the pain was found to be proportional to the quality of sleep.

CONCLUSION

Patients reported their overall quality of sleep to be moderately good due to difficulties falling asleep, waking up during the night or early morning and having pain. The results call for better pain management and non-pharmacological nursing interventions to optimise sleep quality.

Sleep Fragmentation and Cognitive Trajectories After Critical Illness

BACKGROUND

ICU survivors can experience both cognitive dysfunction and persistent sleep disturbances after hospitalization. Sleep disturbances have been linked with cognitive impairment in various patient populations, and the apolipoprotein E (APOE) genotype has been linked to sleep-related impairments in cognition.

RESEARCH QUESTION

Is there an association between sleep, long-term cognition, and APOE status in ICU survivors?

STUDY DESIGN AND METHODS

We enrolled 150 patients from five centers who had been mechanically ventilated for at least 3 days; 102 patients survived to ICU discharge. Actigraphy and cognitive testing were undertaken at 7 days, 6 months, and 12 months after ICU discharge, and sleep duration, quality, and timing were estimated by actigraphy. APOE single nucleotide polymorphisms were assessed for each patient.

RESULTS

Actigraphy-estimated sleep fragmentation, but not total sleep time or interdaily stability (estimate of circadian rhythmicity), was associated with worse cognitive impairment at 7 days of ICU discharge. No actigraphy-estimated variable of sleep estimation at 7 days post-ICU discharge predicted cognitive impairment or persistent sleep abnormalities at 6 and 12 months of follow-up in subsequently assessed survivors. Possessing the APOE ε4 allele was not significantly associated with sleep disturbances and its presence did not modify the risk of sleep-related cognitive impairment at follow-up.

INTERPRETATION

Sleep fragmentation estimated by actigraphy was associated with worse cognitive performance in hospital, but not at later time intervals. Further research is needed to better delineate the relationship between persistent sleep disturbances and cognition in larger numbers of ICU survivors.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT02086877; URL: www.clinicaltrials.gov.

Night-time Noise Levels and Patients’ Sleep Experiences in a Medical Assessment Unit in Northern England

Background:

Hospital in-patients need sleep so that restorative process and healing can take place. However, over one third of in-patients experience sleep disturbance, often caused by noise. This can compromise patients’ perceptions of care quality and cause physical and psychological ill health.

Aims:

To assess 1) in-patients sleep quality, quantity, reported sources of sleep disturbance and their suggestions for improvement 2) objectively measure decibel levels recorded at night.

Methods:

This descriptive study conducted in a Medical Assessment Unit used multi-methods; a semi-structured ‘sleep experience’ questionnaire administered to a purposive sample of in-patients; recording of night-time noise levels, on 52 consecutive nights, using two calibrated Casella sound level meters.

Results:

Patient ratings of ‘in-hospital’ sleep quantity (3.25; 2.72 SD) and quality (2.91; 2.56 SD) was poorer compared to ‘home’ sleep quantity (5.07; 2.81 SD) and quality (5.52; 2.79 SD). The difference in sleep quality (p<0.001) and quantity (p<0.001) ratings whilst in hospital, compared to at home, was statistically significant. Care processes, noise from other patients and the built environment were common sources of sleep disturbance. Participants’ suggestions for improvement were similar to interventions identified in current research. The constant noise level ranged from 38-57 decibels (equivalent to an office environment), whilst peak levels reached a maximum of 116 decibels, (equivalent to banging a car door one metre away).

Conclusion:

The self-rated patient sleep experience was significantly poorer in hospital, compared to home. Noise at night contributed to sleep disturbance. Decibel levels were equivalent to those reported in other international studies. Data informed the development of a ‘Sleep Smart’ toolkit designed to improve the in-patient sleep experience.

The Richards-Campbell Sleep Questionnaire and Sleep in the Intensive Care Unit Questionnaire: translation to Portuguese and cross-cultural adaptation for use in Brazil

Objective:

To translate the Richards-Campbell Sleep Questionnaire (RCSQ) and Sleep in the Intensive Care Unit Questionnaire (SICUQ) to Portuguese, making the appropriate cross-cultural adaptations for their use in Brazil, as well as to determine the interobserver reliability of the instruments.

Methods:

In this study, we evaluated medical and surgical patients admitted to the adult ICU of the Federal University of Paraná Hospital de Clínicas, in the city of Curitiba, Brazil, between June of 2017 and January of 2018. The translation and cross-cultural adaptation of the questionnaires involved the following steps: translation, synthesis, back-translation, revision by an expert panel, approval of the back-translation by the original authors, pretesting, and creation of the final versions. Two researchers applied the Portuguese-language versions in the evaluation of critically ill patients. Interobserver reliability was assessed by calculating the intraclass correlation coefficient (ICC) and 95% CI.

Results:

The sample comprised 50 patients, of whom 27 (54%) were women. The mean age was 47.7 ± 17.5 years. The main reason for ICU admission, in 10 patients (20%), was cancer. The interobserver reliability of the questionnaires ranged from good to excellent. For the RCSQ, the ICC was 0.84 (95% CI: 0.71-0.90). For SICUQ domains 1-5 (sleep quality and daytime sleepiness), the ICC was 0.75 (95% CI: 0.55-0.86), whereas it was 0.86 (95% CI: 0.76-0.92) for SICUQ domains 6 and 7 (causes of sleep disruption).

Conclusions:

The cross-culturally adapted, Portuguese-language versions of the RCSQ and SICUQ appear to have good interobserver reliability.

Effect of Heart Rate Variability Biofeedback Sessions With Resonant Frequency Breathing on Sleep: A Pilot Study Among Family Caregivers of Patients With Cancer

Heart rate variability biofeedback (HRV-BF) is used as a skill in psychosomatic medicine, but is not yet established in the field of sleep. The present study aimed to evaluate the effect of HRV-BF with resonant frequency breathing (RFB) on sleep performed once every 2 weeks and the usefulness of practice of RFB using a portable device at home before bedtime. Participants were 69 family caregivers of patients with cancer that felt burdened by nursing care. We conducted a randomized controlled trial with an HRV-BF+Home practice group and an HRV-BF group. HRV-BF with RFB was administered to both groups at our medical institution for up to 30 min on the experiment days. Home practice involved RFB using a portable device, which was performed at home each day within 20 min before bedtime. Evaluation items were: change ratio of total score of the Pittsburgh Sleep Quality Index (PSQI) at 28 days after the trial started. In total, 52.2% of participants had insomnia. The two HRV-BF groups had decreased PSQI total scores, which indicated an improvement in PSQI total score near 5.5 on Day 28. The two HRV-BF groups had significantly increased HRV scores on Day 28, and there was correlation between the variation of PSQI total score and the variation of HRV score. The quality of sleep assessed by PSQI scores in the HRV-BF+Home practice group was significantly improved compared with the HRV-BF group on Day 28 (p = 0.001). This suggests HRV-BF may be a useful skill for enhancing sleep among family caregivers of patients with cancer, as well as supporting their autonomic nervous function. Additional actual regular practice of RFB (using a portable device at home before bedtime) may further enhance the effect.

Sleep assessment and interventions for patients living with cancer from the patients' and nurses' perspective

BACKGROUND

Difficulty sleeping is a common symptom for patients living with cancer that significantly affects their lives. However, although sleep disorders are common, it is an overlooked problem in cancer care.

PURPOSE

This study assessed the prevalence of sleep disturbances among patients living with cancer, and assessed the adequacy of sleep assessment and intervention for patients from both nurses' and patients' perspectives.

METHOD

Descriptive, cross-sectional and correlational design was used in this study. A convenience sample of 129 patients with cancer and 113 registered nurses working with cancer patients was recruited. A structured face-to-face interview was used to complete the patients' questionnaires and a self-administered questionnaire was given to nurses.

FINDINGS

The majority of patients with cancer reported having poor sleep quality (69.8%). About 86.7% (n=98) of nurses reported that they have never screened patients with cancer for any sleep problems, and 76.7% (n=99) of the patients reported that they have never been assessed for sleep problems by the nursing staff during hospitalisation. Only 8% of patients with cancer who reported having problems sleeping to a nurse received interventions to promote better sleep.

CONCLUSION

Assessment of sleep disturbances in patients with cancer should be unified using a comprehensive reliable valid instrument, as well as providing evidence-based interventions according to patient's need. A written policy should be introduced to encourage sleep documentation and to make sleep care for patients part of routine nursing care.

DISTURBED SLEEP PATTERN (000198): CONTENT ANALYSIS IN PATIENTS WITH ACUTE CORONARY SYNDROME

ABSTRACT Objective: to analyze the content of the defining characteristics of the Disturbed Sleep Pattern Nursing Diagnosis (00198) in patients with Acute Coronary Syndrome. Method: content analysis performed by specialists who achieved a score equal to or greater than five, according to established criteria: clinical experience, teaching and/or research; participation in research groups; doctorate degree; master's degree; specialization and/or residency in cardiology and/or sleep and/or nursing classifications. Eight defining characteristics were evaluated for their relationship to population, relevance, clarity and accuracy. Descriptive statistics were performed to characterize the sample, binomial statistical test to establish if there is agreement between the experts and chi-square and Fisher's exact to establish associations between the evaluated items and the experts' variables. Results: 54 experts participated in the study. The defining characteristics validated by the experts were the following: dissatisfaction with sleep, feeling unrested, sleep deprivation, alteration in sleep pattern, unintentional awakening, difficulty initiating sleep and daytime sleepiness. There was a statistically significant association between evaluated items and the variables time of training, time of operation and punctuation. Conclusion: seven of the eight defining characteristics were considered valid after the application of binomial test. This study will contribute to the refinement of the Disturbed Sleep Pattern Nursing Diagnosis (000198) and may enable the improvement of the quality of care of patients hospitalized with Acute Coronary Syndrome regarding changes in sleep pattern. The content analysis stage will support the next stage of the validation process of the present diagnosis, the clinical validation.

Low daily MEWS scores as predictors of low-risk hospitalized patients

BACKGROUND

The Modified Early Warning System (MEWS) is a well-validated tool used by hospitals to identify patients at high risk for an adverse event to occur. However, there has been little evaluation into whether a low MEWS score can be predictive of patients with a low likelihood of an adverse event.

AIM

The present study aims to evaluate the MEWS score as a method of identifying patients at low risk for adverse events.

DESIGN

Retrospective cohort study of 5676 patient days and analysis of associated MEWS scores, medical comorbidities and adverse events. The primary outcome was the association of average daily MEWS scores in those who had an adverse event compared with those who did not.

RESULTS

Those with an average MEWS score of >2 were over 9 times more likely to have an adverse event compared with those with an average MEWS score of 1-2, and over 15 times more likely to have an adverse event compared to those with an average MEWS score of <1.

CONCLUSIONS

Our study shows that those with average daily MEWS scores <2 are at a significantly lower likelihood of having an adverse event compared with a score of >2, deeming them 'low-risk patients'. Formal recognition of such patients can have major implications in a hospital setting, including more efficient resource allocation in hospitals and better patient satisfaction and safety by adjusting patient monitoring according to their individual risk profile.

Associations of dry skin, skin care habits, well-being, sleep quality and itch in nursing home residents: Results of a multicentre, observational, cross-sectional study

AIM

Dry skin is one of the most frequent cutaneous problems in aged long-term care residents. Although it is clinically relevant, the impact on quality of life is unclear. The objective was to measure well-being, sleep quality and itch in nursing home residents being 65 years and older and to explore possible associations with demographics, dry skin and skincare habits.

DESIGN

Multicentre, observational, cross-sectional.

METHODS

Sleep quality was assessed with the Richards-Campbell Sleep Quality Questionnaire, well-being with the WHO-Five Well-being Index and itch with the 5-D Itch scale. Skin dryness was measured using the Overall Dry Skin score.

RESULTS

A total of 51 residents were included. The item scores of the sleep quality and itch questionnaires were strongly associated with each other. Demographics, dry skin and skincare habits were not associated with the questionnaires. It is unclear whether basic skincare activities can improve the quality of life in this population.

Comparison of Melatonin and Zolpidem for Sleep in an Academic Community Hospital: An Analysis of Patient Perception and Inpatient Outcomes

Hospitalizations can significantly disrupt patient sleep patterns and contribute to insomnia, which places patients at a higher risk of altered mental status as well as other complications. Despite attempts to control environmental factors, deliriogenic medications are often prescribed for the management of hospital-related insomnia. The primary objective of this study is to compare patient-perceived effectiveness of zolpidem versus melatonin in hospitalized patients. All inpatients who received melatonin or zolpidem the previous night as asleep aid and had no acute psychological issues or history of substance abuse were eligible for participation in this single-center, prospective, observational cohort study. The Verran and Snyder-Halpern sleep scale was utilized to evaluate sleep perception in 3 domains: sleep disturbance, effectiveness, and supplementation. A total of 439 patients were screened and 100 patients met study criteria and consented to the study. In the melatonin and zolpidem groups, the estimated adjusted means for the total sleep effectiveness (206.8 mm, 95% confidence interval [CI], 168.7-253.5vs 187.4 mm, 95% CI, 152.8-229.7; P=.513), sleep disturbance(362.1 mm, 95% CI, 310.1-422.7 vs 339.54 mm, 95% CI, 290.8-396.4; P=.573), and sleep supplementation (111.4 mm, 95% CI, 86.3-143.8 vs 120.9 mm, 95% CI, 94.1-155.2; P=.661) domains were not statistically different. Both melatonin and zolpidem were well tolerated with grogginess and headache as the only reported adverse effects. Melatonin demonstrated no significant difference in patient-perceived sleep effectiveness, disturbance, supplementation, or adverse effects when compared to zolpidem.

Prospective repeated assessment of self-reported sleep quality and sleep disruptive factors in the intensive care unit: acceptability of daily assessment of sleep quality

INTRODUCTION

Despite the importance of sleep, the assessment of sleep quality does not form part of standard clinical care in intensive care unit (ICU). Continuous assessment of self-reported quality of ICU patients' sleep has been strongly recommended. Prior to implementing such an assessment in the ICU, it is important to assess the acceptability of this method of assessment to the ICU's patients. The aims of this study were to assess the acceptability to ICU patients of completing daily self-reports on sleep quality during their ICU stay and to assess ICU patients' self-reported sleep quality and sleep disruptive factors during their time in ICU.

METHODS

An observational prospective-repeated assessment was conducted on n=120 patients in an ICU in Saudi Arabia. The participants were both intubated and non-intubated.

OUTCOMES MEASURES

Over a 3-month period, sleep quality was assessed using the Arabic version of the Richards-Campbell Sleep Questionnaire (RCSQ-A), and self-reported sleep disruptive factors were identified. Clinical factors, such as ICU interventions, and previously administered sedatives were also examined. The patients' acceptance of completing daily RCSQ-A reports was assessed using various indicators of acceptability.

RESULTS

A total of 381 self-reports (RCSQ-A) were collected for this analysis. The patients reported 34.4±5.60, indicating that sleep quality was poor on average. The group of intubated patients reported much poorer sleep quality during intubation than after extubation. In the multivariate analysis, factors which most significantly affected sleep (exp(b), p value) were midazolam (-6.424, p<0.0005), propofol (-3.600, p<0.05), noise (-1.033, p<0.05), gender (1.836, p<0.05), daytime sleepiness (0.856, p<0.05) and the presence of mechanical ventilation (-1.218, p<0.05).

CONCLUSION

The acceptability and feasibility of using daily RCSQ-A for sleep quality assessment was demonstrated. Sleep quality was reported as poor by all participants and the factors affecting sleep were varied. This study provided various recommendations for healthcare providers and researchers in terms of evaluating and improving sleep quality in ICU patients.

Day-Night Activity in Hospitalized Children after Major Surgery: An Analysis of 2271 Hospital Days

OBJECTIVES

To characterize the day-night activity patterns of children after major surgery and describe differences in children's activity patterns between the pediatric intensive care unit (PICU) and inpatient floor setting.

STUDY DESIGN

In this prospective observational study, we characterized the daytime activity ratio estimate (DARE; ratio between mean daytime activity [08:00-20:00] and mean 24-hour activity [00:00-24:00]) for children admitted to the hospital after major surgery. The study sample included 221 infants and children ages 1 day to 17 years admitted to the PICU at a tertiary, academic children's hospital. Subjects were monitored with continuous accelerometry from postoperative day 1 until hospital discharge. The National Health and Nutrition Examination Survey accelerometry data were utilized for normative data to compare DARE in a community sample of US children to hospitalized children.

RESULTS

The mean DARE over 2271 hospital days was 57.8%, with a significant difference between the average DARE during PICU days and inpatient floor days (56% vs 61%, P < .0001). The average subject DARE ranged from 43% to 73%. In a covariate-adjusted mixed effects model, PICU location, lower age, orthopedic or urologic surgery, and intubation time were associated with decreased DARE. Hospitalized children had significantly lower DARE than the National Health and Nutrition Examination Survey subjects in all age groups studied, with the largest difference in the youngest PICU group analyzed (6-9 years; 59% vs 75%, P < .0001). A subset analysis of children older than 2 years (n = 144) showed that DARE was <50% on 15% of hospital days.

CONCLUSIONS

Children hospitalized after major surgery experience disruptions in day-night activity patterns during their hospital stay that may reflect disturbances in circadian rhythm.

Development and daily use of a numeric rating score to assess sleep quality in ICU patients

PURPOSE

Insufficient sleep burdens critically ill patients, optimizing sleep may enhance patient's outcomes. Current assessment methods may unnecessary burden patients. Therefore, a single numeric rating score was validated for sleep assessment.

MATERIALS AND METHODS

First, two cross-sectional measurements on two separate days, from cooperative patients from 19 centers assessed their sleep sufficiency, the numeric rating score (NRS) and the Richards Campbell Sleep Questionnaire (RCSQ). Assessments were compared using a Bland Altman plot. A NRS cut-off was determined using regression analysis. Second, daily sleep assessment was implemented and monitored single center for a year.

RESULTS

Multicenter, 194 patients assessed sleep quality, of which 53% was rated as sufficient. Mean (±SD) difference between RCSQ and NRS-Sleep using Bland-Altman analysis was 0.25 (±1.21, 95% limits of agreement -2.12 to 2.62). The optimal cut-off was >5. Single center, 1603 patients ranked 4532 ICU nights of sleep, of which 71% was sufficient; median NRS was 6 [IQR 5-7].

CONCLUSIONS

A single numeric rating score for sleep is interchangeable for the RCSQ score for assessment of sleep quality. Optimal cut-off is >5. Use of a numeric rating score for sleep is a practical way to evaluate and monitor sleep as perceived by patients in daily ICU practice.

Conceptual and operational definitions of the defining characteristics of the nursing diagnosis Disturbed Sleep Pattern

Objective

to present the knowledge produced about sleep and Acute Coronary Syndrome in order to assist in the elaboration of the operational and conceptual definitions of the defining characteristics of the nursing diagnosis Disturbed Sleep Pattern (00198).

Method

integrative review in the following databases: COCHRANE; SCOPUS; MEDLINE (Medical Literature Analysis and Retrieval System Online) via Pubmed; LILACS (Latin American and Caribbean Health Science Literature Database); CINAHL (Cumulative Index to Nursing and Allied Health Literature) and EMBASE (The Excerpta Medical Database). At the end of the search, 2827 studies were found, 43 were selected for reading, and 10 were included in the review. The gray literature was also included.

Results

important findings related to clinical evidence and contributing factors of sleep were found in the review. However, in order to build definitions of the defining characteristics, it was necessary to use gray literature, such as a Portuguese dictionary and two textbooks about sleep.

Conclusion

the definitions will help nurses in their practice in the collection of information, in the determination of the nursing diagnosis studied here, and in directing care measures with respect to quantity and quality of sleep of Acute Coronary Syndrome inpatients. They will also assist in the next steps of the validation of this diagnosis to the referred population.

Non-pharmacological interventions for sleep and quality of life: a randomized pilot study

OBJECTIVE

to estimate the effects of non-pharmacological interventions to improve the quality of sleep and quality of life of patients with heart failure.

METHOD

pilot study of a randomized controlled trial with 32 individuals assigned to four groups. Sleep was assessed using the Pittsburgh Sleep Quality Inventory, while health-related quality of life was assessed using the Minnesota Living with Heart Failure Questionnaire, at the baseline and at the 12th and 24th weeks. The means of the outcomes according to intervention groups were compared using analysis of covariance; effect sizes were calculated per group.

RESULTS

all groups experienced improved quality of sleep and health-related quality of life at the end of the intervention (week 12) and at follow-up (week 24), though differences were not statistically significant (p between 0.22 and 0.40). The effects of the interventions at the 12th week ranged between -2.1 and -3.8 for the quality of sleep and between -0.8 and -1.7 for quality of life, with similar values at the 24th week.

CONCLUSION

the effects found in this study provide information for sample size calculations and statistical power for confirmatory studies. Brazilian Clinical Trials Registry - RBR 7jd2mm.

Evaluating Sleep in a Surgical Trauma Burn Intensive Care Unit: An Elusive Dilemma

BACKGROUND

Evidence points to the adverse effects of sleep deprivation on a person's health. Despite decades of attention to the issue, patients, particularly those in the intensive care unit (ICU), continue to suffer.

OBJECTIVE

The purpose of this pilot study was to examine patients' perceptions of their sleep experience in the surgical trauma burn ICU and identify contributing factors.

METHODOLOGY

Patients were administered the 6-question Richards-Campbell Sleep Questionnaire (RCSQ) consisting of a 0- to 100-mm scale, with a low score indicating poor sleep quality. They were also asked an additional open-ended question.

RESULTS

Sixty patients participated. Data revealed a low overall RCSQ score of 43.6 of 100. Of the 5 validated questions on the RCSQ, the question with the lowest mean (35.6) targeted depth of sleep. The question pertaining to falling asleep immediately scored the highest at 52.2. The open-ended question revealed that 37% reported "interruptions" as the reason for not sleeping. Pain was also cited as a factor by 30%, with 11.7% citing discomfort from the bed as an irritant. An additional 21.6% reported noise as the central reason, with "pumps/monitor" noise as the most frequent culprit at 62%.

DISCUSSION

The pilot study results demonstrate that most participants perceived their sleep as poor in quality. These results direct targeted interventions that can be incorporated to reduce sleep deprivation in ICUs.

Intravenous Chlorpromazine for the Short-Term Treatment of Insomnia in End-Stage Cancer Patients With Difficulty in Oral Administration

The objective of the study was to evaluate effectiveness and safety of intravenous chlorpromazine for the short-term treatment of insomnia in end-stage cancer patients. Insomnia occurs as one of distressing symptoms in 70% of end-stage cancer patients. End-stage cancer patients often have difficulty in oral administration because of disease progress. We retrospectively evaluated 30 end-stage cancer patients with difficulty in oral administration who received intravenous chlorpromazine for the short-term treatment of insomnia. A primary end point was sleep quality based on St. Mary's Hospital Sleep Questionnaire 3 days after the treatment. Improved sleep quality was observed on the day after the treatment and later (P < .001), and the effective rate mean was 0.63 (95% confidential interval: 0.45-0.81) 3 days after the treatment. Increased total sleep time and decreased sleep latency time were observed 3 days after the treatment (P < .001); however, no improvement in depth of sleep was achieved (P = .231). There was no adverse event except for two delirium cases. The study indicated that intravenous chlorpromazine can be applied safely and effectively for the short-term treatment of insomnia in end-stage cancer patients with difficulty in oral administration.

Patients' perceptions of sleep in a Critical Care Unit

INTRODUCTION AND OBJECTIVES

Patients' sleep can be disturbed during their stay in an Intensive Care Unit. Many factors can explain this disturbance, both within the ICU environment and caused by patients' illnesses. There is evidence that patients' sleep can be improved within ICUs. The aim of this study is to describe patientś perceptions of a night's sleep and develop a care plan that promotes a night's sleep.

METHODOLOGY

A prospective descriptive study was performed in the ICU of a training hospital. The sleep of 125 patients was explored. Sociodemographic and clinical variables were collected from patients' medical records. The 5-item Richards-Campbell Sleep Questionnaire was utilised to assess patients' perception of a night's sleep. In addition, an ad-hoc 9-item questionnaire was developed which included factors that can affect sleep according to the literature. Patients had to grade the level of interference of those factors with their night's sleep.

RESULTS

The sleep of patients in our Intensive Care Unit was moderately deep, with light arousals and ease in falling sleep again. The average value on the Richards-Campbell Sleep Questionnaire was 52.92mm. The factors that significantly interfered with sleep were: pain (P=0.009), worries/anxiety (P=.01), staff voices (P=0.033), alarm/medical devices sounds (P=0.047) and peripheral intravenous lines (P=.036).

CONCLUSIONS

Our patients' perception of a night's sleep in the ICU was fair. Optimising pain management, answering questions or worries, minimizing background noise and voices have the potential to improve sleep quality.

Repeated sleep-quality assessment and use of sleep-promoting interventions in ICU

To describe sleep quality using repeated subjective assessment and the ongoing use of sleep-promoting interventions in intensive care. It is well known that the critically ill experience sleep disruption while receiving treatment in the intensive care unit. Both the measurement and promotion of sleep is challenging in the complex environment of intensive care unit. Repeated subjective assessment of patients' sleep in the intensive care unit and use of sleep-promoting interventions has not been widely reported. An observational study was conducted in a 58-bed adult intensive care unit. Sleep quality was assessed using the Richards-Campbell Sleep Questionnaire (RCSQ) each morning. intensive care unit audit sleep-promoting intervention data were compared to data obtained prior to the implementation of a sleep guideline. Patients answered open-ended questions about the facilitators and deterrents of their sleep in intensive care unit. The sample (n = 50) was predominately male (76%) with a mean age: 62.6±16.9 years. Sleep quality was assessed on 2 days or more for 21 patients. The majority of patients (98%) received sleep-promoting interventions. Sleep quality had not improved significantly since the guideline was first implemented. The mean Richards-Campbell Sleep Questionnaire score was 47.9±24.1 mm. The main sleep deterrents were discomfort and noise. Frequently cited facilitators were nothing (i.e. nothing helped) and analgesia. The Richards-Campbell Sleep Questionnaire was used on repeated occasions, and sleep-promoting interventions were used extensively. There was no evidence of improvement in sleep quality since the implementation of a sleep guideline. The use of the Richards-Campbell Sleep Questionnaire for the subjective self-assessment of sleep quality in intensive care unit patients and the implementation of simple-promoting interventions by intensive care unit clinicians is both feasible and may be the most practical way to assess sleep in the intensive care unit context.

Effect of the use of earplugs and eye mask on the quality of sleep in intensive care patients: a systematic review

Intensive care unit (ICU) environment has a very strong and unavoidable negative impact on patients' sleep. Sleep deprivation in ICU patients has been already studied and negative effects on their outcome (prolonged ICU stay, decreased recovery) and complication rates (incidence of delirium, neuropsychological sequels of critical illness) discussed. Several interventions potentially improving the sleep disturbance in ICU (sleep-promotion strategies) have been assumed and tested for clinical practice. We present a review of recent literature focused on chosen types of non-pharmacological interventions (earplugs and eye mask) analysing their effect on sleep quality/quantity. From the total amount of 82 papers found in biomedical databases (CINAHL, PubMed and SCOPUS) we included the 19 most eligible studies meeting defined inclusion/exclusion criteria involving 1 379 participants. Both experimental and clinical trials, either ICU and non-ICU patient populations were analysed in the review. Most of the reviewed studies showed a significant improvement of subjective sleep quality when using described non-pharmacological interventions (objective parameters were not significantly validated). Measuring the sleep quality is a major concern limiting the objective comparison of the studies' results since non-standardised (and mainly individual) tools for sleep quality assessment were used. Despite the heterogeneity of analysed studies and some common methodological issues (sample size, design, outcome parameters choice and comparison) earplugs and eye mask showed potential positive effects on sleep quality and the incidence of delirium in ICU patients.

Non-pharmacological interventions to promote the sleep of patients after cardiac surgery: a systematic review

OBJECTIVE:

to analyze evidence available in the literature concerning non-pharmacological interventions that are effective to treat altered sleep patterns among patients who underwent cardiac surgery.

METHOD:

systematic review conducted in the National Library of Medicine-National Institutes of Health, Cochrane Central Register of Controlled Trials, Latin American and Caribbean Health Sciences Literature, Scopus, Embase, Cumulative Index to Nursing and Allied Health Literature and PsycINFO databases, and also grey literature.

RESULTS:

ten controlled, randomized clinical trials were included in this review. Non-pharmacological interventions were grouped into three main categories, namely: relaxation techniques, devices or equipment to minimize sleep interruptions and/or induce sleep, and educational strategies. Significant improvement was found in the scores assessing sleep quality among studies testing interventions such as earplugs, sleeping masks, muscle relaxation, posture and relaxation training, white noise, and educational strategies. In regard to the studies' methodological quality, high quality studies as established by Jadad scoring were not found.

CONCLUSION:

significant improvement was found among the scores assessing sleep in the studies testing interventions such as earplugs, sleeping masks, muscle relaxation, posture and relaxation training, white noise and music, and educational strategies.

OBJETIVO:

analisar as evidências disponíveis, na literatura, sobre as intervenções não farmacológicas, efetivas para o tratamento da alteração do padrão do sono em pacientes submetidos à cirurgia cardíaca.

MÉTODO:

revisão sistemática realizada por meio de busca nas bases de dados National Library of Medicine National Institutes of Health, Cochrane Central Register of Controlled Trials, Literatura Latino-Americana e do Caribe em Ciências da Saúde, Scopus, Embase, Cumulative Index to Nursing and Allied Health Literature e PsycINFO, e na literatura cinzenta.

RESULTADOS:

dez ensaios clínicos controlados e randomizados foram incluídos na revisão. Constatou-se que as intervenções não farmacológicas agruparam-se em três categorias principais, a saber: técnicas de relaxamento, dispositivos ou equipamentos para minimizar a interrupção do sono e/ou induzir o sono e estratégias educacionais. Houve melhoria significativa nos escores de avaliação do sono entre os estudos que testaram intervenções como tampões de ouvidos, máscara de olhos, relaxamento muscular, treinamento de postura e relaxamento, produção sonora e estratégia educacional. Em relação à qualidade metodológica dos estudos, não foram encontrados estudos considerados de alta qualidade pelo escore de Jadad.

CONCLUSÃO:

houve melhora significativa nos escores de avaliação do sono em estudos que avaliaram intervenções como tampões de ouvidos, máscara de olhos, relaxamento muscular, treinamento de postura e relaxamento, produção sonora e estratégia educacional.

OBJETIVO:

analizar las evidencias disponibles en la literatura sobre las intervenciones no farmacológicas, eficientes para el tratamiento de la alteración del patrón del sueño en pacientes sometidos a una cirugía cardíaca.

MÉTODO:

revisión sistemática realizada mediante búsqueda en las bases de datos de la Librería Nacional de Medicina (National Library of Medicine), de los Institutos Nacionales de la Salud (National Institutes of Health), del Registro Central Cochrane de Ensayos Controlados (Cochrane Central Register of Controlled Trials), de la literatura latinoamericana y del Caribe, en Ciencias de la Salud, Scopus, Embase, Índice Acumulado de Enfermería y Literatura en Ciencias de la Salud, CINAHL (Cumulative Index to Nursing and Allied Health Literature) y PsycINFO, y en la literatura gris.

RESULTADOS:

se incluyeron en la revisión diez ensayos clínicos controlados y aleatorizados. Se constató que las intervenciones no farmacológicas se agruparon en tres categorías principales: técnicas de relajación, dispositivos o equipos para minimizar la interrupción del sueño y/o inducirlo, y estrategias educativas. Hubo una mejora significativa en las puntuaciones de la evaluación del sueño entre los estudios que probaron las intervenciones como tapón de oídos, máscara de ojos, relajación muscular, entrenamiento de postura y relajación, producción sonora y estrategia educacional. Con respecto a la calidad metodológica de los estudios, no se hallaron los considerados de alta calidad mediante la puntuación de Jadad.

CONCLUSIÓN:

hubo una mejora significativa en las puntuaciones de la evaluación del sueño en los estudios que evaluaron intervenciones como tapones de oídos, máscara de ojos, relajación muscular, entrenamiento de postura y relajación, producción sonora y estrategia educacional.

The reliability of the German version of the Richards Campbell Sleep Questionnaire

BACKGROUND

The assessment of sleep quality in critically ill patients is a relevant factor of high-quality care. Despite the fact that sleep disturbances and insufficient sleep management contain an increased risk of severe morbidity for these patients, a translated and applicable instrument to evaluate sleep is not available for German-speaking intensive care settings.

AIM

This study aimed to translate the Richards Campbell Sleep Questionnaire (RCSQ), a simple and validated instrument eligible for measuring sleep quality in critically ill patients, and subsequently to evaluate the internal consistency of the German version of the RCSQ. Furthermore, it also aimed to inquire into the perception of sleep in a sample of critically ill patients.

METHODS

The RCSQ was translated following established methodological standards. Data were collected cross-sectionally in a sample of 51 patients at 3 intensive care units at a university hospital in Germany.

RESULTS

The German version of the RCSQ showed an overall internal consistency (Cronbach's alpha) of 0·88. The mean of the RSCQ in the sample was 47·00 (SD ± 27·57). Depth of sleep was rated the lowest and falling asleep again the highest of the RCSQ sleep items.

CONCLUSION

The study demonstrated very good internal consistency of the German version of the RCSQ, allowing for its application in practice and research in German-speaking countries. Quality of sleep perception was generally low in this sample, emphasizing the need for enhanced care concepts regarding the sleep management of critically ill patients. Relevance to clinical practice Assessment of self-perception of sleep is crucial in order to plan an individually tailored care process.