Rx:

A Good Night’s Sleep

UR Medicine Thompson Health implements new protocol to promote better sleep, speedier recovery.

By Melody Burri

Hospital patients are sleeping better and recovering faster, thanks to new sleep protocols implemented by UR Medicine Thompson Health.

The sleep hygiene guideline was unveiled in 2022 to promote healing and improve patient satisfaction by ensuring a minimum of four hours of uninterrupted sleep for patients. That meant adopting new strategies, including reducing the number of nighttime bedside visits to record vital signs and administer medications, delaying morning lab draws, promoting a wakeful daytime environment and providing patients with items including ear plugs and eye masks.

Leading the charge was an interdisciplinary “Do It group” led by ICU Lead Advanced Practice Provider Anne Finch and ICU–observation unit–diagnostic imaging Nursing Director Mary Kate Corey, both of UR Medicine Thompson Health.

Together with eight additional team members, the DIG created formal guidelines within the hospital’s policy system and placed cues within its electronic health record system to prompt staff to incorporate those guidelines. Staff education was provided, information sheets were distributed to patients and visual reminders were displayed throughout the units.

The changes were essential because the stakes were, and continue to be, high, hospital officials said.

Why sleep matters

“In my interviews with patients, sleep is incredibly important to their satisfaction and overall feeling of wellness,” said DIG co-chair Finch.

Likewise, lack of sleep can be severely detrimental.

“There is increasing research and understanding that sleep deprivation is a major risk factor for ‘hospital acquired delirium,’ an altered mental state that may delay recovery and lead to both short and even longterm confusion and memory issues,” said Finch.

The ICU traditionally sees the highest incidence of hospital acquired delirium — between 70% to 80% of patients, she said. That altered state is also associated with significant morbidity and mortality, she said.

While the sleep guideline was primarily aimed at reducing rates of delirium in the ICU, the scope of the project was quickly expanded to all patients, said co-chair Corey, who was “incredibly proud to be part of such an important initiative for patients.”

The rollout

“The biggest challenge has been in changing the culture,” said Finch. "We rolled out a fair amount of education and I personally did some sleep rounds, going to the floors and presenting the guideline to the staff to educate and give an opportunity for questions and feedback.”

The changes were well received, she said. But at the three-month follow-up, they were still being utilized less than DIG members had hoped.

So sleep champions were adopted for each of the inpatient units, Finch said. These RNs initiate continued education and guideline protocol.

Another challenge, she said, has been getting staff on board with using the laminated sleep preferences worksheets that now hang in every room to help record and understand the patient's baseline sleep patterns — typical bedtime, wake time, preferred sleep position, preferred sleep aids like medication or white noise.

These remain posted as a visual reminder and guide for caregivers to help replicate home sleep.

An unexpected discovery was made at the six-month post roll-out survey point when Finch interviewed 10 patients in one day.

“Three separate patients on three different floors informed me that there was an individual emptying garbage cans and banging the can to remove the bag in the middle of the night,” she said.

“We clearly had not extended the education to our housekeeping staff,” Finch added. “So I quickly got in touch with the manager of the department and we worked to educate on nighttime quiet hours and using the visual cues — the yellow moon magnet on the door — as reminders that patients are trying to sleep. I know it sounds basic, but it's all about changing the sleep culture in the hospital.”

Safeguards

All patients need restorative sleep, but not all can safely achieve it in the same way.

Almost every patient in the hospital can benefit from some aspects of the sleep guideline, Finch said. They can be well served through a completed sleep preferences worksheet, a wakeful daytime environment and overnight medications that have been safely re-timed to wake hours.

But some patients have specific needs that should be assessed daily on a case by case basis. Nighttime options for stable patients might include reducing the frequency of vital signs or discontinuing continuous monitoring when appropriate. Likewise, patients who need to be turned and repositioned every two hours because of pressure ulcer risk, might be eligible for one skipped turn during the night if they are deemed to be low risk as calculated using the Braden scale.

Feedback

To gauge the effectiveness of these changes, the DIG conducted patient surveys which highlighted improvements in a number of areas.

“It really hit home when our sixmonth follow up interviews revealed that patients are, in fact, reporting better sleep,” said Finch. “We noted a more than 10% to 30% improvement in reports of deeper sleep, quicker sleep, fewer awakenings, quicker return to sleep if interrupted and better quality night's sleep. It has been so gratifying to see a need and meet it.”

Finch said there’s still plenty of room for improvement, but she’s happy to see measurable evidence of culture shift.

“Just last week, after more than a year into the initiative, I had a unit coordinator reach out and request more moon magnets for one of the units,” she said. “They had more patients on the guideline than magnets available. That's a great problem to have. Back to the craft room to create more moons!”

“The DIG team can be proud of how they implemented an evidenced-based best practice change to improve the quality of care, and patient satisfaction,” said Corey.

Joining Finch and Corey on the DIG were Thompson employees Stephanie Friel, James Hart, Laurie Malotte, Bridget Osterhout, Erica Iversen, Mary Freeman, Shelby Valenti, and Jill Wilson.

The group will be formally honored in May during the health system’s Shining Star awards ceremony.

By Anne Palumbo