I recently spent the night in the hospital with a friend who underwent a minor procedure.  It was a fascinating experience to watch the hospital “from the other side”.  Overall, I was very impressed  – the nurses, patient assistants, technicians, clerks and food service personnel were universally professional and kind.

But then we went to sleep…. or tried to.  Vital signs, meds, and necessary events were more or less over for the day by 10pm.  The unavoidable noise in the hall, unfamiliar bed, and the events of the day made it difficult to get to sleep, but we both drifted off around midnight.

At 4am there was a cheery “Sorry to bother you, but I’m here to get your weight”.  She couldn’t have been nicer but when I asked why my friend had to be awakened at 4am (!) for a weight (!) she responded, “We have to have the weights, labs, x-rays and vitals all completed before the day shift starts at 6am.”

Not too long after this experience, I admitted a long-term (and adored) patient of mine for an elective procedure.  Her parents reminded me that last time she was admitted I wrote an order to forgo the middle of the night vital signs so their daughter (and they) could sleep.  Coming on the heels of the night I spent with my friend, it made me think about how we manage sleep in the hospital.

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Why do we wake patients up to weigh them?

There are patients who absolutely must be woken up for medical reasons.  If you are admitted for a hypertensive crisis, you need to have your blood pressure checked during the night. Waking patients up in the middle of the night for things that could easily be accomplished during daytime hours is done for three reasons, none of which are medically necessary:

1) To distribute work to the less burdened night-time staff from the day time shifts

2) To have the data available for morning rounds.

3) Because of pressure to get the patient out of the hospital at a certain time

Is there really no way to off load the busy day time shift without waking up patients?  Would it really change things if stable patients (particularly if they are on monitors!) were allowed to sleep through the night?  Would it change therapy if the daily weights were at 10 in the morning instead of 4 in the morning?

There’s no question it’s nice to have data for morning rounds – but is it really essential?  How much of this is a holdover from the paper chart era? In the era of the electronic medical record, access to data- at any time of the day or night – is easier than it used to be.  Granted, morning report or rounds would be different, but I think it’s something we could figure out.

There is financial (and other) pressure to get patients out of the hospital.  But have we looked at ways to manage this that don’t involve waking up patients?  For example, there are hospitals that count the “day” in the hospital by the patient census at midnight.  As long as you are out of the bed at midnight you don’t get charged for the day.

Sleep is important for recovery from illness or injury.

There are numerous studies that suggest that the immune system in particular is affected by disruption of sleep.  The data are not conclusive, but many physicians, nurses and scientists have published work suggesting that protecting sleep for ill or injured patients might be important:

• “When tissues have been damaged, the rate of healing is greater during sleep.”

• “Hospitalization may severely disrupt sleep, which can worsen pain, cardiorespiratory status, and the psychiatric health of acutely ill patients”

• “Immune system dysfunction, impaired wound healing, and changes in behavior are all observed in patients who are sleep deprived.”

• “Disrupted sleep is associated with immune system dysfunction, impaired resistance to infection, as well as alterations in nitrogen balance and wound healing.”

• “Sleep deprivation has been shown to be associated with an increase in inflammation that is also involved in the development of neointimal hyperplasia (or restenosis).”

• “Indirect epidemiological and experimental evidence suggest that the severity of injury during stroke is influenced by prior sleep history.”

• “Both acute and chronic intermittent sleep deprivation exacerbate colonic inflammation.”

Sometimes it’s not about the patient.

In babies with necrotizing enterocolitis, we order abdominal x-rays every 8 hours for at least a day or two (to look for air in the abdomen.).  If the x-ray shows “free air” (like the one below), it means they need emergency surgery to deal with the perforated bowel.

The standard schedule in our hospital for q8 (every 8 hours) x-rays is 6am, 2pm and 10pm.  Here’s the problem with that schedule as far as hospital efficiency goes:

• The 6am xray, if it shows a problem, will result in action around 7.  If the baby needs surgery, the operating room is already set up for the 7:30 cases.  Because the OR schedules is usually very full at the beginning of the day, we often then have to “bump” (postpone) a patient to do this emergency case.
• The 2pm x-ray will result in the surgery being posted around 3,  a complicated time in the OR since day time nursing staff is leaving and the remaining cases are being juggled.
• The 10pm xray will start the process rolling at 11 or so – putting the surgeon in the OR in the middle of the night.

Since the timing of the x-ray has a big effect on the timing of the surgery, it becomes a variable that really affects what happens. Here’s what happens if you change the schedule to 3am, 10am, and 8pm

• The 3am xray, if it shows a problem, will result in action around 4. Surgeons are the early-birds of the hospital. Since they will be waking up early anyway, the case can easily be started at 5 or 6, which helps with the OR schedule and keeps the surgeon from being up all night.
• The 10am x-ray will result in the surgery being posted around 11 – this is a time when “holes” in the OR schedule are easier to find, and getting the baby into the operating room will be easier.
• The 8pm xray will start the process rolling at 9 or so – which means the surgeon is more likely to get some sleep.

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What’s the bottom line?  We don’t think about some of the unintended consequences of our orders.  Sleep is important – for both patients and the people taking care of them. It’s worth thinking about.