Acute hospitalization can precipitate insomnia- the insomnia being related to the underlying illness, medications, change from usual nighttime routines and a sleep disruptive hospital environment. Both insomnia and the drugs used to treat it may contribute to delirium, increased fall rates, increased restraint use, increased length of stay and lower patient/ customer satisfaction. In a prior study that tested a non-pharmacologic sleep protocol by nurses for hospitalized older adults, the use of sedative-hypnotic medications was successfully reduced with an improvement in the quality of sleep.
Purpose: We undertook a multidisciplinary quality improvement project with the objective to use low cost, nonpharmacological methods in order to improve sleep. The intention begets reducing the use of zolpidem, improving the patient experience and reducing falls.
Establishing a pilot medicine unit, a core team including Hospitalists, Geriatricians, Nurses, Pharmacists, Music Therapists, Administrators and Housestaff was built. We administered a 5-question sleep survey to a convenience sample of 125 patients to better understand current sleep barriers. Patients were given a welcome bag with headphones, an eye mask, earplugs and an explanation of the project. Educational material and posters promoting healthy sleep habits were distributed, targeting patients, visitors and medical staff. The team enforced quiet hours (10pm to 6AM), during which vital sign checks and blood draws were minimized . Environmental and individual patient music therapy, as well as a TV Spa channel, were promoted, as well as acupuncture. Nighttime comfort with warm blankets, warm milk and tea was offered. We introduced melatonin to the hospital formulary as an alternative to sedative-hypnotics. Post these interventions, the core team administered 125 patient surveys to evaluate the project. We also tracked the unit’s zolpidem prescribing patterns, HCAHPS scores and fall rates.
There was a significant difference in the mean quality of sleep (pre and post intervention: 2.8 vs 3.34, scale 1- 5, P= 0.0003). There was no significant difference in the mean times woken (pre and post: 2.16 vs 2.12). Significant differences for “reasons why awoken” were reported only in the categories of illness and blood draw, with more patients reporting both post intervention (for unclear reasons). HCAHPS scores showed a trend to improvement in 4 relevant categories including notably, quietness of the environment. A trend was noted of decreased zolpidem orders. There was no difference in falls (however the unit baseline is low at 2- 4 falls per month).
Project Sleep demonstrates that with staff engagement, low cost, easily available interventions can improve quality of sleep and the patient experience, while avoiding zolpidem use.