
Protecting Sleep in the Hospital, for Both Patients and Doctors - rafaelc
https://www.nytimes.com/2019/06/04/well/mind/sleep-hospital-patients-doctors-fatigue.html
======
jcims
My wife has been in the hospital regularly over the past 18 months probably 20
days total. This is a renowned research hospital with a gorgeous, vibrant
facility and spacious rooms.

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.

~~~
xattt
Have you had a conversation to address concerns about your spouse’s care?
There is always some flexibility around the care that she’d be receiving, and
one core component to that is your rational/measured input, either in person
or by phone. Framing your concern as rational helps _immensely_ in
establishing a dialogue with care staff. It sounds like your core problem is
that you want to be bothered less.

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.

~~~
lojack
We ran into this with my daughter who needed multiple surgeries. Two different
experiences in two different hospitals.

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.

~~~
eitally
Our daughter was in for surgery at a world renowned hospital #1 for what she
needed ... and our experience was like your second example. After she moved to
the step-down unit from the ICU, she had the same day nurse for the next three
days and the same night nurse for four, as well as a consistent overnight NP
throughout. We had a private room with a separate vestibule containing a
washing station & laundry bin for scrubs/aprons. Also in the room was a
whiteboard where the current nurse always wrote the intended schedule and
reviewed it with us at the start of their shift. Our room had a single-bed
sized sofa _and_ a fold-out chair. It was quiet, and except when we had to
wake our daughter for overnight oral meds, the nurses let her sleep. To be
honest, while it was a hugely stressful situation, I'm convinced the hospital
recovery environment and staff played an enormous role in our daughter being
able to be discharged only 4 days after open heart surgery.

~~~
lojack
That sounds almost exactly like the hospital we were at (Rainbow Babies, for
the record). Hope your daughter is doing good, my daughter is also a heart
baby -- coarctation and bicuspid valve.

------
Engineering-MD
I’m a doctor and I agree lack of sleep is a huge problem for inpatient care. I
(and most of my colleagues) try to avoid waking patients wherever possible.
The main reasons I need to wake patients at night is: a) they are unwell. This
is unavoidable b) recanullating for fluids/medication that need to be
administered overnight. c) for new admissions I need to do more routine tasks
(ensure regular meds are prescribed in time for morning, or chase scan
results/reassess patient/repeat bloods). This is necessary as for these
patients (and patients who have become more unwell in hospital) there are too
many unknowns to be able to safely leave it until morning, or need to be ready
for theatre the next day.

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.

~~~
kdelok
I must confess that the main reason I'm replying is to correct the darkly
amusing dead->deaf typo that I'm hoping you made.

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)?

~~~
joshgel
Sounds right. I’ll add (as in another comment) that nursing hourly rounds is
mandated by my institution. Personally i go out of my way to avoid waking you
up, but it’s not a hotel and if I’m even a little bit worried about your
trajectory, I won’t hesitate to wake you up.

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.

------
Theodores
There are a lot of exemptions in healthcare, sleep is part of this exceptional
world, I was told bluntly 'we are not operating a hotel here' last time I
spent a sleepless night in a hospital.

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?

~~~
lazyasciiart
> ave 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?

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.

~~~
Theodores
Nice parents!

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.

~~~
arethuza
"There are no up-sells."

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.

~~~
NLips
They still do, or did in 2015 and 2018. We were lucky enough to not need the
doctor-led hospital unit - using the midwife-led maternity unit instead (where
private rooms are standard). However, we were moments away from foreceps being
used - a doctor-administered intervention - for the first birth, which would
have necessitated a move downstairs to the hospital wing, and thus a ward or
payment for a private room.

~~~
Theodores
Forceps?

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.

~~~
NLips
Yep - were going for forceps instead of ventouse.

~~~
Theodores
I was wrong about the forceps. But there is now a new rabbit hole I need to go
down - birth marks and what causes them. Plus this 'ventouse' gadget and the
merits of it compared to ye olde forceps.

Haven't got time for this rabbit hole now, I might save it for when I meet
someone with skin in the game!

------
Tharkun
I know that sleep is critical to healing. And I know that a lot of what
happens to you in a hospital is very unpleasant. And I know that some things
might seem silly, banal or irrelevant. But please remember that this is all
done from a desire to keep you _and other patients_ alive and (relatively)
well.

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.

~~~
Aromasin
It's basic cost-benefit analysis. I completely appreciate where you're coming
from, but despite all your points many of the checks _are_ still silly, banal
and irrelevant - the benefit of waking someone up mid sleep cycle to ask them
what they want to eat, or to get them to fill out a questionnaire, or to take
a blood sample when they've only had one an hour or two before, is not worth
the cost. You're giving a passionate response about how lucky we are to have
that care anyway, but frankly you are vastly underestimating the devastating
effects broken sleep has on the body. Most of the patients are on opiates
anyway, so sleep is already at a premium (sedation =/= sleep).

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.

~~~
Tharkun
If they're waking you up to take blood samples when you're sleeping, it's
probably for good reason. Maybe the patient is at risk for some kind of kidney
complications and maybe not dying from renal failure is more important than
getting a good night's sleep. There could be any number of reasons for this.
Maybe another patient had some kind of emergency that had to be dealt with
first, and your sleep schedule is less important than someone else's life.

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.

~~~
Aromasin
The blood checks I brought up because this was a thing specifically criticised
by my friends in the medical trade. For the vast majority of cases where they
need to take blood, it just so happens to be the _preferred_ method used for
diagnosing the patient, not the _only_ method. There are other things that can
be done beyond waking the patient and sticking a needle in their arm. Often
they just end up disposing it, as they don't even have the resources to test
the blood of every patient every hour; but they will continue to _take_ blood
every hour. If the nurses are told to take blood, they will do it to protocol
- regardless of what common sense might suggest.

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.

------
HeraldEmbar
The arrogance of nurses and physicians in constantly waking patients up,
completely unaware and uncaring of the health detriment that comes with loss
of sleep, is inexcusable. While some people can go back to sleep after being
awakened, there are many of us who have real difficulty getting back to sleep,
and sometimes it doesn't happen at all.

~~~
joshgel
That’s a bit to far in my opinion. I’m a physician. Now days, if you are
admitted to a hospital overnight it implies you are probably pretty ill. We
push hard to ensure that only patients that _need_ to be in the hospital are
(wasn’t always that way). Sometimes in sick patients, checking vitals is
required (to make sure you aren’t dying). Additionally, there is evidence that
hourly rounding prevents some bad outcomes like patient falls. So ‘well-
meaning’ institutions like mine, _mandate_ hourly rounding by nursing staff.

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.

~~~
u801e
> Sometimes in sick patients, checking vitals is required (to make sure you
> aren’t dying).

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?

~~~
joshgel
I'm really excited about [0], but as far as I know there is no way to take
blood pressure without touching the patient. If someone here could invent it,
I could probably provide a test environment for large scale investigations.

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.

[0]:
[http://people.csail.mit.edu/mrub/vidmag/](http://people.csail.mit.edu/mrub/vidmag/)

~~~
eitally
For blood pressure, our experience was that the staff were perfectly happy to
leave a cuff on our daughter's leg, which automatically took a reading every
hour (or on demand).

~~~
joshgel
For some patients, with vascular disease for example, the blood pressure cuff
can be very painful... (What you describe is usually what we do.)

------
tomohawk
When you are given medicines and examinations has more to do with shift
changes than anything else.

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:

[https://www.youtube.com/user/ZDoggMD](https://www.youtube.com/user/ZDoggMD)

------
darkerside
I had an infuriating experience with a young child in the hospital, where
routine checks were being performed at the worst possible times for his sleep
cycles. Sleeping is so critical to healing. Could it be that hospitals are
being counterproductive, sacrificing effectiveness for efficiency?

~~~
hanniabu
All they care about is the bottom line, which is money

~~~
jazoom
All it takes is for one child to die overnight and the parents to sue and you
can be sure all patients will get their vitals checked regularly. This is how
healthcare works.

Source: am a doctor and see this kind of thing on small and large scales

~~~
hanniabu
Isn't this why there's monitors? You can also do a visual checkup without
waking up the patient.

~~~
jazoom
What monitor are you thinking of? Not everyone gets telemetry.

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).

------
irrational
My main experience with this is every time my wife gave birth. She goes
through this long ordeal and is exhausted, but as long as we were there they
were in every 2 hours, day and night, waking her up and talking to her. They
don't seem to have any concept of people needing to sleep more than 2 hours
continuously. The only thing I could come up with is that they really wanted
us to get out of there ASAP and were making things a living hell to encourage
us towards that end. Except, one of my rules is to follow the money and they
make more money the longer we stay, so... it really doesn't make any sense.

~~~
ksdale
We’ve had 4 babies in 3 different hospitals and it seems like it is really
dependent on the hospital and the nursing staff. We’ve had nurses that are
younger and just following the playbook all the way to nurses that are much
older with several of their own children who are much more willing to use
their intuition. While the nurses have all been surprisingly excellent (maybe
it’s a maternity thing? That hasn’t been our experience in other parts of the
hospitals) some of them are happy to let you sleep if it seems like there’s no
bleeding and baby is doing well, and some of them insist on taking all the
readings, though they were all apologetic while they did it.

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.

------
bpyne
When my wife gave birth to our daughter we had a room to stay in. Every 1.5-2
hours the nurses came in to ask questions and run tests. It was maddening. My
wife had to finally cry and beg them to stop. Afterward, we managed about a
few hours of uninterrupted sleep.

~~~
apohn
Our experience as well. I was in the room as well the whole time and it was
ridiculous how often somebody came in to do something.

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.

------
dzink
In the US Hospital reimbursements from insurers and medicare are per
procedure, not duration of stay. Hospitals have a strong vested interest in
both keeping patients alive and reducing length of stay. Food quality and
sleep interruptions for non-critical patients both help the latter metric,
even if that is likely not their sole reason.

~~~
Ayesh
From what I see in Asia and Europe, hospitals charge per night stayed in the
hospital, plus the cost for any procedures.

------
duxup
My 9 year old son had a hospital stay a while ago. I stayed with him in the
hospital, I got less sleep than when he was an infant with the constant
interruptions....

When we returned home in the afternoon ....we both took naps.

------
JauntyHatAngle
I've recently had similar experiences with a loved one.

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.

------
baxtr
We were in the hospital for 2 nights recently. On the second day we counted
how often people got in and out of the room: 29 times. We decided to return
home a day earlier than planned.

------
bdcravens
About once a year I have to spend 3-7 days in the hospital (I have cystic
fibrosis and a round of antibiotics are often needed to bring my lung function
back to baseline). The sleep situation is one of the things that's the most
unpleasant.

------
ngcc_hk
It is universal practice to wake you up all the time. Just to ensure you are
not dead or ensure you are dead of sleep deprivation.

------
hannob
I wondered this a lot before. I'm lucky enough that I haven't spent much time
in a hospital in my life, but visiting people there I often heard how hard it
was to sleep for them due to constant interruption, noise from neighboring
beds or indensive care units where it's constantly busy.

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.

------
smartbit
Even without awakening by medical staff or sounds (ear plugs do wonders), with
some illnesses patients can _only sleep on their back_ which can be a
unpleasant experience if you're used to sleeping on your side. It takes time
to get accustomed to and in the mean time patients get little sleep with all
mentioned effects. Pillows designed for sleeping on your back [0][1] _with
special curvatures for your head and neck to relax on_ ease falling and
staying asleep. If a 10% of the patients sleep better and are released earlier
from hospital or get to work faster, these pillows are a very small costs
compared to costs savings, both personal & society.

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...](https://en.wikipedia.org/wiki/Orthopedic_pillow#Back_sleeping)

[1] eg "Emolli Contour Memory Foam Pillow" on
[https://www.forbes.com/sites/forbes-
finds/2019/02/21/pillows...](https://www.forbes.com/sites/forbes-
finds/2019/02/21/pillows-neck-pain/) (advertising article)

------
vonnik
This is a huge issue. A family member spent two weeks in the hospital last
year, and one of the hardest parts of that experience was how difficult it was
to sleep there. The light, the noise, the demented patient shouting in the
next room, the constant interruptions and questionnaires from nurses and
doctors: you just couldn't sleep more than 90 minutes if you were lucky. We
called them "the bleeping machines", in the double sense. I would turn them
off sometimes, because the stats they were monitoring were not life or death
for us. Hospitals are a place where there is no night. The nurses working on
the graveyard shift under the bright fluorescents cover a third of the day,
and for them, it's just another workday, but it runs from 11pm to 7am. And
they treat patients as though it is daytime. Don't get me wrong, the nurses
were great, but the structure and incentives don't favor sleep. There is so
much that could be done to help patients get better faster, by giving them a
more restful environment. But the incentive is to monitor them until you can
get them out of the bed, to save everybody money.

------
gwright
Don't forget all the interruptions that occur when the staff is visiting your
room mate also.

------
GaurVimen
Good luck trying to change the hospital mindset. Doctors actually have a term
for patients who suffer sleep deprivation: hospital-induced-psychosis. It
should be called a crime and the head nurse and doctor in charge of the
patient ought to be arrested.

~~~
mhalle
Hospital delirium is the current accepted name for this condition. It covers
much more than sleep. It includes the stress of complex and potentially life
threatening medical and social conditions, confusion related to time of day
and time unconscious, the effects of medication, and possible underlying
mental health issues. All compound each other.

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.

------
bigtex
Man is this so true. Years ago I had a daughter spend some time in a hospital
and they wanted to change her diaper every 2 hours...during...the...night!
Sure the child who is recovering from brain surgery should have their sleep
interrupted 5 times to change a diaper. I am fairly certain no sane parent
wakes up a perfectly sleeping baby to change a diaper. My wife kindly told
them we didn't need that and they obliged.

~~~
eitally
Our diapered daughter was recently in the hospital and the only thing they
asked us was to weigh a dry diaper as a reference, and then place any soiled
diapers on a scale in the room so they could be weighed at the nurse's
convenience so they could track I/O, which is otherwise challenging for
babies/toddlers.

------
abarringer
At my recent overnight stay at a large hospital the Nursing staff were very
aware of the necessity of good sleep. They worked hard and went out of their
way to create an environment where I was interrupted as little as possible.
Their first exit interview question was "How well did you sleep? And how can
we improve that?"

------
OldFatCactus
Is there a website or service that scores hospitals? Customer service,
outcomes, incidents, and whatever other relevant data

------
rjohnk
Stayed in the hospital in April for about a week for a colon resection -
without a doubt worst sleep is in a hospital. It was an amazing environment
too and I only had 11:00pm and 4:00am checks. I think it's the nature of the
environment.

------
DoingIsLearning
... and nurses?

------
souprock
It's not just tests. It's also constant beeping and the light from the
hallway.

