No TV show based in a hospital leaves out the trope of the beleaguered, intensely sleep deprived young doctor- often a catalyst for conflict and confusion driving the story forward. There is yet another population of hospitals, who’re are sleep deprived when they need all the rest they can get.
Who is telling their story?
Patients admitted to hospitals in a variety of settings cite lack of adequate sleep as a key stressor, irrespective of the actual illness due to which they’re admitted.
Sleep Deprived in a Hospital
The sleep us healthcare workers often lose to care for our patients is rendered less effective by the sleep they themselves lose. The reasons for this are multiple. The ambient noise in a hospital environment as well as periodic medical interventions sputter asynchronously and continuously. Then there’s the reason for illness warranting admission as well.
WHO recommends that noise levels be kept to below 30 dB around hospitals to minimise sleep disturbance. Yet ICU’s - the place in a hospital with the sickest patients ostensibly most in need of rest - routinely cite noise decibels of above 50 dB. It’s hardly any surprise that patients in ICU’s experience highly fragmented and poor quality sleep, even more so than patients admitted in general wards.
The effects of this sleep deprivation are far-reaching. Raised blood pressure and heart rate have been noted. Processes like insulin release from beta cells of the pancreas and carbohydrate metabolism are adversely impacted.
Sleep is an important contributor to the effective functioning of one’s immune system- a bulwark against COVID disease. Often enough, certain diseases disrupt sleep and disrupted sleep worsens the disease- effectively locked into a vicious circle that could be added to Dante’s hell.
For example, we know that reduced sleep is a symptom of several psychiatric and mood disorders as much as we know that this reduced sleep will further exacerbate disease.
Another example is that people experiencing pain that postsurgical or trauma-induced or acute burn pain report fragmented sleep due to this reason, and this very same fragmented sleep is known to lead to higher pain intensity and lower tolerance.
Very importantly for our times- that is, the times of COVID19- sleep deprivation appears to have profound effects on respiratory function. Respiratory disease often brings with it coughing, dyspnea and wheezing serious enough that it causes inadequate sleep. Evidence suggests that this results in a significant decline in the strength of muscles that help with breathing, contributing to hypoventilation and depleting pulmonary reserves of air, and predisposing those with pulmonary disorders to oxygen desaturation.
Moreover, there seems to be a relationship between patients who are on ventilators- those machines that exploded into public consciousness in the manner of iron lungs during the heights of the polio epidemic- and their relationship with sleep. Though the mechanism is not fully understood, mechanical ventilation is associated with the circadian rhythm going haywire and loss of deep, restorative sleep. Sleep in ventilated patients is disrupted by the mode of ventilation, discomfort from the intubation, stress related to illness and the type of medicines they may be on.
Given the ability of sleep deprived states to deleteriously impact respiratory function, the ability of ventilated patients to sleep should be prioritized.
How Do We Fix Sleep for Hospitalised Patients?
The good thing is, there is some low hanging fruit to help patients sleep better:
Studies have identified noise in the hospital to be a key disturbance to sleep, with one reporting that hospital staff behavior is responsible for greater than 50% of the noise. This likely arises due to some combination of staff not prioritizing sleep due to not being aware of the full extent of the damage sleep deprivation perpetuates, or assuming that a certain noise is acceptable due to patients being sedated.
Low cost interventions like earplugs, education of staff about sleep management could reasonably combat this.
Another key disruptor of sleep are interventions like blood draws, monitoring, administering drugs etc. Co-ordinating workflow across departments such that say, a blood draw coincides with vital monitoring would go a long way in minimising sleep disruptions.
As could a thorough assessment of which nocturnal interventions can be safely omitted, particularly in stable patients.
Given the many benefits of sleep, pharmacological interventions may also be considered. For example, melatonin- an inexpensive, widely available drug that aids sleep- attracted a buzz of interest to improve outcomes of COVID19 patients, and even as a potential prophylactic drug.
The COVID19 pandemic has been on a relentless rampage, tearing systems down, but perhaps giving us a chance to rethink these same systems as we build them back up. It’s high-time we wake up to the role of sleep as a bulwark in our infirmaries, and make hospitals a better place to follow the medical cliché of “sleeping it off”.
(Dr Sumedha is a physician based in Bangalore, India.)
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