Hospital lighting and its association with sleep, mood and pain in medical inpatients

Moderating Effect of Daylight Exposure on the Relationship Between Physical Activity and Sleep in Patients with Upper Digestive Cancer: An Exploratory Study

OBJECTIVES

To examine the moderating effect of daylight exposure on physical activity and objective sleep quality, using wearable actigraph devices.

METHODS

We recruited 324 patients with either gastric or esophageal cancer. Actigraphs were used to measure all objective data including daylight exposure, physical activity, and sleep quality. Pearson's correlation coefficients were used to examine the relationships among demographic data, disease attributes, physical activity, daylight exposure, and sleep. The Hayes PROCESS macro with the regression bootstrapping method was employed to analyze the moderating effect of daylight exposure on the relationship between physical activity and sleep.

RESULTS

Sleep efficiency correlated positively with physical activity, while "wake after sleep onset" correlated negatively with physical activity and mean lux. Mean lux and light >500 lux significantly moderated the association between physical activity and sleep efficiency (P = .002 in both cases). Similarly, mean lux and light >500 lux significantly moderated the association between physical activity and "wake after sleep onset" (P = .002 and .001, respectively).

CONCLUSION

Both average daylight exposure and time of exposure to >500 lux act as moderators of physical activity and objective sleep quality in patients with gastric or esophageal cancer. Healthcare practitioners should encourage patients with cancer to engage in daily outdoor physical activity. Further intervention studies are needed to verify the combined effect of daytime light exposure and physical activity on improving sleep quality.

IMPLICATIONS FOR NURSING PRACTICE

Healthcare practitioners should encourage patients with cancer to engage in daily outdoor physical activity. Further intervention studies are needed to verify the combined effect of daytime light exposure and physical activity on improving sleep quality.

Postoperative cognitive dysfunction: spotlight on light, circadian rhythms, and sleep

Postoperative cognitive dysfunction (POCD) is a neurological disorder characterized by the emergence of cognitive impairment after surgery. A growing body of literature suggests that the onset of POCD is closely tied to circadian rhythm disruption (CRD). Circadian rhythms are patterns of behavioral and physiological change that repeat themselves at approximately, but not exactly, every 24 h. They are entrained to the 24 h day by the daily light-dark cycle. Postoperative CRD affects cognitive function likely by disrupting sleep architecture, which in turn provokes a host of pathological processes including neuroinflammation, blood-brain barrier disturbances, and glymphatic pathway dysfunction. Therefore, to address the pathogenesis of POCD it is first necessary to correct the dysregulated circadian rhythms that often occur in surgical patients. This narrative review summarizes the evidence for CRD as a key contributor to POCD and concludes with a brief discussion of how circadian-effective hospital lighting can be employed to re-entrain stable and robust circadian rhythms in surgical patients.

A Systematic Approach to Evidence-Based Design for Measurable Health and Wellness Outcomes: Curating and Translating Evidence to Practice

OBJECTIVES

Evaluating evidence from peer-review literature for use in evidence-based design is often challenging for the design disciplines, requiring access to the peer-reviewed literature, expertise in evaluating methods and findings, and translating the results into actionable design and operational recommendations.

PURPOSE

The purpose of this methods paper is to elucidate the process for systematic evaluation of research to translate evidence into practical application to improve design for occupant health and wellness.

BACKGROUND

Researchers have found strong connections in environmental design influence on health and wellness that have proven to be substantiative in the effort to improve health and well-being. Design has the capacity to encourage healthy choices and decisions within the built environment. Translation of evidence into applied design solutions may improve public health.

METHODS

A protocol is presented that culminates in the translation of evidence into design recommendations focused on improving occupant health. The protocol includes preparation for the literature search and review, search strategy, study selection, data analysis, and development of the literature review.

RESULTS

After evaluation of the evidence is completed, there were several positive findings in the example that stakeholders could utilize to improve the health of building occupants with programs and design to support nutrition, physical activity, and circadian entrainment.

CONCLUSIONS

There are a variety of software tools and processes to utilize in the curation of evidence to improve the built environment with relevant design recommendations and operational considerations affecting the personal, social, and economic health of our society.

"The Days Are Long But the Nights Are Even Longer": A Mixed-Method Study of Sleep Disturbances Among Patients in an Inpatient Rehabilitation Program

Objective

To assess sleep quality of patients on a rehabilitation ward and to identify staff practices and beliefs about management of sleep disturbance.

Design

Mixed-methods design including patient surveys and staff interviews.

Setting

Inpatient rehabilitation ward in a tertiary teaching hospital in Adelaide, Australia.

Participants

Of the 345 screened inpatients who had been in a mixed post-acute rehabilitation ward for at least 5 days, 120 (43% women) were included. The mean age was 67.7 years and the main admission reason was functional decline (40%). Patients with stroke or traumatic brain injury were excluded. Eleven (n = 11) staff (a mix of doctors, nurses, and allied health) were interviewed.

Main Outcome Measures

The surveys comprised of the Pittsburgh Sleep Quality Index, the Epworth Sleepiness Scale, the Flinders Fatigue Scale, and the Sleep Inertia Questionnaire. The survey results were compared with functional outcomes using the functional independence measure (FIM). Staff interviews delved into barriers to good sleep, ward practices, and knowledge about sleep hygiene.

Results

43% of the surveyed patients reported having healthy amount of sleep. Sleep quality was not significantly correlated with rehabilitation outcomes (assessed using FIM). Staff reported having a good awareness of sleep hygiene; however, acknowledged limitations about the environment and routine which were not conducive to healthy sleep. They identified several actions which could be taken to improve patients' sleep hygiene.

Conclusions

Sleep disturbance is common for patients in rehabilitation. Rehabilitation wards should address this often-neglected critical component of rehabilitation to improve patient experience and potential participation in therapy. Introducing a systematic approach for assessing sleep during admission, establishing clear roles regarding sleep assessment and intervention among staff, and ensuring that patients and staff are aware of good sleep hygiene practices may promote better sleep during inpatient rehabilitation.

Effects of Image Quality on the Accuracy Human Pose Estimation and Detection of Eye Lid Opening/Closing Using Openpose and DLib

OBJECTIVE

The application of computer models in continuous patient activity monitoring using video cameras is complicated by the capture of images of varying qualities due to poor lighting conditions and lower image resolutions. Insufficient literature has assessed the effects of image resolution, color depth, noise level, and low light on the inference of eye opening and closing and body landmarks from digital images.

METHOD

This study systematically assessed the effects of varying image resolutions (from 100 × 100 pixels to 20 × 20 pixels at an interval of 10 pixels), lighting conditions (from 42 to 2 lux with an interval of 2 lux), color-depths (from 16.7 M colors to 8 M, 1 M, 512 K, 216 K, 64 K, 8 K, 1 K, 729, 512, 343, 216, 125, 64, 27, and 8 colors), and noise levels on the accuracy and model performance in eye dimension estimation and body keypoint localization using the Dlib library and OpenPose with images from the Closed Eyes in the Wild and the COCO datasets, as well as photographs of the face captured at different light intensities.

RESULTS

The model accuracy and rate of model failure remained acceptable at an image resolution of 60 × 60 pixels, a color depth of 343 colors, a light intensity of 14 lux, and a Gaussian noise level of 4% (i.e., 4% of pixels replaced by Gaussian noise).

CONCLUSIONS

The Dlib and OpenPose models failed to detect eye dimensions and body keypoints only at low image resolutions, lighting conditions, and color depths.

CLINICAL IMPACT

Our established baseline threshold values will be useful for future work in the application of computer vision in continuous patient monitoring.

Sleep in hospitalized pediatric and adult patients - A systematic review and meta-analysis

Background

Sleep is essential for recovery from illness. As a result, researchers have shown a growing interest in the sleep of hospitalized patients. Although many studies have been conducted over the past years, an up to date systematic review of the results is missing.

Objective

The objective of this systematic review was to assess sleep quality and quantity of hospitalized patients and sleep disturbing factors.

Methods

A systematic literature search was conducted within four scientific databases. The search focused on synonyms of 'sleep' and 'hospitalization'. Papers written in English or Dutch from inception to April 25th,2022 were included for hospitalized patients >1 year of age. Papers exclusively reporting about patients receiving palliative, obstetric or psychiatric care were excluded, as well as patients in rehabilitation and intensive care settings, and long-term hospitalized geriatric patients. This review was performed in accordance with the PRISMA guidelines.

Results

Out of 542 full text studies assessed for eligibility, 203 were included, describing sleep quality and/or quantity of 17,964 patients. The median sample size of the studies was 51 patients (IQR 67, range 6-1472). An exploratory meta-analysis of the Total Sleep Time showed an average of 7.2 h (95%-CI 4.3, 10.2) in hospitalized children, 5.7 h (95%-CI 4.8, 6.7) in adults and 5.8 h (95%-CI 5.3, 6.4) in older patients (>60y). In addition, a meta-analysis of the Wake After Sleep Onset (WASO) showed a combined high average of 1.8 h (95%-CI 0.7, 2.9). Overall sleep quality was poor, also due to nocturnal awakenings. The most frequently cited external factors for poor sleep were noise and number of patients in the room. Among the variety of internal/disease-related factors, pain and anxiety were most frequently mentioned to be associated with poor sleep.

Conclusion

Of all studies, 76% reported poor sleep quality and insufficient sleep duration in hospitalized patients. Children sleep on average 0.7-3.8 h less in the hospital than recommended. Hospitalized adults sleep 1.3-3.2 h less than recommended for healthy people. This underscores the need for interventions to improve sleep during hospitalization to support recovery.

ICU Patients’ Perception of Sleep and Modifiable versus Non-Modifiable Factors That Affect It: A Prospective Observational Study

Background: Good sleep quantity and quality are essential for patient recovery while in the intensive care unit (ICU). Patients commonly report poor sleep while in the ICU, and therefore, identifying the modifiable factors that patients perceive as impacting their sleep is important to improve sleep and recovery. This study also assessed night-time light and sound levels in an ICU in an effort to find modifiable factors. Methods: A total of 137 patients (51F) aged 58.1 ± 16.8 years completed a survey including questions about their sleep before and during their ICU stay, factors contributing to poor sleep in the ICU, and perceived factors that may have improved their sleep in the ICU. Night-time light and sound levels were measured in patient rooms and nurses’ stations. Results: Patients reported poorer sleep quantity and quality while in the ICU compared to home. Among the most common reasons for poor sleep, easily modifiable factors included noise (50.4%) and lights (45.3%), potentially modifiable factors included pain (46.7%), and non-modifiable factors included IV lines (42.3%). Patients felt their sleep would have been improved with interventions such as dimming lights (58.4%) and closing doors/blinds at night (42.3%), as well as potentially implementable interventions such as a sleeping pill (51.8%). Overnight sound levels in bedrooms were above the recommended levels (40 dB) and light levels averaged over 100 lux. Conclusions: Sleep quality and quantity were both worse in ICU than at home. Modifiable factors such as sound and light are common factors that patients perceive impact their sleep in the ICU. Readily implementable sleep management strategies aimed at minimizing the impacts of sound and light levels in the ICU are ways to improve patients’ sleep in the ICU.

Adding Insult to Injury: Sleep Deficiency in Hospitalized Patients

Sleep deficiency is a common problem in the hospital setting. Contributing factors include preexisting medical conditions, illness severity, the hospital environment, and treatment-related effects. Hospitalized patients are particularly vulnerable to the negative health effects of sleep deficiency that impact multiple organ systems. Objective sleep measurement is difficult to achieve in the hospital setting, posing a barrier to linking improvements in hospital outcomes with sleep promotion protocols. Key next steps in hospital sleep promotion include improvement in sleep measurement techniques and harmonization of study protocols and outcomes to strengthen existing evidence and facilitate data interpretation across studies.

The effects of lamp types and surface reflectance combinations on the subjective perception of a simulated lit hospital ward environment

Purpose

Good illumination creates an aesthetic environment that may positively influence patients’ well-being and provide comfort to the hospital staff. This study aims to focus on exploring the energy efficiency of lighting and subjective perception of the lit environment in a hospital ward to assess quality indicators of ambient lighting conditions.

Design/methodology/approach

The existing conventional tubular fluorescent lamp–based lighting system in the surveyed patients’ ward was retrofitted with light-emitting diode (LED) luminaires to explore illumination and energy parameters. Thereafter, a software lighting model was created, simulated and analyzed. A Web-based survey with five bipolar adjective pairs in a semantic differential scale was conducted with 48 participants to record and analyze their subjective responses pertaining to the variations in lamp types and surface reflectance combinations.

Findings

The findings imply that the LED tubular lamp–based illumination was deemed more adequate compared to other lamp types and the effects of variations in room surface reflectance combinations on the participants’ responses were statistically significant at α = 0.05 level. The simulated horizontal work plane average illuminance level varied from 131 to 171 lx, mean room surface exitance (MRSE) levels remained between 30 and 90 lm/m2 and overall uniformity of illuminance remained between 0.5 and 0.7.

Originality/value

In a hospital ward illuminated by LED tubular lamps, variations in room surface reflectance combinations for a constant luminous flux package output from the lamps may affect the subjective perception of users and the correlation between horizontal work plane average illuminance and MRSE is found to be highly linear (coefficient of determination > 0.97).

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.

Is it Noise? Factors Linked With Sleep Interruption in Hospitalized Patients

PURPOSE/AIM

The aim of this study was to explore the perceived quality of sleep and sleep disturbances in hospitalized patients.

DESIGN

A prospective descriptive, exploratory, cross-sectional study was conducted at a 172-bed community hospital in Northeast Ohio. A convenient sample of 100 hospitalized patients was recruited from medical/surgical, progressive care, and intensive care units.

METHODS

Participants used the Richards-Campbell Sleep Questionnaire to report sleep. A quality of sleep assessment survey was used to collect information regarding 17 factors leading to decreased quality of sleep.

RESULTS

Mean sleep score was 47.92 for each question regarding sleep depth, latency, awakenings, time spent awake, and overall sleep quality. Pearson's correlation showed a significantly positive correlation between measure of noise and sleep score. Five environmental factors were identified as most disruptive to sleep: pain, laboratory draws, staff, blood pressure checks, and intravenous alarms.

CONCLUSION

The positive correlation between sleeping well and higher noise levels is noteworthy. Raising awareness about the importance of sleep in the hospital setting and introducing interventions to promote a quiet environment and minimize sleep-disturbing factors may increase patient satisfaction scores and improve healing.

Quasi-Experimental study of effects of lighting on rest, activity and melatonin in postpartum women

OBJECTIVES

to compare the parameters of the activity/rest cycle of early postpartum breastfeeding women under a controlled and uncontrolled long wavelength ray light regimen.

METHODS

quasi-experimental study with breastfeeding women and their babies during postnatal rooming-in, São Paulo, Brazil. Participants were allocated to either an experimental (intervention) or a comparison group. The intervention involved exposure of the woman in a controlled room with artificial long wavelength ray light at night. Each woman's level of 6-sulfatoxymelatonin at 24 hours and activity/rest times was analyzed.

RESULTS

the mean activity/rest times of women in the experimental and comparison groups were similar. The mean percentages of total load of 6-sulfatoxymelatonin during the day and night were similar (p=0.09). At 24 hours, the experimental group presented a significantly lower mean percentage of total load compared to the comparison group (p=0.04).

CONCLUSIONS

women who stayed in the room with long-wavelength artificial light showed no difference in activity/rest and 6-sulfatoxymelatonin levels in the early postpartum period.

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.

Environmental factors related to sleep latency among inpatients in rehabilitation wards according to functional independence measure cognitive scores

BACKGROUND

No study has investigated sleep-related environmental factors in patients according to their functional independence measure (FIM) cognitive scores.

AIMS

The aim of this study is to examine the associations between environmental factors such as noise and sleep latency according to the FIM cognitive scores among inpatients in rehabilitation wards.

DESIGN

This is a prospective longitudinal study.

METHODS

This study measured the sleep state using a bed-based actigraphy, environmental data from Environmental Sensor®, and medical record information of 33 inpatients in the rehabilitation wards during 2018. A linear mixed-effect model was used to analyse the associations between sleep latency and environmental factors. Participants were grouped according to high or low FIM cognitive scores.

RESULTS

The average patient age was 77.2 ± 10.9 years, and 48.5% were male. In the high FIM cognitive score group, the loudness and frequency of noise exceeding 40 dB during sleep latency were significantly associated with sleep latency. In the low FIM cognitive score group, only the noise frequency was associated with sleep latency, and intra-individual variance was larger than that of the high group.

CONCLUSION

These findings suggest that providing night care with attention to subdued noise is important, particularly for patients with low cognitive functional independence levels measured by the FIM cognitive score.

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.

Light in the Senior Home: Effects of Dynamic and Individual Light Exposure on Sleep, Cognition, and Well-Being

Disrupted sleep is common among nursing home patients and is associated with cognitive decline and reduced well-being. Sleep disruptions may in part be a result of insufficient daytime light exposure. This pilot study examined the effects of dynamic “circadian” lighting and individual light exposure on sleep, cognitive performance, and well-being in a sample of 14 senior home residents. The study was conducted as a within-subject study design over five weeks of circadian lighting and five weeks of conventional lighting, in a counterbalanced order. Participants wore wrist accelerometers to track rest–activity and light profiles and completed cognitive batteries (National Institute of Health (NIH) toolbox) and questionnaires (depression, fatigue, sleep quality, lighting appraisal) in each condition. We found no significant differences in outcome variables between the two lighting conditions. Individual differences in overall (indoors and outdoors) light exposure levels varied greatly between participants but did not differ between lighting conditions, except at night (22:00–6:00), with maximum light exposure being greater in the conventional lighting condition. Pooled data from both conditions showed that participants with higher overall morning light exposure (6:00–12:00) had less fragmented and more stable rest–activity rhythms with higher relative amplitude. Rest–activity rhythm fragmentation and long sleep duration both uniquely predicted lower cognitive performance.

Managing insomnia in older adults

Nurses frequently care for patients with complaints of insomnia in the hospital and community settings. Because older adults with insomnia present unique challenges for successful patient management, nurses should understand the latest assessment and treatment options.

Healthy Behaviors through Behavioral Design-Obesity Prevention

Evidence for behavior modification for improved health outcomes was evaluated for nutrition, physical activity (PA), and indoor environmental quality (IEQ). The databases searched included LISTA, PubMed, and Web of Science, with articles rated using an a priori baseline score of 70/100 to establish inclusion. The initial search produced 52,847 articles, 63 of which were included in the qualitative synthesis. Thirteen articles met inclusion for nutrition: cafeteria interventions, single interventions, and vending interventions. Seventeen articles on physical activity were included: stair use, walking, and adjustable desks. For IEQ, 33 articles met inclusion: circadian disruption, view and natural light, and artificial light. A narrative synthesis was used to find meaningful connections across interventions with evidence contributing to health improvements. Commonalities throughout the nutrition studies included choice architecture, increasing the availability of healthy food items, and point-of-purchase food labeling. Interventions that promoted PA included stair use, sit/stand furniture, workplace exercise facilities and walking. Exposure to natural light and views of natural elements were found to increase PA and improve sleep quality. Overexposure to artificial light may cause circadian disruption, suppressing melatonin and increasing risks of cancers. Overall, design that encourages healthy behaviors may lower risks associated with chronic disease.

Effect of Morning Light Glasses and Night Short-Wavelength Filter Glasses on Sleep-Wake Rhythmicity in Medical Inpatients

Sleep and circadian rhythm disorders are common amongst medical inpatients. They are caused by a mixture of factors, including noise, loss of habitual daily routines, and abnormal exposure to light, which tends to be insufficient in the day and too high at night. The aim of the present study was to test the efficacy of morning light therapy plus night short-wavelength filter glasses on sleep quality/timing, and sleepiness/mood over the daytime hours, in a group of well-characterized medical inpatients. Thirty-three inpatients were enrolled and randomized (2:1) to either treatment (n = 22; 13 males, 48.3 ± 13.3 years) or standard of care (n = 11; 8 males, 56.9 ± 12.9 years). On admission, all underwent a baseline assessment of sleep quality/timing and diurnal preference. During hospitalization they underwent monitoring of sleep quality/timing (sleep diaries and actigraphy), plus hourly assessment of sleepiness/mood during the daytime hours on one, standard day of hospitalization. Patients in the treatment arm were administered bright light through glasses immediately after awakening, and wore short-wavelength filter glasses in the evening hours. Treated and untreated patients were comparable in terms of demographics, disease severity/comorbidity, diurnal preference and pre-admission sleep quality/timing. During hospitalization, sleep diaries documented a trend for a lower number of night awakenings in treated compared to untreated patients (1.6 ± 0.8 vs. 2.4 ± 1.3, p = 0.057). Actigraphy documented significantly earlier day mode in treated compared to untreated patients (06:39 ± 00:35 vs. 07:44 ± 00:40, p = 0.008). Sleepiness during a standard day of hospitalization, recorded between 09:30 and 21:30, showed physiological variation in treated compared to untreated patients, who exhibited a more blunted profile. The level of sleepiness reported by treated patients was lower over the 09:30-14:30 interval, i.e., soon after light administration (interaction effect: F = 2.661; p = 0.026). Mood levels were generally higher in treated patients, with statistically significant differences over the 09:30-14:30 time interval, i.e., soon after light administration (treatment: F = 5.692, p = 0.026). In conclusion, treatment with morning bright light and short-wavelength filter glasses in the evening, which was well tolerated, showed positive results in terms of sleepiness/mood over the morning hours and a trend for decreased night awakenings.

An exploratory investigation of the effect of naturalistic light on fatigue and subjective sleep quality in stroke patients admitted for rehabilitation: A randomized controlled trial

BACKGROUND

Daylight entrains the central circadian pacemaker to the 24-hour day and is crucial for optimal alertness and sleep-quality. Rehabilitation patients tend to lack exposure to sufficient natural light.

OBJECTIVE

Installed diurnal naturalistic light may reduce the known disrupted sleep quality and fatigue seen in post stroke patients.

METHODS

Stroke patients were randomized to either an intervention rehabilitation unit (IU) equipped with naturalistic lighting (artificial sunlight spectrum) or to a control rehabilitation unit (CU) with standard indoor lighting. At inclusion and discharge, fatigue and subjective sleep quality were measured.

RESULTS

Ninety stroke patients were included between May 2014, and June 2015. At discharge, patients from the IU experienced less fatigue than the CU patients, based on the Multidimensional Fatigue Inventory questionnaire general (IU, n = 28; CU, n = 30; diff - 20.6%, 95% confidence interval (CI) [- 35.0%; - 3.0%]; P = 0.025) and the Rested Statement (IU, n = 28; CU, n = 30; diff + 41.6%, 95% CI [+4.6%; +91.8%]; P =  0.025). No differences were detected between groups in sleepiness or subjective sleep quality by the Pittsburgh Sleep Quality Index.

CONCLUSIONS

Fatigue was significantly reduced in rehabilitation patients exposed to naturalistic lighting during admission.

Effect on nurse and patient experience: overnight use of blue-depleted illumination

BACKGROUND

Typical hospital lighting is rich in blue-wavelength emission, which can create unwanted circadian disruption in patients when exposed at night. Despite a growing body of evidence regarding the effects of poor sleep on health outcomes, physiologically neutral technologies have not been widely implemented in the US healthcare system.

OBJECTIVE

The authors sought to determine if rechargeable, proximity-sensing, blue-depleted lighting pods that provide wireless task lighting can make overnight hospital care more efficient for providers and less disruptive to patients.

DESIGN

Non-randomised, controlled interventional trial in an intermediate-acuity unit at a large urban medical centre.

METHODS

Night-time healthcare providers abstained from turning on overhead patient room lighting in favour of a physiologically neutral lighting device. 33 nurses caring for patients on that unit were surveyed after each shift. 21 patients were evaluated after two nights with standard-of-care light and after two nights with lighting intervention.

RESULTS

Providers reported a satisfaction score of 8 out of 10, with 82% responding that the lighting pods provided adequate lighting for overnight care tasks. Among patients, a median 2-point improvement on the Hospital Anxiety and Depression Scale was reported.

CONCLUSION AND RELEVANCE

The authors noted improved caregiver satisfaction and decreased patient anxiety by using a blue-depleted automated task-lighting alternative to overhead room lights. Larger studies are needed to determine the impact of these lighting devices on sleep measures and patient health outcomes like delirium. With the shift to patient-centred financial incentives and emphasis on patient experience, this study points to the feasibility of a physiologically targeted solution for overnight task lighting in healthcare environments.

Managing insomnia in older adults

NPs frequently care for patients with complaints of insomnia in the hospital and community settings. Because older adults with insomnia present unique challenges for successful management, NPs should understand the latest assessment and treatment options.

A narrative review of interventions for improving sleep and reducing circadian disruption in medical inpatients

Sleep and circadian disruptions are frequently observed in patients across hospital wards. This is alarming, since impaired nocturnal sleep and disruption of a normal circadian rhythm can compromise health and disturb processes involved in recovery from illness (eg, immune functions). With this in mind, the present narrative review discusses how patient characteristics (sleep disorders, anxiety, stress, chronotype, and disease), hospital routines (pain management, timing of medication, nocturnal vital sign monitoring, and physical inactivity), and hospital environment (light and noise) may all contribute to sleep disturbances and circadian misalignment in patients. We also propose hospital-based strategies that may help reduce sleep and circadian disruptions in patients admitted to the hospital.

Blue Light Enhances Bacterial Clearance and Reduces Organ Injury During Sepsis

OBJECTIVES

The physiology of nearly all mammalian organisms are entrained by light and exhibit circadian rhythm. The data derived from animal studies show that light influences immunity, and these neurophysiologic pathways are maximally entrained by the blue spectrum. Here, we hypothesize that bright blue light reduces acute kidney injury by comparison with either bright red or standard, white fluorescent light in mice subjected to sepsis. To further translational relevance, we performed a pilot clinical trial of blue light therapy in human subjects with appendicitis.

DESIGN

Laboratory animal research, pilot human feasibility trial.

SETTING

University basic science laboratory and tertiary care hospital.

SUBJECTS

Male C57BL/6J mice, adult (> 17 yr) patients with acute appendicitis.

INTERVENTIONS

Mice underwent cecal ligation and puncture and were randomly assigned to a 24-hour photoperiod of bright blue, bright red, or ambient white fluorescent light. Subjects with appendicitis were randomized to receive postoperatively standard care or standard care plus high-illuminance blue light.

MEASUREMENTS AND MAIN RESULTS

Exposure to bright blue light enhanced bacterial clearance from the peritoneum, reduced bacteremia and systemic inflammation, and attenuated the degree of acute kidney injury. The mechanism involved an elevation in cholinergic tone that augmented tissue expression of the nuclear orphan receptor REV-ERBα and occurred independent of alterations in melatonin or corticosterone concentrations. Clinically, exposure to blue light after appendectomy was feasible and reduced serum interleukin-6 and interleukin-10 concentrations.

CONCLUSIONS

Modifying the spectrum of light may offer therapeutic utility in sepsis.

"They can rest at home": an observational study of patients' quality of sleep in an Australian hospital

Background

Poor sleep is known to adversely affect hospital patients’ recovery and rehabilitation. The aim of the study was to investigate the perceived duration and quality of patient sleep and identify any environmental factors associated with patient-reported poor sleep in hospital.

Method

A cross-sectional study was conducted involving 15 clinical units within a 672-bed tertiary-referral hospital in Australia. Semi-structured interviews to determine perceptions of sleep quantity and quality and factors that disturb nocturnal sleep were conducted with patients and nursing staff. Environmental noise, light and temperature were monitored overnight, with concurrent logging of noise sources by observers.

Results

Patients reported a mean reduction in hospital sleep duration, compared to home, of 1.8 h (5.3 vs. 7.1 h; p < 0.001). The proportions of patients reporting their sleep quality to be poor/very poor, fair and of good quality were 41.6, 34.2 and 24.2% respectively. Patients reported poorer sleep quality than nurses (p < 0.05). Patients, nurses and observers all reported the main factors associated with poor sleep as clinical care interventions (34.3%) and environmental noise (32.1%). Noise levels in all 15 clinical areas exceeded WHO recommended levels of < 30 dB [A] by 36.7 to 82.6%, with peak noise levels of 51.3 to 103.3 dB (A).

Conclusion

Hospital in-patients are exposed to factors which reduce the duration and quality of their sleep. These extrinsic factors are potentially modifiable through behaviour change and reconfiguration of the clinical environment. The findings from this study provided the foundation for a quality improvement project currently underway to improve patients’ sleep.

A Sleep Education and Hypnotics Reduction Program for Hospitalized Patients at a General Hospital

OBJECTIVE

We applied a program of sleep education and hypnotics reduction for inpatients (the i-sleep program). This study explored whether the i-sleep program is effective for reducing the prescription rate of sleeping pills to inpatients in a general hospital.

METHODS

We estimated the proportion of inpatients prescribed hypnotics at admission to and discharge from the hospital, excluding pediatric care units, before (2014) and after (2015) the program. In addition, we estimated the proportion of inpatients prescribed sleeping pills among all inpatients on the first day of each month of 2014 and 2015.

RESULTS

The proportion of inpatients prescribed hypnotics as discharge medication among inpatients who had been prescribed them at the time of admission decreased significantly, from 57.0% to 46.8%, after the i-sleep program (RR=0.82, 95% CI: 0.79-0.86). The proportion of inpatients newly prescribed sleeping pills after admission to the hospital did not significantly decrease (1.97% to 2.00%; RR=1.01, 95% CI: 0.96-1.07). The mean prescription rate of sleeping pills per day was 8.18% in 2014 and 7.78% in 2015.

CONCLUSION

The i-sleep program reduced the proportion of inpatients who continued to take sleeping pills from admission until discharge, although it did't reduce the prescription rate per day.

Impact of naturalistic lighting on hospitalized stroke patients in a rehabilitation unit: Design and measurement

INTRODUCTION AND RATIONALE

Stroke is a major cause of acquired cerebral disability among adults, frequently accompanied by depression, anxiety, cognitive impairment, disrupted sleep and fatigue. New ways of intervention to prevent these complications are therefore needed. The major circadian regulator, the suprachiasmatic nucleus, is mainly controlled by natural daylight, and the blue spectrum is considered the most powerful. During stroke rehabilitation, patients typically are mostly indoors and therefore not exposed to the natural daytime variation in light intensity. Furthermore, several rehabilitation hospitals may be exposed to powerful light in the blue spectrum, but at a time that is adversely related to their endogenous circadian phase, for example in the late evening instead of the daytime.

HYPOTHESIS

Naturalistic light that mimics the natural daytime spectrum variation will have a positive impact on the health of poststroke patients admitted to rehabilitation. We test specifically for improved sleep and less fatigue (questionnaires, polysomnography, Actiwatch), improved well-being (questionnaires), lessen anxiety and depression (questionnaires), improved cognition (tests), stabilizing of the autonomous nervous system (ECG/HR, blood pressure, temperature) and stabilizing of the diurnal biochemistry (blood markers).

STUDY DESIGN

The study is a prospective parallel longitudinal randomized controlled study (quasi randomization). Stroke patients in need of rehabilitation will be included at the acute stroke unit and randomized to either the intervention unit (naturalistic lighting) or the control unit (CU) (standard lighting). The naturalistic light is installed in the entire IU (Cromaviso, Denmark).

CONCLUSION

This study aims to elucidate the influence of naturalistic light on patients during long-term hospitalization in a real hospital setting. The hypotheses are based on preclinical research, as studies using naturalistic light have never been performed before. Investigating the effects of naturalistic light in a clinical setting is therefore much needed.

Sleep Disruption in Pediatric Cancer Survivors: Conceptual Framework and Opportunities for Clinical Assessment and Behavioral Treatment

Sleep disruption is a commonly reported consequence of cancer and its treatment in pediatric patients and survivors. This review summarizes common sleep concerns in this population and introduces a multidimensional framework of risk factors specific to childhood cancer that may interact to develop and maintain disrupted sleep. Based on the extant literature, parameters of the cancer and its treatment, physical and social environmental conditions both during and after treatment, changes to family behavior and norms, psychological factors and traumatic stress, and reduced physical activity are hypothesized to be the most pertinent risk factors for disrupted sleep in this population. Potential clinical assessment strategies and behavioral interventions relevant to these considerations are discussed, with reference to the behavioral model of insomnia. The review concludes by offering directions for research and clinical practice, including developing and testing comprehensive assessment tools, intervention effectiveness studies in both oncology and primary care clinics, and efforts to increase patient-provider communication about sleep in pediatric oncology.

Re-conceiving building design quality: A review of building users in their social context

Considerable overlap exists between post-occupancy research evaluating building design quality and the concept of 'social value', popularised by its recent application to issues of the public realm. To outline this potential research agenda, the paper reviews design quality research on buildings in relation to users and their social context where the term 'social context' refers to building user group dynamics, a combination of organisational cultures, management strategies, and social norms and practices. The review is conducted across five key building types, namely housing, workplaces, healthcare, education, and the retail/service sector. Research commonalities and gaps are identified in order to build a more comprehensive picture of the design quality literature and its handling of users in their social context. The key findings concerning each building type are presented visually. It is concluded that the design quality field comprises a patchwork of relatively isolated studies of various building types, with significant potential for theoretical and empirical development through interdisciplinary collaboration. Users tend to be conceived as anonymous and autonomous individuals with little analysis of user identity or interaction. Further, the contextual impact of user group dynamics on the relationship between building design and building user is rarely addressed in the literature. Producing a more nuanced understanding of users in situ is proposed as an important area for future design quality research.

Sleep Patterns During Hospitalization Following Hematopoietic Stem Cell Transplantation

PURPOSE/OBJECTIVES

To characterize patient-reported and objective sleep assessments and provide a preliminary examination of the relationships among sleep, quality of life, and demographic or treatment factors.

DESIGN

A secondary data analysis using a descriptive-correlational design.

SETTING

University of Illinois Hospital and Health Sciences System.

SAMPLE

40 patients undergoing a hematopoietic stem cell transplantation (HCT) hospitalized for the conditioning regimen, stem cell infusion, and immediate recovery period.

METHODS

Each patient wore a wrist actigraph continuously from the fourth day following HCT to the eighth day to objectively assess sleep patterns (total sleep time, sleep onset latency, sleep efficiency, wake after sleep onset, and number of awakenings). At the end of the five-day period, patients completed measures of sleep disturbance and quality of life.

MAIN RESEARCH VARIABLES

Objective sleep (total sleep time, sleep onset latency, sleep efficiency, wake after sleep onset, and number of awakenings), subjective sleep (sleep disturbance), and quality of life.

FINDINGS

The mean total nighttime sleep (objectively obtained) was 232 minutes (SD = 71 minutes), with 14 patients (35%) sleeping less than three consecutive hours during one or more study days. Age was negatively correlated with patient-reported sleep disturbance. Patient-reported sleep disturbance was significantly associated with length of hospital stay. No correlations were found between patient-reported and objective sleep assessments.

CONCLUSIONS

This study objectively documents inadequate and irregular sleep in hospitalized patients undergoing HCT. Sole reliance on patient-reported sleep assessments may not represent the full extent of the problem.

IMPLICATIONS FOR NURSING

Attempts to streamline care during the night by not waking patients for routine care unless indicated by the patient's condition (as advocated by the American Academy of Nursing) and providing supportive care for symptoms (such as diarrhea) during the night may reduce the number of awakenings and possibly improve overall sleep quality.

Pilot trial of light therapy for depression in hospitalized patients with cystic fibrosis

BACKGROUND

Depression is common in cystic fibrosis (CF) and linked with worse outcomes during hospitalization. Bright-light therapy during hospitalizations augments antidepressant regimens and reduces length of stay (LOS) in depressed non-CF patients, but has not been examined in CF METHODS: Thirty subjects used a light box emitting 10,000lx for 30min each day for 7 straight days following hospital admission for pulmonary exacerbation. Depressive symptom severity (QIDS-C) and quality of life factors (CFQ-R) were recorded pre/post light therapy.

RESULTS

Eighty percent of subjects had at least mild depressive symptoms upon admission. Hospitalized CF patients had a significantly lower mean LOS of 11.0±3.6 days compared to a historical cohort from the year prior (13.3±4.4 days, p value=0.038). There was a significant decrease in depressive symptoms for all subjects receiving light therapy (p value<0.0001). There was no relation between depressive symptoms and lung function or vitamin D. Six out of twelve quality of life indicators improved with light therapy including the domains of vitality, emotion, and health perceptions. There were no adverse events reported.

LIMITATIONS

As a pilot study, the design was limited by a lack of a control group and possible confounding effects of hospitalization treatment on systemic symptoms.

CONCLUSIONS

Light therapy was well tolerated by hospitalized CF patients and resulted in improved depressive symptoms and quality of life. Light therapy was associated with a reduced length of stay. Large, randomized trials of light therapy may be indicated for hospitalized CF patients.

The Role of Daylighting in Skilled Nursing Short-Term Rehabilitation Facilities

Objective:

The aim of this study is to investigate the best placement of windows in short-term rehabilitation facilities in terms of daylighting and outdoor views by exploring the impact of windows on resident perception of stress, mood, activities, and satisfaction.

Background:

The physiological and psychological benefits of daylighting have made it an increasingly important topic in multidisciplinary research. Although multiple studies have been written about the impact of daylight on physiological responses, few investigations have been made into the nonvisual effects related to resident mood, satisfaction, and stress level. In addition, researchers typically propose recommendations for quantitative aspects of illuminance, rather than addressing the behavioural outcomes.

Methods:

A combination of qualitative and quantitative methodologies were used to address the research questions. Thirty-four participants, who were living temporarily in the inpatient rehabilitation units of two skilled nursing facilities, were subjects in semistructured interviews and a 7-question 5-scale survey. While residents expressed the need to have direct visual access to the outdoors, they indicated that daylight was of even higher benefit. Additionally, they noted that size and location of windows impacted their stress levels, moods, and activities. More than half of the facility residents reported changing their postures for either better outdoor views or less light disturbance while sleeping.

Conclusions:

The results of this study emphasize the importance of daylighting for residents in rehabilitation units. Architects should acknowledge the role of daylighting and window views in the design of rehabilitation facilities.

The influence of environmental factors on sleep quality in hospitalized medical patients

Introduction: Sleep–wake disturbances are common in hospitalized patients but few studies have assessed them systematically. The aim of the present study was to assess sleep quality in a group of medical inpatients, in relation to environmental factors, and the switch to daylight-saving time.

Methods: Between March and April 2013, 118 consecutive inpatients were screened and 99 (76 ± 11 years; hospitalization: 8 ± 7 days) enrolled. They slept in double or quadruple rooms, facing South/South-East, and were qualified as sleeping near/far from the window. They underwent daily sleep assessment by standard questionnaires/diaries. Illuminance was measured by a luxmeter at each patient’s eye-level, four times per day. Noise was measured at the same times by a phonometer. Information was recorded on room lighting, position of the rolling shutters and number/type of extra people in the room.

Results: Compliance with sleep-wake assessment was poor, with a range of completion of 2–59%, depending on the questionnaires. Reported sleep quality was sufficient and sleep timing dictated by hospital routine; 33% of the patients reported one/more sleepless nights. Illuminance was generally low, and rolling shutters half-way down for most of the 24 h. Patients who slept near the window were exposed to more light in the morning (i.e., 222 ± 72 vs. 174 ± 85 lux, p < 0.05 before the switch; 198 ± 72 vs. 141 ± 137 lux, p < 0.01 after the switch) and tended to sleep better (7.3 ± 1.8 vs. 5.8 ± 2.4 on a 1–10 scale, before the switch, p < 0.05; 7.7 ± 2.3 vs. 6.6 ± 1.8, n.s. after the switch). Noise levels were higher than recommended for care units but substantially comparable across times/room types. No significant differences were observed in sleep parameters before/after the switch.

Conclusion: Medical wards appear to be noisy environments, in which limited attention is paid to light/dark hygiene. An association was observed between sleep quality and bed position/light exposure, which is worthy of further study.