Nonpharmacologic Interventions Improve Sleep Time in Hospitalized Patients


Findings from a nonrandomized controlled trial in the Netherlands suggest that sleep time of hospitalized patients may be significantly improved with nonpharmacologic interventions such as the postponement of morning vital sign checks and medication administration rounds from the night to the day shift.

Eva S. van den Ende, MD, Section of General Internal Medicine, Department of Internal Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC location Vrije Universiteit Amsterdam

Eva van den Ende, MD

The findings of a nonrandomized controlled trial in the Netherlands (NL7995) with 372 patients showed that hospitalized patients may significantly improve their sleep time with nonpharmacologic interventions utilized by hospital staff.1

The improvement of sleep time with hospitalized patients in the trial included morning vital sign checks postponement and moving medication administration rounds from the night to the day shift. Although nonpharmacologic interventions have been recommended as a treatment for patients for improving sleep, present studies show equivocal results and have been generally poor in quality.

In the intervention group, patients had a total sleep time (TST) of 40 minutes longer, with the control group reporting an average of 6 h 5 min of sleep time (IQR, 4 h 55 min-7 h 4 min). In comparison to the control group, the intervention group had 6 h 45 min of sleep time (IQR, 5 h 47 min-7 h 39 min; P < .001). This was associated with a 30-minute delay in final wake time, where the average time for waking up for the control group was 6:30 am (IQR, 6:00 am to 7:22 am) while the intervention group woke up on average at 7:00 am (IQR, 6:30-7:30 am; P < .001).

Eva S. van den Ende, MD, Section of General Internal Medicine, Department of Internal Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC location Vrije Universiteit Amsterdam, and colleagues observed that the nightly vital sign checks performed on the patients decreased significantly, with the control group having them done 54% of the time, while the intervention group experienced them only 11% of the time(P <.001). Overall, the sleep quality between both groups did not differ significantly.

“First, postponement of early morning nursing rounds is recommended because the delays were associated with delayed final wake times and increased TST. These changes in morning routines were well received by the hospital staff and maintained after the study was completed. We therefore recommend this intervention because it is relatively simple and may have a potentially large benefit for inpatient sleep,” van den Ende et al noted.

Patients for the trial were recruited on the acute medical unit and medical and surgical wards of 39 Dutch academic hospitals in the Netherlands. Recruitment for the control group patients (n = 222) was held between September 1, 2019, and May 31, 2020, for all adults who spent exactly 1 full night in the hospital. The intervention group patients (n = 152) were recruited between September 1, 2020, and May 31, 2021, with the average age of both groups being 65 years (IQR, 52-74). The analysis included 331 of the patients with 59% of them men (n = 195). Most patients (138 controls [77%]; 127 intervention patients [84%]) were in the acute medical unit.

State of Insomnia Care and Overcoming Inconsistencies in the Traditional Care Strategies

Ashgan Elshinawy, DO, a pulmonologist at Penn Medicine, assessed the current ways to treat patients with insomnia and the areas of needed improvement.

“Despite the fact that patients often stated they were disturbed by noise and light, interventions such as sleep masks and earplugs were unpopular. Although some individuals reported benefit, to improve the overall sleep of patients it seems reasonable to implement more systemic solutions,” van den Ende and colleagues wrote.

The main sleep-disturbing factors were noises, pain, toilet visits, and being awakened by hospital staff for both groups. Earplugs, an eye mask, and aromatherapy were given to the intervention group to use during the intervention period. Of the items given to the intervention group, and out of 147 patients, the sleep masks (16%) and the earplugs (12%) were the most used. This supports findings in earlier randomized controlled trials where the adherence rates ranged from 60% to 65% for patients when night nurses recommended these sleep tools.2-4

The researchers used an actigraphy and the Dutch-Flemish Patient-Reported Outcomes Measurement Information System sleep disturbance item bank for measuring sleep with the patients. Patient-reported sleep disturbing factors and the use of sleep-enhancing tools were other outcomes that were included.

van den Ende and colleagues noted that future studies should investigate whether having patients wear more comfortable sleeping masks and earplugs would increase popularity of the intervention. Also, that future research should focus at the patient level on whether there are alternatives to attenuate external stimuli without completely shutting the patient off from the outside world, in effort to reduce exposure to sound and light.

1. van den Ende ES, Merten H, Van der Roest L, et al. Evaluation of Nonpharmacologic Interventions and Sleep Outcomes in Hospitalized Medical and Surgical Patients: A Nonrandomized Controlled Trial. JAMA Netw Open. 2022;5(9):e2232623. doi:10.1001/jamanetworkopen.2022.32623
2. Bourne RS, Mills GH, Minelli C. Melatonin therapy to improve nocturnal sleep in critically ill patients: encouraging results from a small randomised controlled trial. Crit Care. 2008;12(2):R52. doi:10.1186/cc6871
3. Sweity S, Finlay A, Lees C, Monk A, Sherpa T, Wade D. SleepSure: a pilot randomized-controlled trial to assess the effects of eye masks and earplugs on the quality of sleep for patients in hospital. Clin Rehabil. 2019;33(2):253-261. doi:10.1177/0269215518806041
4. Leong RW, Davies LJ, Fook-Chong S, Ng SY, Lee YL. Effect of the use of earplugs and eye masks on the quality of sleep after major abdominal surgery: a randomised controlled trial. Anaesthesia. 2021;76(11):1482-1491. doi:10.1111/anae.15468
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