What is this research about?
The hospital environment is notoriously poor for getting a good night’s sleep, especially among older adults who are more prone to awakenings from noise, light and other environmental disruptions. Each year, over 13 million older adults are hospitalized in the United States, 45 percent of whom report poor sleep quality, averaging less than four hours of total sleep and 13 awakenings per night. Poor sleep reduces the brain’s health and increases the chance of experiencing episodes confusion, inattention and agitation (i.e., delirium). This is alarming, especially for older adults who are more prone to both sleep disruption and risk of delirium. Each year after age 65, the chance of developing in-hospital delirium increases by 2 percent.
Delirium leads to multiple short- and long-term adverse effects that increase length of hospital stay and chance of death. Even a short episode of in-hospital delirium can worsen someone’s physical disabilities, causing significant deterioration in memory, thinking and concentration. This results in lower quality of life for the patient, leaving them more dependent on caregivers and increasing caregiver burden.
Many preventable reasons for sleep disturbance exist in the hospital, yet practical sleep studies in hospital settings are rare as culture-shifting can be difficult to implement. Other teams have proposed multimodal sleep hygiene (MMSH) interventions in the intensive care unit, but more scientific studies are needed to improve inpatient sleep and reduce incidence and burden of delirium in medical/surgical inpatient units, accounting for both patient perspectives and hospital workflow.
Who can this research help?
The research team believes older adults will benefit most from the proposed study, given their increased susceptibility to sleep disruption and delirium, but all hospital patients and visitors will likely benefit from a more sleep-friendly hospital environment. Hospital administrative stakeholders will also appreciate the potential impacts on patient safety, quality and satisfaction from an intervention bundle with concrete implementation guidance to help them determine how best to shift their hospital culture toward better inpatient sleep hygiene.
What is the research team doing?
This study aims to prevent and reduce delirium among hospitalized older adults. Specifically, to protect patients’ sleep from 10 pm to 5 am (starting a culture of protected “Z-time”), the study team will implement its bundled intervention across four hospitals in a diverse healthcare system. The intervention has multiple components informed by scientific evidence, the team’s patient and family advisory council, and patient survey data, which have directed them to:
- Reduce noise and bright lights
- Bundle care-procedures to limit night-time interruptions
- Monitor vital signs by non-intrusive biosensors
- Increase daytime activity/mobility with less day napping
- Move medication order times, with sensitivity to pain management needs, among other changes
The study team combines this with a preexisting strong practice of frequent delirium screening at each site.
To track this method’s impact and implementation success, researchers will study 11 medical/surgical inpatient units randomized to roll out the bundle in a stepwise period over five years. Using electronic health record data and regular delirium screening, researchers will compare the rate of hospital-acquired delirium and burden of existing delirium between patients aged 70 years and older on units using the intervention bundle with those managed only by standard protocols (i.e., pre MMSH Z-time). Researchers will study the intervention’s effect in over 10,000 hospitalized older adults and will also evaluate unit-level compliance rates (e.g., via remote light and noise sensors) and hold stakeholder focus groups on the perceived facilitators and barriers to making the strategy work on the hospital units. Sleep duration and disruptions are monitored by wrist-worn devices, and patient-reported sleep quality and satisfaction will be compared between groups. Secondarily, the team will use remote sensors and data dashboards to analyze daytime activity and mobility, as day-napping is disruptive to nighttime sleep. Other outcomes of interest to hospital stakeholders (e.g., hospital length of stay and safety outcomes) will be included.
The research team combines expertise in sleep medicine, delirium prevention, conducting research and patient experience with advisory board input from system- and unit-level hospital operations, patient and family advisory council members and volunteers, and a representative from the Alzheimer’s Association, to ensure the feasibility, relevance and translatability of the interventions and implementation strategies more broadly. The study team’s advisors have influenced the intervention design and will regularly monitor progress to provide additional insights.
*All proposed projects, including requested budgets and project periods, are approved subject to a programmatic and budget review by PCORI staff and the negotiation of a formal award contract.