Blood draws at the crack of dawn. The endless beeps and chimes of electronic monitors. Loud conversations in hallways.
For a long list of reasons, many patients don't sleep well in U.S. hospitals. Yet while medical errors and health-care acquired infections have inspired major reforms, the toll of poor sleep gets less attention, say experts who want that to change.
"The hospital itself and its barrage of stress can become a toxic place - a place actively causing harm," Yale cardiologist Harlan Krumholz argues.
He and other experts count sleep deprivation as a key contributor to "post-hospital syndrome" - Krumholz's term for the weakened immune systems, loss of body mass and other impairments that land many people back in a hospital soon after discharge.
Krumholz first explored "post-hospital syndrome" in a New England Journal of Medicine article, writing: "At the time of discharge, the physiological systems are impaired, physiological reserves are depleted, and the body cannot effectively avoid or mitigate health threats."
Ten years have passed since then, and he says, "it gnaws at me that I'm somehow not able to get people's attention."
An exception came Jan. 22, however, after Krumholz tweeted about a major hospital sleep disrupter: the frequent early-morning blood draws he and colleagues have documented at Yale New Haven Hospital. Researchers found that 4 in 10 blood draws occurred before 7 a.m.
"Sleep as medicine," Krumholz wrote on Twitter, following up with some pragmatic suggestions. What if doctors stopped ordering routine blood draws before 7 a.m.? What if, instead, they wrote orders for seven hours of peace and quiet?
Disrupted sleep instead of recovery time
Krumholz's tweet has since received more than 2,400 "likes," with several patients sharing their own tales of misery. After her mother was hospitalized, one woman wrote, "My brother and I LIVED in the hospital A nurse came in every 40 min." After two days, she added, "We had to beg the nurses to combine visits and we got a 3hr nap 1 day. We kept asking 'how do sick [people] rest to get better?'"
Krumholz suspects his tweet's narrow emphasis on sleep helped focus people's minds. In recent years, research and media coverage have stressed the key health benefits of high-quality sleep, the lack of which raises the risk of ailments ranging from heart disease and stroke to obesity and dementia, according to the National Institutes of Health.
There's also a link between sleep deprivation and elevated blood sugar in hospitalized patients with and without diabetes, says Vineet Arora, the dean for medical education at the University of Chicago Biological Sciences Division.
And, worryingly, as Arora and colleagues have found, sleep continues to be disturbed at home for many patients after discharge.
At Columbia University Irving Medical Center, Donald Edmondson, associate professor of behavioral medicine, has been researching factors, including shortened sleep, contributing to a "PTSD-like response" to hospitalization. "We can turn the dial up or down as to how traumatic an experience may be through these hospital factors," he said.
Prolonged sleep deprivation remains pervasive at top hospitals, Krumholz and other experts say. Fewer than half have sleep-friendly practices, such as reducing overnight vital sign monitoring, decreasing ambient light in the wards, adjusting lab and medication schedules, and implementing "quiet hours," a study in August revealed.
A 2012 study documented hospital noise levels similar to those of a chain saw 15 feet away.
Krumholz blames "a lack of creativity and imagination, and an almost military mentality" in most hospitals. "The idea is everyone has to tough it out," he says. "But this is different than just patient satisfaction and customer care. People are getting sick and some are surely dying because of this."
At the American Hospital Association, which represents 5,000 medical centers, Nancy Foster, vice president for quality and patient safety policy, said experts' arguments linking poor sleep and poor outcomes were "interesting and certainly an issue where clinicians are going to have to weigh the pros and cons." But the AHA hadn't "called that out" to its members due to what Foster said was a lack of evidence that one caused the other.
"For most clinicians to act we have to show that action A results in outcome B," Foster said.
Sweeter dreams
Some hospitals nevertheless have already instituted policies to protect patients' sleep.
In Derby, Conn., Patrick Charmel, chief executive of Griffin Health, says his hospital's sleep-related policies are part of its credo to "put patients first." He takes special pride in Griffin's "needle-free blood draw," which collects blood samples through the same IV catheter that delivers medication, allowing patients to sleep through the procedure. (Griffin helped pioneer the invention, known as PIVO, which is now used in some 60 other hospitals.) Encouraging good sleep is also built into the hospital's design.
Two-thirds of its licensed 160 beds are private rooms, Charmel said, while the remainder are designed to reduce noise and improve privacy, with measures such as putting the bathroom and entrance between the beds, making it easier for caregivers to attend to one patient without disturbing a roommate.
Griffin is the flagship health center for Planetree, which has certified 160 hospitals throughout the world, including 80 in the United States, for "person-centered care."
At UChicago Medicine, Arora, one of the nation's leading evangelists for improved patient sleep, has championed efforts to enlighten hospital staff.
A few years ago, her team found that doctors were routinely ordering blood draws at 4 a.m. every day, to be ready for their rounds at 6 a.m. This was even as many patients, whose conditions were stable, didn't need them so early or so often. She and fellow researchers have encouraged doctors to prescribe more sleep for such patients by writing orders in their electronic records for blood draws every 48 instead of 24 hours, and at later times.
Wake-up calls
Researchers and some professional organizations are urging doctors and hospitals to do more to protect patients' sleep.
In the journal Sleep last year, Arora and her co-author, Nicola M. Orlov, called for a "sleep-friendly" designation to increase hospital incentives to change their policies. The Society of Hospital Medicine and American Academy of Nursing both advise against unnecessarily waking hospitalized patients.
Absent broader change, many patients and family members find themselves warring with hospital techs.
Stanford University anesthesiology professor Rita Agarwal tells the story of her niece, who was hospitalized at age 8 with a pituitary tumor. After her surgery, doctors following her from several different services, including endocrinology, neurosurgery, neurology and pediatrics, initially didn't communicate with one another about her blood draws. "As a result she was getting woken up at night every two to three hours," Agarwal said in an interview.
In a response to Krumholz's tweet, Agarwal wrote that she would never forget listening to her niece scold her doctors, telling them, "Don't you know how important sleep is?"
