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Sleep: The Sixth Vital Sign
A Toolkit for Success
Background
The Choosing Wisely Campaign is an initiative of the ABIM (American
Board of Internal Medicine) Foundation to promote conversations
between clinicians and patients by helping patients choose care that is
supported by evidence, not duplicative of other tests or procedures
already received, free from harm and truly necessary.
A major initiative was released in 2014 by The American Academy of
Nursing stating “don’t wake the patient for routine care unless the
patient’s condition or care specifically requires it”.
Sleep deprivation is a public health issue1
Sleep deprivation negatively affects breathing, circulation, immune
status, hormonal function and metabolism and the ability to perform
physical activities2,3
Objective
To improve patient safety by standardizing surveillance and evidence
based practices to promote sleep and rest times for hospitalized patients.
Introduction
Materials and Methods
Discussion and ConclusionsAbstract
Literature Cited
Contact Information
9th Annual Centura Health Evidence-Based Practice, Research and Innovation Conference
October 28, 2016
Centura Nurse Practice Council
Liz Dahlem, BSN, RN
Discussion
Hospital sound levels have increased to around 72dB during the day
and 60dB at night. The World Health Organization (WHO)
recommends hospital noise levels less than 40dB during the day and
34dB at night. The Environmental Protection Agency (EPA)
recommends hospital noise less than 45 dB during rest periods.
• Noise increases oxygen consumption and decreases oxygen
saturation. It increases blood pressure, heart rate, and muscle
tension. Noise impairs sleep, increases stress and anxiety. Altered
sleep cycles delay wound healing. Noise impairs immune function
and leads to longer length of stay.
Challenges
• Centura Health Facilities will require a cultural shift in promoting sleep
in the hospitalized patient. It will require educating the medical staff,
nurses and employees throughout the hospital in their role in
promoting rest and sleep.
Peer reviewed by South Denver Evidence-Based Practice, Research and Innovation Council; Castle Rock, Littleton, Parker and Porter Adventist Hospitals.
Liz Dahlem, BSN, RN
Longmont United Hospital
Outcome Metrics
Simple things – like rest times and sleep– go a long way toward protecting the health of
our patients. One major area of concern nationally is the lack of sleep patients get
during their hospital stay due to care tasks and noise.
Sleep deprivation while being cared for in health care facilities threaten the lives of
patients and the financial health of the organization. This is true here at Longmont
United Hospital, too. Research shows sleep deprivation has negative effects on
breathing, circulation, immune status, hormonal function and metabolism, and ability to
perform physical activity.
Centura Health is launching a major initiative to improve rest and sleep for hospitalized
patients and every staff member plays a critical role if we are to be successful.
Our nurses will be assessing the patient’s sleep quality from the previous night and their
sleep goal and will be documenting this information on the whiteboards in patient
rooms.
Our Sleep initiative, Sleep; The Sixth Vital Sign includes educating medical staff, nurses
and employees across the hospital in their role in promoting rest and sleep for the
hospitalized patient. Nurses and care providers are expected to allow rest times during
the day and sleep at night. In addition, all staff will be expected to reduce noise levels
on inpatient units.
We will also engage patients and families, encouraging them to allow rest and sleep for
their loved one during the hospitalization.
• 1 Murphy, G., Bernardo, A., & Dalton, J. (2013), Quiet at night: implementing a nightingale principle. The
American Journal of Nursing 113(12), 43-51. Doi: 10, 1097/01.NAJ.0000438871.60154.a8
• 2 Buxton, O.M., Ellenbogen, J.M., Wang, W., Carballeira, A., O'Connor, S., Cooper, D.,…& Solet, J.M.
(2012), Sleep disruption due to hospital noises: a prospective evaluation. Annals of Internal Medicine,
157(3), 170-179
3 Li, S.Y., Wang, T.J., Vivienne Wu, S.F., Liang, S.Y., & Tung, H. H. (2011). Efficacy of controlling night-
time noise and activities to improve patients' sleep quality in a surgical intensive care unit. Journal of
Clinical Nursing, 20(3-4), 396-407.
IMPROVEMENT IN PATIENT SATISFACTION SCORES: QUIET AT NIGHT
Goal: An improvement in patient satisfaction scores: Quiet at Night in all Centura Facilities.
The institutional benchmarks will be used to measure improvement rates.
Measurement: HCACPS reporting: Quiet At Night
Improvement Noted As: To realize any improvement in the Patient Satisfaction Scores:
Quiet At Night after six months of implementation with continued progress over time.
Measurement Period: Baseline March 1, 2016 - September 30, 2016. Post implementation
measurement as determined by facility
Frequency of Reporting: Target is monthly to Facility and System
REDUCTION IN FALL RATE
Goal: A reduction of falls in all Centura Facilities. The institutional benchmarks will be used
to measure reduction rates.
Measurement: Rate of in-hospital falls
o Numerator: Number of patient falls.
o Denominator: Number of inpatient days.
o Multiply by 1,000 so that the measure is expressed as number of falls per 1,000 days.
Improvement Noted As: To realize any reduction in patient falls after six months of
implementation with continued progress over time.
Measurement Period: Baseline March 1, 2016 - September 30, 2016. Post implementation
measurement as determined by facility.
Frequency of Reporting: Target monthly to Facility and System
Definition of Terms: Rate of patient falls: Number of patient falls per 1000 patient days
Toolkit Design Strategy
Centura Nurse Practice Council
FY 2015 strategic goal
• Toolkit Development Procedures
Systematic review of the literature
Developed toolkit content
Toolkit Content
• Executive Summary
Communication
Communication Plan Template
Employee Newsletter Article
Physician Newsletter Article
Documentation
Meditech and EPIC Documentation Plans
Meditech and EPIC Screenshots
Education
Education Plan for RN Associates and CNA Associates
Metrics and Reporting
Outcome, Process and Structure Metrics Reporting Plans
Communication Board Documentation of Sleep Goal and Assessment
Falls, HCHAPS: Quiet at night, Length of Stay
Practice Plan
Supply Chain
Eye Masks, Ear Plugs, Aromatherapy
Surveillance
Audits
References
Review of the Literature
Implications for Practice
Strategies for Noise Reduction & Sleep Promotion include a Sleep
Assessment, Designated Day and Night Quiet Times, Relaxation and
sleep inducing interventions including warm blankets, warm drinks, eye
masks, ear plugs and aromatherapy.
