When people are in a hospital they get much less sleep, wake up more often during the night and awaken earlier in the morning than they do when they’re in their own homes, reports a study published recently in JAMA Internal Medicine.

Yes, yes. Those findings may make this seem like a “duh” study. Anybody who has spent a night in a hospital knows only too well that a host of factors can interfere with sleep in those institutions. Some are patient-related, like pain and worry, while others are hospital-related, like noise and being awoken for medical tests and procedures.

Yet, despite the ubiquitousness of the problem — or perhaps because of it — hospitals need to figure out ways of minimizing it. That’s because sleep deprivation in hospitals has been linked to a host of medical complications. Not getting enough sleep can, for example, negatively affect the way the body’s immune and endocrine systems work, thus interfering with healing. Interrupted sleep can also play havoc with blood pressure, raising the risk of a heart attack or stroke.

In addition, sleep deprivation increases the risk of a hospitalized patient becoming delirious or experiencing a fall.

“When our patients relate their difficulty sleeping in the hospital, they are not reporting only a nuisance but also a direct contributor to adverse outcomes, even mortality,” write the authors of a commentary that accompanies the study.

A ‘flash mob’ survey

To find out just how bad the sleep deprivation problem is at hospitals, a team of Dutch scientists used a “flash mob” research technique. On a single day — February 22, 2017 — they descended on 39 Dutch hospitals to survey 2,005 patients. The patients ranged in age from 18 to 81, although half of them were over the age of 68. 

All the patients had spent at least the night before the survey day in a general hospital ward. The researchers did not survey patients from intensive care, coronary care or stroke units. 

When the survey data was analyzed, it revealed that the patients reported sleeping an average of one hour and 23 minutes less in a hospital bed than they did in their own bed at home. They also woke up an average of 3.3 times per night in the hospital compared to 2.0 times a night at home. And they awakened in the morning an average of 44 minutes earlier than at home.

In two thirds of the cases, hospital-related factors were the source of the sleep disruptions. The most common factors were noises made by other patients (cited by 23.6 percent of the survey’s respondents) and middle-of-the-night awakenings by the medical staff (cited by 20.1 percent of the respondents).

The leading patient-related factor behind nocturnal awakenings was a need to use a toilet (cited by 21.6 percent of the patients).  

Only 28.2 percent of the patients said their morning awakening in the hospital had been spontaneous. The rest said it had been caused by hospital staff, the noise of other patients or other hospital-related factors. 

Interestingly, the study found no significant difference in the quantity and quality of sleep reported by patients who slept in a private hospital room versus those who shared a room with other patients. 

“A probable explanation is that in most Dutch hospitals, the sickest patients are prioritized for sleeping in a single room because of scarcity and need for more care-related disruptions,” the researchers explain.

Limitations and implications

The study comes with several important caveats. Most notably, it relies on participants to recall how much they slept while in the hospital and on a typical night at home. Such information is subject to bias, particularly since patients may have overly positive estimates of their in-home sleep habits.

In addition, the survey did not collect the patients’ clinical data, such as the severity of their illness, how much pain they were experiencing or what medications they were taking. The lack of such data limits the generalizability of the findings.  

Also, this study involved only patients in Dutch hospitals. Its results, therefore, may not be transferable to other patient populations, including those in the United States.

Still, as the two American doctors who wrote the accompanying commentary stress, the study should serve as  “a wake-up call” to U.S. hospital administrators and staff. 

“In some cases, the medical necessity of hospital-level care may take precedence over a strategy that optimizes sleep for hospitalized patients,” they write. But these latest findings “build a compelling case for questioning this tradeoff and inciting a much-needed hospital-wide culture change to minimize sleep disruption in the hospital setting.’’

Prioritizing a patient-centered environment

“Most of the sleep-disturbing factors found in our study seem easy to address by incorporating simple changes in nightly hospital routines,” the study authors emphasize. 

They point to a recent pilot study which found that educating nurses about how to help patients get a good night’s sleep, minimizing light and noise disturbances, and reducing care-related disruptions and overnight fluids significantly increased the total amount of time patients slept while in the hospital.

The commentary’s writers also point to a long list of interventions that can help decrease sleep disruptions in hospitals — including giving patients less fluids and no caffeine after 3 p.m. and providing them with eye masks, earplugs, extra pillows, and relaxing music at bedtime.

“Only with widespread shifts in current practice and consistent implementation of such interventions can we reconfigure the U.S. hospital as a more humanistic, healing, patient-centered environment where the essential human need for sleep is prioritized,” they stress.

FMI: You’ll find abstracts for both the study and the commentary on the JAMA Internal Medicine website, but, unfortunately, the full papers are behind a paywall.