Give patients a rest

Background

A few years ago, Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) reports were telling leaders at Barnes-Jewish Hospital a story familiar to many facilities.

“We had HCAHPS scores coming back suggesting that it was noisier than we'd like overnight in some areas, and that patients were not getting appropriate rest,” said Patrick G. Lyons, MD, MSc, an intensivist and medical director of the health system's Innovation Lab at the time. Simultaneously, the hospital's leaders were looking for strategies to empower clinicians and nurses to “care about people individually and provide the type of attention that improves experiences for patients,” he said.

The Innovation Lab decided to work on both goals by interviewing patients and nurses, studying what was happening in the hospital at night, and designing strategies to improve rest in conjunction with the frontline staff.

How it works

Out of 39 possible rest-promoting interventions developed in brainstorming sessions, the researchers chose nine to test, grouped into four bundles.

The first bundle involved education, with a one-page document and informal sessions with nurses. Next came specific advice for clustering overnight care and reducing associated light and noise. The nurses also got red-light flashlights to use instead of turning on overhead lights in patient rooms as part of this step. The third step was a recommendation to avoid unnecessary overnight care for stable patients. Finally, the research team encouraged nurses to find out patients' sleep preferences, give them white noise machines and eye masks, and help them stay awake during the day by providing activities. All of the bundle components were optional—the team provided education, materials, and broad recommendations with each bundle but did not make any specific patient care recommendations or change any formal care pathways.

“Everything that we put out there was actually an idea that a nurse brought to us in these focus groups and design sessions, and then they helped us fine-tune them,” said Dr. Lyons, who is now an assistant professor at Oregon Health & Science University in Portland. “We coalesced around these four bins of activities and tried them out in sequence.”

Results

There were several changes in the nighttime experience at the hospital after the interventions, according to results published by JAMA Network Open on Dec. 4, 2024.

The percentage of patients who perceived the ward as always quiet at night rose from 51% to 86% (although the difference was not statistically significant). The number of excessive noise events dropped from 0.65 per 100 patient-nights to 0, and the mean number of overnight hours patients went without interruptions for routine vital signs, lab tests, or medications rose from 4.94 to 5.10.

“We figured that we would be able to make it quieter,” said Dr. Lyons. “What we didn't expect, though, was that we would actually see the needle change on the overall ratings of experience.”

The statistically significant increase in uninterrupted sleep was another unexpected result. “That's been hard to show in other studies,” he said. “I think that says that there's opportunity to push that further.”

Next steps

The current push for this intervention has been to spread the changes to the rest of the hospital. “There was a big desire for other wards in the hospital to do the same thing. The challenge was figuring out who could go next,” said Dr. Lyons. “How do you balance the need for administrative attention on a scale-up versus the other concurrent needs within the organization?”

Challenges

Competing priorities within the hospital were the main challenge faced during implementation, Dr. Lyons noted. “In the throes of COVID, it was such a dynamic environment,” he said. “There were weeks where it was really tough to find time to sit down with staff, because there were so many patients that had to be gowned up for or other meetings that were competing for their time. … It made us double down on what was the most practical: Where can we meet nurses where they are? Where can we meet patients where they are?”

Words of wisdom

Dr. Lyons hopes that other hospital teams can apply much of what his group learned about effective interventions to promote patients' rest, but he also thinks there's value in doing some of their own interviewing and observation.

“That gets you facts, and that's really important, but it also gets you empathy and buy-in with the people you're trying to help. The fact that our medical students and our program managers [who were doing the interviewing] were out on the wards, day in and day out, including nights and weekends … made uptake a lot more straightforward,” he said.

Lessons learned

An important component of the effort was that it was “truly multidisciplinary,” involving not just physicians and nurses but others including patients, unit secretaries, and therapists, according to Dr. Lyons.

“This really was a project where every single person involved in patient care and the patients themselves contributed to this improved outcome,” he said. “I would encourage folks, as they're thinking about these sorts of projects, to really make sure that they've identified who all of their constituents are to maximize inclusion.”