Anyone who has been a hospital patient knows one undeniable truth: it is impossible to get a good night’s sleep. Daily labs are drawn at 1 a.m. SCDs squeeze your legs every 10 minutes. Machines beep in your room. Chatter and alarms flood the hallways. Even the most exhausted of us would have trouble drifting off amidst this clamor.
As third-year medical students, we often hear something to the effect of, “I’d have slept better if you guys hadn’t woken me up 20 times last night!” We are among the first waves of sleep disruption in the morning, followed by our residents, attendings and other essential members of the care team. Living in a world where F.lux will adjust the intensity and color of your computer screen at night, the question stands — how is it that sleep is not given importance in hospitals, our places of healing? In this reflection, we delineate the negative consequences of disrupted sleep in patients, highlight the largest contributing modifiable factors and offer solutions to this pervasive problem.
Patients and providers understand that sleep deprivation is a nuisance. Patients ranked sleep deprivation as their third greatest fear after only pain and intubation. Providers understand the need to perform essential care tasks at night, but 88% of 1,220 surveyed agreed that poor sleep negatively impacts healing and therapeutic response. A 2004 study reported an average of 42.6 overnight care interactions in critical care units, namely monitoring of vital signs and I/Os. Sitting outside a standard patient room on the fifth floor of the Gibbon building at Thomas Jefferson University Hospital, we observed that the lights were turned on over 20 times between 9 p.m. and 7 a.m. alone.
What effect does sleep deprivation have on the human body? After one day of sleep deprivation, COPD patients experience a significant decline in FEV1, FVC and maximal inspiratory pressure. Sleep-deprived cardiac patients demonstrate surges in stress hormones that drive up their heart rate and increase their risk of heart attack. Studies have shown that as little as two nights of sleep deprivation produces deficits in innate and cellular immunity. The inability to rest also unsettles the body’s metabolic equilibrium, decreasing insulin sensitivity.
Reinforcing circadian rhythms in the hospital — i.e. exposing patients to light during the day and maintaining darkness at night — has been studied in a wide variety of contexts with tangible results for patients and hospitals. A 2005 study of post-operative patients found that those on the “sunny” side of the hospital used 22% less analgesic medications per hour, producing a 21% decrease in pain medication costs per patient. Coordinating care and readjusting workflow can even reduce the use of nighttime sedatives from 32% to 16%. Lighting patterns that reflect natural day-night cycles reduce agitation in dementia patients, shrink length of stay for cardiac patients and reduce depression in psychiatric patients.
While not every issue negatively impacting patient sleep is modifiable, minor changes can decrease the amount of disruptive noise and light overnight in the hospital. A 1998 ICU study reported that 49% of major noise in the ICU was attributed to talking and televisions. When providers in the ICU adjusted their behaviors (e.g., conducting team meetings away from patient rooms), 75% of the 24-hour care cycle became significantly quieter. Light stimuli, especially the 4000K blue- and red-enriched lighting that is used in lots of hospitals, is especially effective at driving down melatonin production in the brain. With each flick of the light switch, the body’s natural mechanisms for sleep are broken down. Practitioners can help reduce unnecessary light stimuli by rounding later in the morning, keeping the lights off during questioning and remaining cognizant of the times tests and medications are carried out.
Circadian-friendly technology also has a growing presence in healthcare. Several large children’s hospitals throughout the country (like the University of Minnesota Masonic Children’s) have piloted global circadian-informed lighting systems to help their patients get better sleep. From personal experiences, rounds usually begin later on pediatrics rotations. Pediatric surgeons even defer early morning pre-rounding on their patients so that they can sleep and feel more at ease. These interventions are excellent, but why are they limited to pediatric patient populations? Poor sleep affects adult patients in the same, if not worse, ways, especially when you consider their co-morbid conditions (see above).
Sleep deprivation makes it harder for patients to heal, produces increased medication costs and ultimately impacts outcomes. Simple workflow modifications, from noise reduction to reduced light disruptions, have been shown to produce demonstrable improvements in hospital sleep quality. Even as we are growing to become competent healthcare providers, we can demonstrate empathy for those receiving care by respecting the role of rest in effective healing.