Hospitals are causing already seriously ill patients to become even sicker by withholding food and interrupting sleep, according to a commentary published recently in the British-based journal BMJ Quality & Safety.
The commentary’s authors argue that hospitals need to work harder at creating more humane environments and practices for their patients.
“In our personal experience as surgeons at a busy tertiary hospital [Johns Hopkins Hospital in Baltimore], the goal of avoiding unnecessary malnutrition and sleep deprivation in our patients has all too often been forgotten or prioritised far behind other more technical goals of surgical care,” write Dr. Elizabeth Wick, Dr. Martin Makary and medical student Tim Xu (with British spellings).
Too often, they argue, hospitals impose needlessly long fasts on patients both before and after surgery.
Hospitals also tend to bombard patients with constant noise from “alarms, phones, hallway conversations and patients sharing a room,” which is then “compounded by intercoms, chatter, lights, plus sometimes frequent interruptions at night for medications, vital signs and lab draws,” they add.
All these factors can be detrimental to patient health:
Even a young, extremely healthy person at home without illness will become physiologically stressed and transiently immunocompromised after a mere 24 [hours] of starvation and a poor night’s sleep. These stressors alone can result in acne, fatigue, oral ulcers and impaired judgment — conditions that in the presence of illness can worsen or obscure the clinical picture being evaluated by clinicians.
In frail patients, the stressors of sleep deprivation and malnutrition are magnified further, and, in conjunction with the stress of the patient’s underlying medical condition, can overwhelm a patient’s physiological reserve and lead to or worsen complications.
On the issue of withholding food, Wick, Makary and Xu note that as many as a third of hospitalized patients, particularly the elderly, are already in a frail, malnourished state when they arrive at a hospital. Their illness may have caused them to lose their appetite or to refrain from eating out of fear of exacerbating their symptoms.
So withholding nourishment from them for even longer — often because of delays in getting the patient through a battery of medical tests and into surgery — has the serious potential of further degrading their medical condition:
Many of the fasting demands placed on patients represent out-of-date medical practices, the commentary’s authors add. In 2009, for example, a panel of surgical experts determined that prolonged fasting after gastrointestinal surgery — often justified for safety reasons — actually increases the risk of infection and does nothing to lower the risk of post-surgical complications.
“Physicians, nurses and other staff should all be aware that extended periods without food stresses a patient’s physiological reserves,” Wick, Makary and Xu write.
Hospital noise can also have a negative effect on the health of patients.
One study found, for example, that hospitalized patients recovering from heart attacks in “quiet” rooms fitted with sound-absorbing surfaces had lower heart rates and required less medication than patients recovering in standard rooms. They were also significantly less likely to be readmitted to the hospital within 90 days.
The World Health Organization recommends a maxium noise level of 40 decibels during the day and 35 decibels during the night for the average hospital room. Research has shown, however, that hospitals often exceed those levels — and by as much as 50 to 100 percent.
“Hospitals should conduct noise studies, obtain more feedback from patients on the most disruptive sources of noise and aim to mitigate them,” the commentary’s authors write. “There may be even simpler interventions, such as encouraging use of personal or furnished noise-reduction headphones, eye masks, massage and music therapy, and placing art in hospital rooms to promote relaxation.”
The environmental factor in hospitals most disruptive to patients’ sleep, however, is the every-four-hour vital sign check, a practice that dates back to the 1890s. The fragmented sleep that results from these interruptions (which occur half the time in patients who are at very low risk of having their health deteriorate while in the hospital) has been linked to poorer recoveries, greater patient distress — and a increased likelihood that patients will be readmitted to the hospital within 30 days.
“As we seek to improve quality through patient-centredness, basic human needs are important in the context of complex medical care,” the commentary’s co-authors conclude. “We should view hospitals as healing environments rather than isolated clinical spaces and design patient care accordingly.”
You can download and read the commentary in full on the BMJ Quality & Safety website.