Sleep in hospitalized pediatric and adult patients - A systematic review and meta-analysis

Routine Overnight Assessments in Stable Pediatric Surgery Patients: A Critical Reconsideration

BACKGROUND

Hospitalized patients are subject to overnight vital sign (OVS) monitoring which leads to subsequent sleep disturbance and contributes to adverse outcomes and negative hospital experiences. Studies in pediatric populations have shown that routine OVS checks infrequently detect significant events. We hypothesized that OVS monitoring in pediatric surgery patients rarely detects abnormalities resulting in meaningful interventions.

MATERIALS AND METHODS

We performed a retrospective chart review of patients ≥ 5 years old admitted to the pediatric surgery service at a stand-alone Children's Hospital from 2019 to 2021. ICU patients were excluded from analysis. Overnight vital signs were defined as those recorded every 4 h between 10:00 PM and 6:00 AM. Abnormal OVS and subsequent interventions were recorded.

RESULTS

Analysis included 354 patients aged 5-19 years old. At least one OVS was abnormal in 62% of patients. Abnormal blood pressure was the most commonly flagged OVS (80%). The rate of intervention for flagged OVS was 58%. Medication administration was the most common intervention (54%). Unplanned operative intervention and transfer to the ICU were uncommon but did occur in this cohort (0.9% and 1.4%, respectively).

CONCLUSION

The majority of pediatric surgery patients had at least one flagged OVS and, while rare, some serious complications were detected. While minimizing sleep disturbance and maximizing patient satisfaction is valuable, these results support prioritizing patient safety with routine vital sign assessments until we can determine if there are sub-populations that can be safely managed without sleep disruptions.

LEVEL OF EVIDENCE

Level 4.

STUDY TYPE

Retrospective chart review.

Sleep Quality of Patients on a General Department During the First Days of Hospitalization

Purpose

The main aim of the study was to record subjective assessment of sleep quality between men and woman in hospitalised patients over 3 nights and look for associations with other basic hospitalisation data (age, type of department, surgery, pain, type of admission, previous hospitalisation, sleep-inducing medication). The secondary aim was to determine whether the Ford Insomnia Response to Stress Test (FIRST) questionnaire is an appropriate tool for identifying hospitalised individuals prone to situational sleep disturbance.

Methods

A multicentre descriptive cross-sectional study was conducted in regular surgical and medical departments of seven selected hospitals in the Czech Republic. On the first day of hospitalization, patients completed the FIRST screening questionnaire. Their subjectively perceived sleep quality for the previous night was assessed from the second to the fourth day of hospitalization using the Richards-Campbell Sleep Questionnaire (RCSQ).

Results

The study included 340 patients (172 females and 168 males; mean age 58.9 ± 14.9 years and 57.3 ± 15.0 years, respectively). No significant differences in RCSQ scores were observed between men and women or across the three nights of hospitalization. Moderate correlations were identified between hospitalization data and RCSQ scores, with the strongest positive correlation for alprazolam use (Ra = 0.604). Other positive correlations included surgical department hospitalization, sleep-inducing medications, surgery, male sex, and age. The strongest negative correlation was with pain (Ra = -0.498), while other negative correlations included elective admission, medical department hospitalization, and previous hospitalization. The studied factors explained 18% of the RCSQ variability. The association between FIRST scores and RCSQ was statistically significant (p < 0.001) but weak (Spearman's -0.1734, Kendall's tau -0.1234).

Conclusion

Subjective sleep quality during hospitalization is related to the type of department, care provided, and pain, age, and sex. There were no significant changes in subjective sleep quality ratings during the first three days of hospitalization. The FIRST questionnaire is not a suitable screening tool for identifying individuals with situational sleep disturbance in hospital.

Quality of sleep in severe acute respiratory distress syndrome survivors requiring invasive mechanical ventilation: a prospective observational study

PURPOSE

Sleep disturbances arising during ICU stay among ARDS (acute-respiratory-distress-syndrome) patients may continue long after discharge. This study is aimed at evaluating the sleep quality in severe-pulmonary-ARDS survivors.

METHODS

This was a prospective-observational study recruiting all eligible patients, who survived after invasive-ventilation for ARDS diagnosis. Subjects were evaluated just before discharge and at 6-weeks after discharge with Epworth Sleepiness Scale(ESS), Richards-Campbell Sleep Questionnaire(RCSQ), Insomnia severity index(ISI), Pittsburgh Sleep Quality Index (PSQI) and overnight level 1 polysomnography(PSG).

RESULTS

Out of 54 non-COVID19 severe ARDS survivors, 23 were included and Scrub Typhus was the most common etiology. The mean PaO2/FiO2 ratio and APACHE-II scores were 110.90 ± 21.6 and 19.04 ± 5.1, respectively. The mean duration of stay in the ICU was 14.22 ± 10.5 days. The change in mean ESS and RCSQ scores at discharge and 6-weeks were statistically significant (p < 0.001). During the early evaluation, sleep efficiency was low (mean 61.6 ± 7.2% and predominantly N1 and N2 stage) which improved at 6-weeks evaluation (mean 68.52 ± 7.8%, p < 0.001). At 6 -weeks REM component increased from 10.96 ± 2.83 to 15.31 ± 9.96 (p < 0.001). Out of the total 23 patients, 7 had AHI > 5 in early and 4 in late evaluation. Oxygen desaturation index also decreased significantly at 6-weeks follow up. PSQI > 5 was present in 13 patients at 6 weeks after discharge. PaO2/FiO2 ratio had positive correlation with RCSQ score and duration of mechanical ventilation had positive correlation with PSQI and ISI score at 6-weeks (p < 0.001 for all 3).

CONCLUSION

Sleep disturbances are common in ARDS survivors in both early and late period after discharge from ICU.

Sleep-enhancing nursing interventions in hospital wards: A systematic review

AIM

To identify sleep-promoting nursing interventions in hospitalized adults and older people.

BACKGROUND

Sleep is necessary for maintaining good physical and mental health, as well as a high quality of life. Hospitalization can significantly disrupt sleep patterns, which is an often-overlooked issue. Nurses are the main participants in promoting sleep in hospitalized patients.

METHODS

Systematic literature review based on the question: "What interventions can nurses implement to promote sleep in hospitalized adults and older people?". The research was conducted on April 4, 2023, in CINAHL Complete, MEDLINE, Cochrane, Scopus, and Web of Science, filtering the articles published in the last 10 years. For a study to be included, it must feature adult or older participants, an intervention that aims to enhance sleep, and the research should have been conducted within a hospital setting. We followed the PRISMA flow diagram and analyzed the quality of the articles according to the Joanna Briggs Institute criteria for quality assessment. The results were subjected to a narrative synthesis.

RESULTS OR FINDINGS

Of the 712 articles found, 13 were selected. The sample encompasses 1975 participants. These selected articles emphasize educational and communicative interventions, dietary and sensory interventions, symptomatic and environmental control, daily activity planning, sleep assessment and documentation, and individualized nursing care.

DISCUSSION

There is a need for a systematic approach incorporating physical, psychosocial, and relational dimensions within the care context.

CONCLUSION

It is necessary to raise the nurses' awareness of the factors that affect sleep experience and empower them to promote sleep in partnership with hospitalized patients.

IMPLICATIONS FOR NURSING AND HEALTH POLICY

Sleep interventions can be promoted by implementing hospital policies, including environmental modifications in the design and refurbishment of facilities and restricting nighttime patient transfers to reduce noise and disturbances. Encouraging research studies that explore the effectiveness of these interventions will further support the development of evidence-based policies aimed at improving sleep quality in hospitalized patients.

Rest assured: High sleep efficiency reduces postoperative complications and opioid prescriptions in patients undergoing surgeries with gynecologic oncologists

OBJECTIVE

To assess the relationship between preoperative sleep efficiency (percentage of time asleep while in bed) and postoperative outcomes in gynecologic oncology patients.

METHODS

This is a secondary analysis of a prospective cohort study that included 90 patients undergoing gynecologic surgeries from March 2021 to November 2023. Preoperative sleep efficiency was measured via Oura rings over the seven days prior to surgery and analyzed as a continuous variable and in quartiles. Primary outcomes were 30-day postoperative complications, with secondary outcomes including total morphine milligram equivalents (MME) prescribed at discharge and pain scores on postoperative day 1 (POD1). Multivariable analyses controlled for age, body mass index, frailty status, neoadjuvant chemotherapy, use of preoperative sleep medications, and surgical approach.

RESULTS

Higher preoperative sleep efficiency was independently associated with fewer 30-day postoperative complications. On multivariable analysis, each 1 % increase in sleep efficiency was associated with 6 % lower adjusted odds of complications. (aOR: 0.94; 95 % CI: 0.89-0.996) and significantly lower total MME prescribed at discharge (β = -13.94; 95 % CI: -19.35 to -8.53). Patients in the highest sleep efficiency quartile (>89.0 %) had lower odds of experiencing a complication compared to those in the lowest quartile (aOR: 0.28; 95 % CI: 0.09-0.92). Sleep efficiency was not significantly associated with POD1 pain scores (β = -0.06; 95 % CI: -0.13 to 0.01).

CONCLUSION

Preoperative sleep efficiency is associated with fewer postoperative complications and lower MME prescribed at discharge. This may be modifiable risk factor to improve recovery and outcomes.

Nurses' Perspectives on the Sleep Quality of Hospitalized Patients in Al Ahsa, Saudi Arabia

BACKGROUND

Sleep quality is crucial for patient recovery and well-being, yet hospitalized patients often suffer from poor sleep due to environmental disruptions, clinical routines, and psychosocial stressors. While these challenges are well-documented, qualitative insights into nurses' perspectives-essential frontline providers shaping the sleep environment-are scarce, especially within rapidly evolving healthcare systems like Saudi Arabia's. This study explores nurses' perceptions of factors influencing patient sleep quality in a private hospital in Al Ahsa, Saudi Arabia, and identifies strategies for improvement.

METHODS

We conducted a qualitative, cross-sectional study using semi-structured interviews with 14 registered nurses from diverse nationalities, specialties (Obstetrics/Gynecology, Medical-Surgical, Pediatrics, Intensive Care, Orthopedics, Bariatrics), and experience levels. Interviews were conducted in Arabic or English, audio-recorded, transcribed, and thematically analyzed using ATLAS.ti software. Roy's Adaptation Model guided the examination of environmental, patient-specific, and systemic factors affecting sleep.

FINDINGS

Four primary themes emerged: (1). Environmental Factors: noise from alarms, equipment, family presence, and late-night activities, along with abrupt lighting changes, consistently disrupted sleep. (2). Patient-Specific Factors: pain, emotional distress, cultural expectations, and family involvement influenced sleep experiences. (3). Systemic and Contextual Factors: language barriers, infrastructural disparities between private and governmental hospitals, and limited resources can impeded effective sleep-promoting strategies. (4). Role of Health Technology: nurses recognized the potential of innovations like smart lighting and wearable monitors to enhance sleep quality but faced challenges in implementation due to knowledge gaps and limited familiarity. Roy's Adaptation Model highlighted how effective adaptation through physiological and cognitive-emotional pathways, as observed by nurses, was facilitated or hindered by these factors.

CONCLUSIONS

Enhancing in-hospital sleep quality requires a holistic, culturally sensitive approach that integrates environmental modifications, patient-centered care, and systemic improvements. Strategic investments in staff communication training, infrastructural upgrades, language support services, and the adoption of health technologies can promote adaptive responses and optimize patient rest. By leveraging theory-driven insights and context-specific strategies, healthcare systems-particularly those undergoing rapid development-can better support nurses in fostering restorative sleep environments as a fundamental component of patient-centered care, thereby enhancing patient recovery, satisfaction, and overall well-being.

Optimizing Sleep Disorder Management in Hospitalized Patients: Practical Approach for Healthcare Providers

PURPOSE

To provide a comprehensive review of sleep disturbances in hospitalized patients, focusing on a case-based approach to illustrate the multifaceted nature of this clinical challenge.

METHOD

An extensive review of related literature was conducted to determine the common causes of sleep disturbances in hospitalized patients, such as environmental, medical, psychological, and physiological factors. The case of Mrs. Z was used to illustrate how these factors interact in a clinical setting.

FINDINGS

The study revealed a high prevalence of sleep disturbances in hospitalized patients, which can lead to significant adverse outcomes. A multidisciplinary approach involving physicians, nurses, pharmacists, and other healthcare professionals is essential to effectively manage sleep disorders due to the interplay of various factors. Nonpharmacological interventions are fundamental to a comprehensive sleep management plan. Pharmacotherapy may sometimes be necessary to improve sleep quality and duration.

CONCLUSION

Health professionals can significantly enhance the sleep quality of hospitalized piatients by understanding the value of sleep and providing evidence-based strategies for improvement. In return, this improves patient outcomes, reduces healthcare costs, and advances general patient satisfaction.

Factors affecting sleep quality in hospitalised patients

INTRODUCTION

Hospitalised patients are at increased risk of poor sleep quality which can negatively impact on recovery and quality of life. This study aimed to assess sleep quality in hospitalised patients and explore the factors associated with poor sleep.

METHODS

Prospective data were collected from 84 respiratory ward inpatients at time of discharge using a Likert scale questionnaire on contributing factors to sleep quality. Differences between groups reporting good and poor quality sleep were recorded.

RESULTS

Most participants (77%) described inpatient sleep quality to be worse or much worse compared to their home environment. Noise (39%), checking of vital signs (33%) and light (24%) were most frequently identified as factors disrupting sleep. Binary logistic regression analysis demonstrated that men (OR 2.8, CI 1.1-7.4, p = 0.037) and those in shared rooms (OR 3.9, CI 1.4-10.9, p = 0.009) were more likely to be affected by noise. Younger patients (OR 0.92, CI 0.88-0.96, p < 0.001) and those in shared rooms (OR 8.5 CI 1.9-37.9, p < 0.001) were more likely to be affected by light.

CONCLUSION

In conclusion, a high proportion of hospitalised respiratory patients on a medical ward reported poorer sleep quality compared to home due to operational interruptions and noise. Age, gender and room type further modified the sleep disruption. Future research should focus on whether strategies to reduce interruptions and noise will improve sleep quality and clinical outcomes.

Sleep disturbances in hospitalized children: a wake-up call

Although sleep is essential for (recovery of) health, it is adversely affected by hospitalization, due to disease discomfort, environmental noise, and care routines, causing reduced sleep and increased disturbances. This study evaluates factors affecting sleep quality and quantity in hospitalized children and compares inpatient sleep with sleep at home. Using an observational, prospective study design, we assessed sleep in hospitalized children aged 1-12 years, admitted to a tertiary center, and compared this with home 6-8 weeks after discharge. We measured total sleep time (TST), sleep onset latency (SOL), wake after sleep onset (WASO), sleep efficiency, awakenings, and subjective sleep quality, using actigraphy, sleep diaries, and PROMIS questionnaires. We explored an array of sleep-disturbing factors. Regression analyses identified key determinants affecting sleep patterns, while mixed linear models compared sleep in hospital to sleep at home. Out of 621 eligible patients, 467 were invited, and 272 (58%) consented to participate. Key determinants of sleep included pain, number of previous admissions, (underlying) chronic illness, and environment-, staff-, and disease-related factors. Parents reported lower perceived sleep quality in the hospital compared to at home, 97-min (SE 9) lower TST, 100-min (5) longer WASO, more difficulties with falling asleep, lower sleep satisfaction, and more awakenings. Actigraphy outcomes revealed shorter TST (20 min (6)), but better sleep efficiency and fewer awakenings in the hospital. Conclusion: Sleep in hospital was compromised in comparison to sleep at home, primarily due to disturbances related to treatment, environment, and staff. These findings underscore the necessity and potential of relative simple interventions to improve sleep quality and minimize sleep disturbances in hospitalized children.

Orthopaedic patients' experiences of their sleep during hospitalisation and suggestions for improvements

PURPOSE

To describe orthopaedic patients' perspectives on their sleep quality and their suggestions for improvement initiatives to achieve better sleep quality during hospitalisation.

METHODS

In a qualitative design, 265 (50%) of 533 patients from a questionnaire survey responded to two free-text questions. Data were analysed based on a phenomenological-hermeneutic approach inspired by Paul Ricoeur's theory of narrative and interpretation.

RESULTS

Three themes emerged: 1) Sleeping environment and preferences tailored to the individual patient, 2) The link between orthopaedic surgery care and sleeping, and 3) Noise challenged a good night's sleep. Good sleep was related to nurses' professional behaviour and the physical environment, such as quality beds and sleeping aids. Single and shared rooms, room lighting, and fresh air all influenced sleep quality. Unfamiliar and uncomfortable sleeping positions posed a challenge for orthopaedic patients but aids such as pillows, and duvets could provide more comfort at night. Offset circadian rhythms could affect sleep quality, as could nausea and vomiting. Pain and lack of pain relief were associated with poor sleep quality. Noise from both nurses and other patients affected sleep quality. Therefore, unnecessary care activities should be kept to a minimum, and a "night noise level" was suggested.

CONCLUSION

Patients' sleep disturbance following orthopaedic surgery needs to be addressed by both nurses and hospital management. Patients' involvement is essential to create a sleep environment tailored to individual needs and to provide strategies patients use at home for addressing sleeping problems.

Can extending time between vital sign checks improve sleep in hematopoietic stem cell transplant patients? Testing feasibility, acceptability, and preliminary efficacy

BACKGROUND

Patients undergoing hematopoietic stem cell transplant (HSCT) experience barriers to quality sleep. Frequent vital sign checks are necessary early posttransplant given risk of complications but can disrupt sleep. This study tested feasibility and acceptability of extending time between checking vitals (EVs) from every 4 to every 6 h to improve sleep.

PROCEDURE

HSCT patients ages 8-21 years (N = 50, mean age = 14.06, SD = 3.58) and their caregivers were enrolled 1-2 days prior to transplant, and 40 patients completed the 15-day study (NCT04106089). Patients wore an actigraph to estimate sleep and provided self- and caregiver-report of sleep. Sleep was observed for nights 0 to +4 posttransplant, and patients were then randomized to EVs either Days +5 to +9 or +10 to +14. Patients were assessed daily for medical eligibility to receive EVs; on days patients were eligible, nightshift nurses (N = 79) reported EV acceptability.

RESULTS

Of 200 potential nights for EVs (5 nights x 40 patients), patients were eligible for EVs on 126 nights (63% of eligible nights), and patients received EVs on 116 (92%) of eligible nights. Most patients received EVs ≥3 nights (n = 26, 65%, median = 3 nights). Most patients (85%), caregivers (80%), and nurses (84%) reported that patients used the additional 2 h during EVs for sleep, with reporters indicating moderate to high acceptability. There was preliminary evidence of efficacy indicated by caregiver-reported sleep disturbance and actigraphy-estimated improvements in sleep efficiency during EVs.

CONCLUSION

Extending time between vitals checks is highly acceptable to patients, caregivers, and nurses, and may offer a feasible approach to improve sleep in pediatric HSCT.

Pain and sleep after open-heart surgery-inhalation peppermint essence: double-blind randomized clinical trial

OBJECTIVE

The aim of this study was to determine the effect of inhaling peppermint essence on pain relief and sleep quality after open-heart surgery.

METHODS

In a double-blind randomised clinical trial carried out in Iran in 2020, 64 cardiac patients were selected by convenience sampling and randomly allocated to aromatherapy (n=32) and placebo (n=32) groups. The aromatherapy and control groups received inhaled aromatherapy using peppermint essence and distilled water, respectively. Data gathering tools were the Numeric Pain Rating Scale and St Mary's Hospital Sleep Questionnaire. Data were analysed using an independent t-test, χ2 test, Mann-Whitney U test and generalised estimating equation analysis.

RESULTS

The mean severity of pain in the aromatherapy and placebo groups was 3.22±0.88 and 4.56±0.90, respectively, which was a statistically significant difference (p=0.0001). The mean sleep scores after the intervention on day 1 were 20.10±4.90 and 25.76±6.36 in the aromatherapy and placebo groups, respectively, and 18.63±5.56 and 22.62±5.69, respectively, on day 2. The difference between the two groups was statistically significantly different after the intervention in terms of sleep quality (p<0.05).

CONCLUSION

Aromatherapy attenuated pain and improved sleep quality after open-heart surgery. Peppermint essence aromatherapy is therefore recommended after surgery.