Protecting Sleep in the Hospital, for Both Patients and Doctors
nytimes.com
nytimes.com
They absolutely 100% ignore any semblance of a sleep cycle for their patients (as well as proper nutrition but that's for another day). Constant interruptions to check vitals, ask if we want to pick a meal, beeping infusion pumps, a whole squad going on rounds with banal questions...it seems to never end.
I'd like to find a watch/fitbit for her and either find or write an app that just fills the screen with a color based on her current sleep phase...green she's awake, yellow light sleep and red means she's in REM or deep sleep and should not be disturbed unless necessary. Place that by the door so the nurses can see and hopefully adjust their timing accordingly.
I also had 32db NRR earplugs that I take with me everywhere (my hearing can be very sensitive), and I used those extensively.
I got lucky and I wasn’t in the hospital for long. Once I got home, I could sleep as much as I needed.
Related to this: I looked into trying to get real time sleep data found it surprisingly hard. Fitbit, for example, only makes sleep data available after sleeping is over and the device is synced to the cloud. If anyone has a good solution to this I'm all ears.
All it can do is measure movement (which might mean they are awake, or it might mean they are in REM) and no movement.
Then it can post-process it later and use the length of stillness and the patterns/amount of movement to infer probable sleep cycles.
I don't think it's possible to get real-time sleep phase data without proper EEG sensors to measure brainwaves.
Note that your heart rate slows during sleep, which is useful for detecting sleep cycles etc. Which is why I mentioned the heart monitor.
There seem to be an endless stream of companies trying to make easier to use EEGs, either for clinical or home use, and it seems like almost all of them go bankrupt in a few years. I suspect most of them are also not very accurate. A couple of years ago I saw an interesting one that tried to automate most of the scoring but would send the more difficult cases for human scoring. I'd guess that one at least has a better chance of reasonable accuracy than most. I think it was dreem (dreem.com), although they only mention automated scoring at this point. Possibly they managed to train their automated system sufficiently or maybe it was a different company. In any case, I would be suspicious of claims that they are as accurate as a sleep study, although it is certainly possible that someone has come up with an actually accurate method. You would still be spending hundreds of dollars for a device that sends all the data it collects into the cloud and in most cases will be useless if the company goes out of business or decides to stop supporting older products. They usually aren't clear about what, if anything, will still work if the company goes out of business.
Of course, less than ideal results can still be interesting. Once a few years ago I managed to set up my laptop's microphone to record might sleep at just the right level and it was very interesting. Unfortunately, I didn't write down how I changed the settings to get the right volume and could reproduce it when I tried a couple of times, although I imaging there are online guides for this type of thing and I didn't go looking for them. For anyone who sleeps alone and does not use CPAP I'd recommend giving it a try. With builtin laptop speakers you can only hear when sleeping on one side (I never sleep on my back, so not sure if that would be covered), but I bet it wouldn't be too hard to set up two or three microphones to get a good recording in any position. It isn't trivial to review, but looking at the recording in audacity it is possible to see the regular parts and just listen to the less regular parts. You can't even fully tell asleep or not from that, but you can notice when your breathing changes and in my case it was very interesting to see how that often happened due to quiet noises (e.g. a dog barking in the distance, car going by quietly). You can also tell how often you move at night (about every 45 minutes in my case, at least that night).
I've also used a basic pulse oximiter (Contec CMS-50I, was about $90 new on ebay) with the Sleepyhead software. It has pulse, SpO2, and perfusion index. At quick count it looks like I've used it 24 nights over the past couple years and I'm not sure the device will necessarily last much longer, hopefully it will (the display has an always on line and there are sometimes issues with the sensor that might be due to an issue in the cord, although it is sometimes due to not being cleaned sufficiently or to my hand moving in the sensor; the sensor can be replaced for something like $20 and it came with a second "one time use" sensor that I haven't tried but I suspect might be possible to use more than once). The pulse reading seems to accurately show when I first get to sleep, but doesn't help determine when I am sleeping for the rest of the night. SpO2 is the main thing I use it for, but doesn't help determine anything about sleep. Perfusion index mostly seems to indicate how warm my hand is and so can sometimes indicate when I change position.
https://help.fitbit.com/articles/en_US/Help_article/2163#Aut...
> a whole squad going on rounds with banal questions
I’m sure there’s a better way, but that’s par for the course for a research/teaching hospital. The patient’s room is a real-life classroom and lab, with everything that goes along with that.
Nurses are not there to make every patient's stay miserable. At least in my practice setting, we are extraordinarily receptive to suggestions around care and stepping in as informal advocates when families are not available.
First hospital was world renowned, ranked #1 in the world for the category of care she needed. This hospital seemed to spend all their money on what I would call “celebrity surgeons”. World renowned, only the best. I suspect the side effect is that they spent much less money on nursing care. There was only one or two nurses to a single floor overnight, and they utilized nursing assistants for everything. I got lots of attitude from the nurses, I suspect it was part of the culture. Their schedules were also much more rigid since they had a lot more patients to cover with limited resources. They also seemed to focus a lot more on the raw numbers and not the individuals. We fought tooth and nail to get a schedule that worked, and got a small amount of wiggle room, but it took a lot of work.
Second hospital was a completely different experience. They had a good surgeon, who had good outcomes, but didn’t have as many surgeries under his belt, so less data. I suspect this meant he took up less of the budget. This hospital had zero nursing assistants, and each nurse only had one or two patients at any given time. This resulted in the nurses advocating for us, and actually working their schedule around us.
In a way, it shows how powerful someone is, that they could take something so valuable from another with almost no effort, and yet so lost if they would do so.
This is vital tech.
Getting started:
https://www.sleepcycle.com/how-sleep-cycle-works/
https://www.instructables.com/id/Sleep-Cycle-Alarm-Clock-wit...
https://github.com/npes-95/sleeping-beauty/wiki/Hardware-&-E...
https://github.com/npes-95/sleeping-beauty/blob/2f32d4722d3d...
https://www.psychologytoday.com/intl/blog/brain-babble/20131...
https://play.google.com/store/apps/details?id=com.fullpower....
https://www.businessinsider.com/does-apple-watch-track-sleep...
The main problem I have is that I often wake up everyone else in the same bay due to lack of private rooms and the need to turn on lights and often shout at dead patients so they can hear me.
Beeping machines is a big problem, and the sooner they are made to wirelessly notify the better.
However, I wonder if you could comment on whether you think a) that you and your colleagues' approach is reflective of the broader medical community, b) you think earplugs could be feasibly issued in shared wards (from a financial/hygiene/other perspective)?
My hospital gives out ear plugs. Luckily never had to test it but the beeping is so loud and annoying that I doubt they’d work for me.
That said, besides the specific reason our daughter was in-patient to address, she was otherwise vigorous and healthy, and that absolutely was not the case for the majority of the other kids no the ward, most of whom had congenital heart defects and other developmental conditions, and I can completely understand why it becomes more important to interrupt less stable patients.
Do they usually respond? Have you ever had a reply "from beyond"?
Food is another area of concern. You can starve during a hospital visit or end up broke buying supplemental calories in the shop.
Then there is the sheer difficulty of navigating the typical hospital if you are somewhat disabled or in agonising pain.
It is as if that every hospital operates at some subliminal level as a field hospital in some 19th century war. It is thoughtcrime to think of how the place is run is less than heroic. There is also triage so that people with serious problems get dealt with before those with minor ailments. Therefore it is fine to keep a lot of people waiting. Or is it?
In places that have a customer service ethos you don't keep people waiting. Apart from anything else it is just plain inefficient. The sleep thing is what I would consider inefficient. It is a given that at a typical hospital none of the patients are sleeping too well, if it is not disruption then it can be flimsy blankets. Sure any ward is not going to be your own bed, but we are way off any customer first thinking when it comes to this.
I have had discussions about this with plenty of people and the idea of customer service in healthcare is poo-pooed. Is there anywhere in the world where it has been given a try? Scandinavia? Or even Cuba? It is not rocket surgery giving the patients a good night's sleep and enjoyable food. In our private lives we recommend to others that have a big day ahead of them that they get a good night's sleep. Why does this go out the window in the world of healthcare, whether it be staff or patients?
It really is amazing that hospitals are not patient-focused. I think the problem is that their real customers are insurance companies, who don't generally care how patients are treated.
I spent several days in hospital for surgery as a teenager in Australia and my parents (with private health insurance) paid for me to have a private room, which I remember as being pretty comfortable and not filled with interruption. On the other hand I was on serious painkillers and couldn't even stand up so I may not be a reliable witness.
But what if you were born into a family that were not able to look out for you?
From the sibling comments I get the feeling that people in countries where private health insurance is needed that the concept of healthcare for all is not imaginable. I was writing in the context of the NHS, as introduced by the Labour government in the post WW2 UK when Britain was broke and broken.
It goes against the NHS ideal to have some patients be able to pay for an upgrade, you get what you are given. There are no up-sells.
In recent years the neo-liberal politicians have chipped away at the NHS, slashing budgets and outsourcing services. Now that I consider what people in the USA get for healthcare I wish to take back all of my grumblings about the UK's beloved NHS! Sure it can be improved on but the values that go with it - universal and for all - are important to me. I would not feel happy paying for a better bed than the next guy or being the person that can't pay for that better bed. I have a sense of fairness that this goes against. I imagine I would not have that 'survivors guilt' feeling if private healthcare was all I knew.
That's not completely true - when our son was born we paid for a private room in an NHS hospital. Mind you that was ~20 years ago don't know if they still do it.
I thought that forceps had been replaced by sink plungers. Obviously not the sort you buy in the DiY store but the expensive medical grade. The same principle applies though, suction cup goes on baby's head and with one pull the baby is born!
I thought the suction cup approach was standard now with the benefit to the technique being no birth marks.
Haven't got time for this rabbit hole now, I might save it for when I meet someone with skin in the game!
Hospitals are always understaffed. Doctors and nurses don't have the time to keep the sleeping schedule of all their patients into account. If you want that to change, I guess more investments in healthcare would be the way to go.
People die in hospitals every day. If you're woken up a bunch of times while recovering from something, count your blessings that you're well enough to be woken up in the first place.
Hospitals are understaffed, but that does not mean they have an excuse to endanger patient safety by ruining their best method of recovery; sleep. Many of my friends work in sleep science. Ask any of them what they think about the current ways we treat patient sleep, and they'll go on an hour long tirade about how absolutely ridiculous it is - how there are 100s of things that we could be doing differently, but don't because of antiquated science and work dogma, and there is almost no reason for close to 50% of times we wake patients up.
I highly recommend "Why We Sleep" by Matthew Walker. He puts a massive spotlight on the health implications that are cause by lack of sleep, especially for the elderly who make up the most hospital patients.
Generally speaking, doctors and nurses care about patients (some more than others, sure). They're also aware of the importance of sleep. If you're a nurse on a night shift, and you have to take care of a ward of 20 patients, you'll quickly find yourself too busy to be terribly considerate. Especially when something unexpected happens.
The main criticism they had was that of treatment for patients with infection. It's nice for a doctor to know whether the body is fighting it off effectively or not. Many doctors will ask for blood tests every hour because it's so nice to know, and you'll get a pretty graph to tell you what's going on by the hour. You know what's better than a graph? Letting the patient fight off said infection. Best way to do that? Decent sleep. Apparently the education on sleep is abysmal in most institutions currently, purely because it's been a branch of medicine that has bloomed late, and it has resulted in doctors who often don't give sleep the respect it deserves.
Again, this is not from the horses mouth. I am only passing on the information my friends gave me as effectively and accurately as I can. I'm not trying to shit on those in the medical profession, as it's a career I envy, but it is something that is a chronic issue in most wards and many sleep specialists across the globe are trying their hardest to rectify it with significant push back.
Just because doctors and nurses have a desire to help, doesn't mean that anything they do is therefore the right thing to do. Like you said, we know that sleep is critical to healing so doesn't that go against nurses and doctors having a desire to prevent harm? I would think that something preventing healing or causing emotional stress is de-facto harm.
Yes, hospitals can be understaffed and underfunded, but that's hardly an excuse when we know some of their practises can cause harm. You wouldn't let a nurse do something harmful and let them say "Sorry we don't have the budget". We can sit here and say that yes, here's the reason but that doesn't actually mean that's what they ought to be doing.
There seems to be quite a lot of bias for doctors and nurses because they do work that is seen as very important and good. While that is true, it can often cloud judgement when deciding what we ought to do in a prescriptive medical sense. There's been many occassions where doctors or nurses were holding back advancement of their own field because they're just people and like all people they have their own faults and their own bias. I don't say this to say that doctors are bad, or cause harm, but rather that some are bad and some do cause harm, even if they're trying their best to stop you dying.
When my daughter of three weeks old was in the hospital she needed to get some checks at night. Some doctors would walk in with a little flashlight, do the checks and leave the room without waking her up.
Others would switch on the ultra bright hospital lighting waking up the little one, only to do checks which take 10 seconds but kept my daughter up for hours.
Speaking from the UK, where this problem has been well publicised, the biggest complaint being disturbance during the night when it ought to be obvious that most people will be asleep?
Accepted there will be exceptions where patients are sleeping during the day and this does present obvious problems. However, where medical staff are carrying on their normal work routines or idly gossiping at night time without regard for their patients is inexcusable.
When you overhear the nurses commenting " its xxxxx he might die in the night - you might think getting woken up is not that important.
Now is this absurd in some patients, yes! In very elderly patients this may do more harm than good by causing delirium, which can be deadly...
Personally, I go out of my way to not wake anyone up, but that’s often not an option in some situations.
But to say it is doctor or nursing arrogance is to not really understand healthcare.
Could this be accomplished by using devices that monitor patients vital signs and report the data back to the nurses station? Then spot checks would not really be needed.
> Additionally, there is evidence that hourly rounding prevents some bad outcomes like patient falls.
Could you list some of the studies you're referencing?
Doubly so when, now nurses have to track uptime of all those sensors.
Re: studies. I can't say I know the evidence that well, so I wouldn't want to mislead, this isn't my area. A google search for Hourly Rounding reveals lots of articles, but I haven't poked into the underlying data that proves it is a successful strategy (if that exists). I guess I overstated my confidence above.
For example, many doctors write prescriptions at the end of shift and neglect to put a specific time to administer on it. The nurses are then required to use the time the prescription was created as when the medicine must be provided, which is often a very inconvenient time for the patient.
If doctors received adequate training in how hospitals actually worked, in what nursing staff does, and in how they can best interact for optimum care, many of these problems could be resolved.
In the hospital you rarely get patient centric care. Instead, you get institution centric care.
This guy's channel brings up a lot of interesting points:
Source: am a doctor and see this kind of thing on small and large scales
BP cuffs get very tight and will probably wake you up. You may even wake up if a saturation probe is put on your finger.
>You can also do a visual checkup without waking up the patient.
You can get respiratory rate visually. What other vital sign can you get without touching the patient? Transdermal temp. maybe (inaccurate).
"When disagreeing, please reply to the argument instead of calling names. "That is idiotic; 1 + 1 is 2, not 3" can be shortened to "1 + 1 is 2, not 3.""
I woke up once in the night and saw a shadow with a tiny led light, carefully taking a look at the sleeping child before disappearing just as quitely.
(FWIW the nurse was there every night, but this was the only time I observed it.)
My daughter slept very well during those days, as did I.
IIRC they'd also plan with me in advance to know when the best time would be for checks and blood works, at least it came across as very thoughtful.
This was Norway, not one of the major hospitals, so not so relevant for many others except as proof that it isn't like that everywhere in the world.
I was even more motivated when I overheard a phone call from a patient down the hall. It was so loud that my nurse rolled her eyes and informed me he be awake until 3am. I was sure between him and the nurses there wouldn't be any sleep in that place. I got out about 20 minute before the cutoff time for being stuck in hell.
Since we went through different hospitals, it’s hard to compare, but at the last one, it seemed like the fact that we had 3 healthy children at home already made the nurses surprisingly willing to defer to our preferences, and we got as close to a full night of sleep in the hospital with a newborn that you can get.
As an added data point, we also told the nurses at every hospital that we wanted to leave as soon as possible, so trying to kick us out wasn’t a consideration.
With exception of one nurse, every single person pushed back against us asking for fewer interruptions and said it was for the baby and mom. One nurse basically acted like my spouse was acting entitled for wanting to sleep. I wanted to swear at that nurse and throw her out of the room.
One of the night nurses realized my spouse was about to collapse and found a way to let her sleep for 3 hours.
for which they charge facility fees
When we returned home in the afternoon ....we both took naps.
Older (Geriatric) friend of mine, serious medical condition, which necessitated (I'm told) continuous tests, medication & checks to be run to make sure he was in a "serious but stable" condition instead of a "on the way to death" situation.
But this was for a number of days (nearly a week) and essentially it meant the few times he was able to sleep past the pain/illness, he'd be woken up within a few hours for another round of tests, medication, etc.
He managed to get through it somehow, and I don't have any solutions to how they could have done it better (I'm no doctor), but it can't help the condition that he was getting by on one to two hours of sleep a day on top of the medical problems.
Yet on the other hand it's so often emphasized how important good sleep is for health. It seems such a nobrainer to do everything possible to make sure people can sleep well in a hospital.
Anyone seen hospitals with Orthopedic pillows? Or doctors recommending pillows for sleeping on your back?
[0] https://en.wikipedia.org/wiki/Orthopedic_pillow#Back_sleepin...
[1] eg "Emolli Contour Memory Foam Pillow" on https://www.forbes.com/sites/forbes-finds/2019/02/21/pillows... (advertising article)
Your charge against doctors and nurses is extreme and unwarranted. Health professionals don't exacerbate these problems willingly or intentionally. ICU delirium puts doctors and nurses at risk of injury or even assault by patients with vivid hallucinations.