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Efficacy of Sleep Tool Education During Hospitalization: A Randomized Controlled Trial

      Abstract

      Background

      Patients are commonly provided tools in the hospital to overcome poor sleep. Whether education on use of sleep tools can impact health outcomes from a patient perspective is not known.

      Methods

      We recruited 120 adults admitted to a nonintensive care unit cardiac-monitored floor. All patients received a set of sleep-enhancing tools (eye mask, ear plugs, and a white noise machine) and were randomized to receive direct education on use of and benefit of these sleep-enhancing tools (intervention), or an equal amount of time was spent discussing general benefits of sleep (control). Measurement of several symptom domains was assessed daily by health outcome survey responses, and change from baseline was assessed for differences between groups. Inpatient opioid use and length of stay were also measured.

      Results

      Participants randomized to receive the education intervention had a significantly greater decrease in fatigue scores over the 3 days, compared with controls (5.30 ± 6.93 vs 1.81 ± 6.96, t = 2.32, P = .028). There was a trend toward improvements in multiple other sleep-related domains, including sleep disturbance, sleep-related impairment, physical functioning, pain severity, or pain interference (all P >.140). There was no difference in length of stay between intervention and control groups (7.40 ± 7.29 vs 7.71 ± 6.06 days, P = .996). The change in number of opioid equivalents taken did not differ use between the groups (P = .688).

      Conclusion

      In a randomized trial of education in the use of sleep-enhancing tools while hospitalized, patient fatigue was significantly improved, whereas several other patient-reported outcomes showed a trend toward improvements. Implementation of this very low-cost approach to improving sleep and well-being could substantially improve the patient care experience.

      Keywords

      Clinical Significance
      • In a randomized controlled trial, education on using sleep-enhancing tools significantly improved fatigue scores in hospitalized patients and led to nonsignificant trends in improvement in multiple other related symptom domains.
      • Patient education on improving hospital sleep is a simple intervention to improve patient care experience.
      Numerous studies demonstrate that patients experience disturbed sleep during hospitalization.
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      Sleep in hospitalized medical patients, part 1: factors affecting sleep.
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      Sleep in the critically ill patient.
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      A meta-analysis of sleep-promoting interventions during critical illness.
      Poor sleep in the acutely ill can result from multiple factors, including reduced restorative sleep, greater awakenings, reduced total sleep time, and greater daytime sleep.
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      Environmental noise as a cause of sleep disruption in an intermediate respiratory care unit.
      Factors difficult to modify that impact sleep are patient age, staff behavior, and equipment. One modifiable risk for disruptive sleep is hospital noise, which can be challenging to address.
      • Farrehi P.M.
      • Nallamothu B.K.
      • Navvab M.
      Reducing hospital noise with sound acoustic panels and diffusion: a controlled study.
      Medical factors such as advanced age, comorbidities, and taking 3 or more prescription medications are more likely among the hospitalized, and are risk factors for abnormal sleep physiology.
      • Weinhouse G.L.
      • Watson P.L.
      Sedation and sleep disturbances in the ICU.
      Sleep disorders are linked with an increased risk of cardiovascular disease,
      • Bradley T.D.
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      Obstructive sleep apnoea and its cardiovascular consequences.
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      • Cooper D.
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      Sleep duration predicts cardiovascular outcomes: a systematic review and meta-analysis of prospective studies.
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      • et al.
      Short sleep duration as a risk factor for hypertension: analyses of the first national health and nutrition examination survey.
      and poor sleep has been associated with increased all-cause mortality among community-dwelling populations.
      • Suzuki E.
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      • et al.
      Sleep duration, sleep quality and cardiovascular disease mortality among the elderly: a population-based cohort study.
      • Vgontzas A.N.
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      • Pejovic S.
      • et al.
      Insomnia with short sleep duration and mortality: the Penn State cohort.
      In addition to therapeutic interventions, an aim of hospitals is to provide individuals comfort regarding their illness. Patients—especially the critically ill—commonly report negative experiences during hospitalization as a consequence of poor sleep.
      • Poongkunran C.
      • John S.G.
      • Kannan A.S.
      • Shetty S.
      • Bime C.
      • Parthasarathy S.
      A meta-analysis of sleep-promoting interventions during critical illness.
      • Beecroft J.M.
      • Ward M.
      • Younes M.
      • Crombach S.
      • Smith O.
      • Hanly P.J.
      Sleep monitoring in the intensive care unit: comparison of nurse assessment, actigraphy and polysomnography.
      • Kamdar B.B.
      • Needham D.M.
      • Collop N.A.
      Sleep deprivation in critical illness: Its role in physical and psychological recovery.
      Improving patient-related sleep quality is a growing quality metric in hospitals participating in value-based purchasing.
      • Elliott M.N.
      • Cohea C.W.
      • Lehrman W.G.
      • et al.
      Accelerating improvement and narrowing gaps: trends in patients' experiences with hospital care reflected in HCAHPS public reporting.
      • VanLare J.M.
      • Conway P.H.
      Value-based purchasing — national programs to move from volume to value.
      Although there have been several studies of sleep-promoting strategies in hospitalized patients, nearly all have been conducted in the intensive care unit (ICU) setting.
      • Poongkunran C.
      • John S.G.
      • Kannan A.S.
      • Shetty S.
      • Bime C.
      • Parthasarathy S.
      A meta-analysis of sleep-promoting interventions during critical illness.
      • Weinhouse G.L.
      • Watson P.L.
      Sedation and sleep disturbances in the ICU.
      • Beecroft J.M.
      • Ward M.
      • Younes M.
      • Crombach S.
      • Smith O.
      • Hanly P.J.
      Sleep monitoring in the intensive care unit: comparison of nurse assessment, actigraphy and polysomnography.
      Focus in these ICU studies has been predominantly on pharmacologic and ventilator-assisted interventions. However, most patients spend the majority of their hospital stay outside the ICU. Studies are needed about sleep-promoting education strategies among the hospitalized in non-ICU settings where hospitals could most impact patient sleep.
      We performed a double-blinded randomized controlled trial to determine whether a simple education intervention would improve patients' perception about sleep quality, sleep-related impairment, fatigue, physical function, and pain in the hospital. We hypothesized that active education intervention about the use of sleep-enhancing tools, for example, earplugs, will have greater improvement in patient-reported outcome measures compared with those receiving a control. The control group also received identical sleep-enhancing tools, but was given education lasting the same length of time on the general benefits of sleep—rather than on specific use of the tools.

      Methods

      Study Design and Setting

      This was a single-center prospective, double-blind, randomized clinical trial undertaken from January 2014 to September 2015. The study team member obtaining consent was unblinded and did not have contact with the enrollee for the remainder of the study. The patient and all other study team members were blinded to the randomization. The study was designed to assess the impact of a patient education intervention using sleep-enhancing tools on patient-reported outcomes. All patients provided written informed consent. This trial was approved by the University of Michigan Institutional Review Board and was registered on the National Clinical Trials database (NCT02068703). The University Hospital discharged over 50,000 patients last fiscal year.

      Selection of Participants

      Adults aged 18-75 years who were admitted to a non-ICU monitored cardiac unit who were anticipated to have a length of stay of 4 or more days were recruited on hospital day 2. The first day served as an acclimatization period, and patients were enrolled on hospital day 2. Eligible participants were required to have an estimated length of hospital stay >4 days to ensure that adequate follow-up data were available. Reasons for exclusion included wearing hearing aids, being bedridden, receiving treatments for high-acuity medical conditions, or judgment of research team based on unstable medical illness. Clinical factors contributing to high acuity included low blood pressure, multiple intravenous medications that might require night-time adjustments, and recent transfers from ICU stay leaving the patient debilitated.

      Randomization and Measurements

      Following consent, an unblinded member of the research team randomly assigned patients (2:1) to the intervention or control group, through the use of a computer-generated 2, 4-variable block randomization list. The a priori sample size was based on previous trials examining the effect of an intervention program in chronic pain.
      • Williams D.A.
      • Kuper D.
      • Segar M.
      • Mohan N.
      • Sheth M.
      • Clauw D.J.
      Internet-enhanced management of fibromyalgia: a randomized controlled trial.
      One hundred twenty participants with a 2:1 allocation ratio yielded 80% power to detect a 10% difference with α = 0.05 (independent samples Student's t test). Each patient was supplied with 3 sleep-enhancing tools: 1) sleep mask (Centurion Medical, Williamston, Mich.); 2) ear plugs (3M TaperFit2, St. Paul, Minn.); and 3) white noise machine (Homedics, Commerce Township, Mich.). Patients were able to choose which aid they used, to change aids during their hospital stay, and could use one or more at any time or not use aids at all. Patients received similar contact time with study staff, regardless of group allocation, lasting approximately 10 minutes (see Appendixes A and B, available online). Both groups were read scripted discussions by the study staff on the importance of sleep and good health. Included in the intervention script, patients were given active instruction on tool use and encouraged to utilize the tools. Immediately following randomization, patients completed baseline surveys. On subsequent hospital days, a blinded study team member collected survey responses to the Patient-Reported Outcomes Information System (PROMIS; Short Form) and Brief Pain Inventory
      • Tan G.
      • Jensen M.P.
      • Thornby J.I.
      • Shanti B.F.
      Validation of the brief pain inventory for chronic nonmalignant pain.
      (BPI) survey measurements as well as documenting self-reported use of sleep tools.
      Baseline PROMIS surveys were obtained at randomization.
      • Buysse D.J.
      • Yu L.
      • Moul D.E.
      • et al.
      Development and validation of patient-reported outcome measures for sleep disturbance and sleep-related impairments.
      Each Short Form represents a specific domain (sleep disturbance, wake disturbance, fatigue, and physical functioning) and includes 8-10 questions with 5-point Likert-style response scale (Never, Rarely, Sometimes, Often, Always).

      Health Measures. PROMIS. Patient-reported outcomes information system. Available at: http://www.nihpromis.org. Accessed November 16, 2015.

      Patients were asked in the survey battery and verified by medical record to report use of opioid-derived pain and sleep-enhancing medication use.

      Outcomes and Analysis

      The primary outcome was not a composite but an improvement in sleep, pain, and fatigue—based on the specific domain PROMIS survey responses—over 3 days in the intervention group compared with controls. The secondary outcome was whether the intervention reduced chronic pain medication use. The secondary analysis included: use of sleep-promoting and analgesic medication. Patients discharged prior to hospital day 4 or transferred off the unit were excluded from final analysis.
      The PROMIS Short Form raw scores were standardized to a 0-100-point scale, where 50 is representative of the mean score in the population, a similar process to other standardized mental/physical assessment surveys. For all PROMIS domains except physical function, a higher score is indicative of worse outcome (eg, worse sleep). The BPI consists of the pain severity and pain interference scores and is on a 0-10 scale, with higher scores indicating worse outcome. Baseline scores were assessed for potential bias in demographics (sex, race, ethnicity) using independent samples t tests and one-way analysis of variance for continuous and categorical data, respectively. Sex and race distributions in arms were assessed using chi-squared analysis.
      In the primary analysis, we compared the change in scores between groups, using an independent samples t test. Change scores were calculated as (study day 3—baseline), where ‘x’ is the mean difference. Due to unequal sample sizes, we utilized Levine's test to assess for unequal variances prior to t-test analysis. Continuous data are presented as mean ± standard deviation and categorical data as frequency and percentage. All tests were 2-tailed, and statistical significance was established at P <.05. All data analysis was performed with SPSS version 22 (IBM, Armonk, NY).

      Results

      Altogether, 702 patients were screened and 120 were randomized 2:1 to the (active) education intervention or control (Figure). Because the prespecified endpoint required at least 2 additional nights in the hospital after enrollment, 34 were excluded because they stayed only 1 or 2 nights after randomization. A total of 86 patients (mean age 56.22 ± 11.41 years) were eligible for analysis, with 52 intervention (44.2% female) and 34 control (35.3% female) patients. Age, sex, race, ethnicity, and body mass index did not differ between groups (Table 1). Demographics of those randomized but later excluded were similar to those cases used in final analysis.
      Figure
      FigureStudy enrollment of 702 screened; 582 were excluded. An additional 34 were excluded after randomization, leaving 86 patients included and followed in the hospital for at least 3 nights.
      Table 1Baseline Demographics
      Mean ± SD or frequency (%).
      Study Population

      n = 86
      Intervention

      n = 52
      Control

      n = 34
      Sex (male)51 (59.3%)29 (55.8%)22 (64.7%)
      Age (y)56.22 ± 11.4257.73 ± 9.8354.26 ± 13.36
      Race
       Caucasian71 (82.6%)41 (78.8%)30 (88.2%)
      Ethnicity
       Non-Hispanic84 (97.7%)51 (98.1%)33 (97.1%)
      Body mass index31.42 ± 9.4631.90 ± 9.2431.03 ± 9.82
      Length of hospital stay (d)8.59 ± 6.788.65 ± 7.288.59 ± 6.15
      Room type (private)43 (50.0%)27 (51.9%)16 (47.1%)
      Outpatient opioid use
      Includes daily and as-needed use.
      30 (37.0%)19 (36.5%)11 (32.3%)
      Mean ± SD or frequency (%).
      Includes daily and as-needed use.

      Sleep-Enhancing Tools

      After 1 night of hospital acclimation, frequency of sleep-enhancing tools use was significantly higher among the active intervention group, suggesting that this brief education intervention was successful in having more patients to utilize the sleep tools (Table 2). The proportion of patients using sleep-enhancing tools was significantly higher in the active intervention group on both follow-up day 2: 35.3% vs 62.7%, P = .013, and day 3: 31.3% vs 61.5% for control and intervention, P = .007. A significantly greater proportion of the intervention patients (69.2%) utilized the sleep tools at least once during the 3 days, compared with the control (41.2%) group (χ2 = 6.65, P = .01). On day 2, 52.9% of intervention patients used the white noise machine, 29.4% used the sleep mask, and earplugs were used by 17.6%. On day 3, 50.0% of patients used the white noise machine, 25.0% the sleep mask, and 9.6% used earplugs.
      Table 2Proportion of Patients Reporting Use of Sleep-Enhancing Tools on Days 2 and 3
      On day 1 patients were enrolled and had not yet the opportunity to use the tools; (within variable %, frequency).
      Any Tool UsedEar PlugsSleep MaskNoise Machine
      Day 2
       Control (n = 34)35.3% (12)8.8% (3)8.8% (3)26.5% (9)
       Intervention (n = 52)62.7% (32)17.6% (9)29.4% (15)52.9% (27)
      Day 3
       Control (n = 34)31.3% (10)3.1% (1)15.6% (5)21.9% (7)
       Intervention (n = 52)61.5% (32)9.6% (5)25.0% (13)50.0% (26)
      On day 1 patients were enrolled and had not yet the opportunity to use the tools; (within variable %, frequency).

      Patient-Reported Outcomes or Primary Outcome

      At baseline, scores for patient-reported outcomes were similar in the active intervention and control groups (all P >.100). Mean scores for each hospital day can be seen in Table 3. Fatigue scores improved a significantly greater amount in the intervention group compared with the control group (P = .028). The education intervention had greater improvement in sleep disturbance scores compared with the control intervention, although considerable overlap exists in standard deviation (P = .140). Groups did not differ significantly in wake disturbance (P = .810) or physical functioning (P = .460). Change in pain severity and pain interference scores did not differ significantly between the 2 groups (P = .388, and P = .920) (Table 4).
      Table 3Mean Scores Across Study Days in Intervention and Control Patients
      Study Day

      Mean (SD)
      123
      Fatigue
      PROMIS (Patient-Reported Outcomes Information System) domain score scale (0-100).
       Control58.73 (8.37)56.41 (7.81)56.54 (9.07)
       Intervention61.6 (7.56)58.48 (8.24)56.37 (8.54)
      Sleep disturbance
      PROMIS (Patient-Reported Outcomes Information System) domain score scale (0-100).
       Control59.12 (9.51)56.26 (9.71)57.17 (8.86)
       Intervention61.26 (7.89)54.80 (10.24)56.14 (8.99)
      Wake disturbance
      PROMIS (Patient-Reported Outcomes Information System) domain score scale (0-100).
       Control57.97 (7.81)55.69 (7.31)55.99 (6.21)
       Intervention58.71 (7.66)57.24 (7.66)55.64 (7.32)
      Physical function
      PROMIS (Patient-Reported Outcomes Information System) domain score scale (0-100).
       Control36.85 (5.25)36.81 (5.69)37.68 (5.32)
       Intervention34.95 (7.52)34.65 (7.63)36.13 (7.69)
      Pain severity
      Pain domain score scale (0-10).
       Control3.82 (2.54)4.34 (2.40)3.77 (2.48)
       Intervention4.16 (2.50)4.26 (2.56)4.34 (2.57)
      Pain interference
      Pain domain score scale (0-10).
       Control4.55 (3.19)4.42 (3.19)4.04 (3.22)
       Intervention4.47 (3.27)4.43 (2.40)4.37 (3.11)
      PROMIS (Patient-Reported Outcomes Information System) domain score scale (0-100).
      Pain domain score scale (0-10).
      Table 4Impact of Patient Education on Fatigue, Sleep, Wakefulness, and Pain Survey Scores
      ControlEducation InterventionP-Value
      Fatigue1.81 ± 6.965.3 ± 6.93.028
      Sleep disturbance1.67 ± 11.485.12 ± 9.37.140
      Wake disturbance2.06 ± 6.513.07 ± 5.82.461
      Physical function0.81 ± 3.430.94 ± 4.66.899
      Pain severity0.08 ± 1.28−0.22 ± 1.63.388
      Pain interference0.15 ± 2.240.1 ± 2.25.920
      Mean (SD); independent samples t test.

      Post Hoc Assessments

      Both groups were assessed to see if the intervention significantly improved outcome scores from baselines in the intervention group alone and whether the control group scores improved due to improved health status over time in the hospital. In the intervention group alone there was a significant improvement from baseline in sleep disturbance (x = 5.12 ± 9.37, t = 3.94, P <.001), wake disturbance (x = 3.07 ± 5.82, t = 3.81, P <.001), and fatigue (x = 5.31 ± 6.93, t = 5.46, P <.001). Physical function (P = .158), pain severity (P = .404), and pain interference (P = .748) did not differ significantly from baseline. In the control arm alone, there was no significant change from baseline in any outcome: sleep disturbance (P = .425), wake disturbance (P = .614), fatigue (P = .201), physical function (P = .157), pain severity (P = .727), or pain interference (P = .710).
      In another effort to determine what aspect of the intervention is improving patient-reported outcomes, we assessed patients that reported sleep-enhancing tools use (n = 50) during the 3 days analyzed, regardless of randomization group. We found similar results, where sleep disturbance (x = 4.95 ± 9.21, t =3.76, P <.001), wake disturbance (x = 3.28 ± 5.85, t = 3.96, P <.001), and fatigue (x = 4.32 ± 7.27, t = 4.16, P <.001) decreased significantly following intervention. However, physical function, pain severity, and interference did not differ significantly between groups.

      Secondary Outcomes

      Length of hospital stay was nearly identical in the intervention, 8.60 ± 7.21 days, and control arms 8.59 ± 6.15 days (P = .996), a duration influenced by the minimum length of hospital stay study requirement. A small percentage of patients utilized sleep-enhancing medications, with similar group proportions that did not differ (36.5% cases vs 29.4% controls, P = .490). The proportion of patients receiving chronic pain medication during study days did not differ between arms (53.8% intervention vs 47.1% control, P = .538). One reason why pain severity and interference scores did not change from baseline is the treat to maintain approach that many inpatient units utilize, where the amount of medication is changing in order to keep pain constant. Chronic pain medications were converted to opioid equivalent units (oeu), a continuous variable, and assessed for differences. The intervention group had a greater decrease (−1.17 oeu) in the number of oeu from baseline compared with controls (+0.34 oeu), but did not reach significance (P = .688). Further, when we assessed patients that used sleep tools, regardless of randomization, there was a greater decrease in oeu compared with those who did not use sleep tools, however, this did not reach significance (P = .278).

      Discussion

      The main findings of this study are that a simple educational intervention at the point of hospital care led to improved self-reported fatigue, compared with control education. The secondary study findings suggest that the added education led to greater use of sleep-enhancing tools among hospitalized patients, and this was likely responsible for the observed improvement and trends toward improvement in study outcomes.
      Physicians and hospital staff are reminded daily by patients about their perception of sleep in the hospital. The problem is multifactorial, making a panacea unlikely. We utilized tools commonly available on many hospital floors today. A recent meta-analysis of ICU studies utilizing sleep promotion interventions did show improved sleep among the critically ill.
      • Poongkunran C.
      • John S.G.
      • Kannan A.S.
      • Shetty S.
      • Bime C.
      • Parthasarathy S.
      A meta-analysis of sleep-promoting interventions during critical illness.
      However, this benefit pooled results involving both heterogeneous patients and sleep interventions. To our knowledge, this is the first randomized clinical trial in a non-ICU setting to study perception of sleep, wake, and pain disturbance and fatigue in a group of noncritically ill patients. We chose to study several domains due to the overlap of sleep and its correlates among the acutely hospitalized: fatigue, wakefulness, and pain.
      Our intervention was an easily reproducible educational script with an active control group. Other common chronic conditions respond to patient-based education interventions. Effective pain control can improve with behavior modification through a clinician's guidance as well as medication adherence.
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      Individual patient education for low back pain.
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      How effective are patient-based educational interventions in the management of cancer pain? Systematic review and meta-analysis.
      Ear plugs and white noise machines improve hospital sleep.
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      The effects of ocean sounds on sleep after coronary artery bypass graft surgery.
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      When healthy patients were exposed to simulated ICU light and noise, use of ear plugs and eye masks reduced sleep disruption.
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      One small study similarly concluded that eye masks and ear plugs improved subjective evaluations of sleep of ICU patients.
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      Increased light levels disrupt sleep and suppress melatonin, a key factor that plays a role in sleep promotion.
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      A key advantage to our study was the homogeneity of the population studied and the relatively large acutely ill population randomized. Whether study patients would be discharged (or moved off the unit) prior to the prespecified endpoint of 3 days of PROMIS surveys was not foreseeable. The intervention arm did not have significantly greater improvement compared with the control arm in our primary analysis; however, the intervention was successful in significantly improving patient perception of sleep, wakefulness, and fatigue, whereas the control arm did not differ from baseline. Thus, improved health status during the study period is insufficient to explain the improved outcome. If that were the case, a similar observation would have been found among controls.

      Limitations

      This randomized controlled trial was not designed as a study of sleep, but rather an intervention to improve a patient's perception of sleep and its correlates. Hospitals are increasingly compared with one another based on satisfaction scores, one of many reasons that patient-reported outcomes are important.
      • Elliott M.N.
      • Cohea C.W.
      • Lehrman W.G.
      • et al.
      Accelerating improvement and narrowing gaps: trends in patients' experiences with hospital care reflected in HCAHPS public reporting.
      We intentionally designed the trial with all patients receiving tools, to avoid staff bias toward patients with bedside tools. Our study included hospitalized patients with primary cardiac conditions, limiting generalization to other populations. Although objective measures of sleep have advantages, they are time consuming, labor intensive, and results differ from self-reported surveys of patients.
      • Redeker N.S.
      • Tamburri L.
      • Howland C.L.
      Prehospital correlates of sleep in patients hospitalized with cardiac disease.
      This education-based approach using self-reported surveys was easier to apply and allowed a larger study sample. Whether a similar educational intervention would improve sleep as patients transition to other facilities or home is unknown and merits investigation.

      Conclusions

      A patient-based education intervention can improve the use of sleep-enhancing tools in a non-ICU setting. In this randomized clinical trial, education on the use of sleep-enhancing tools improved perceptions of fatigue compared with a control, and within the active education intervention arm itself, improved sleep, wakefulness, and fatigue from baseline. A better understanding of hospital sleep and its correlates will be essential to identify specific sleep-promoting interventions and determine which patients are most likely to benefit.

      Acknowledgment

      We kindly acknowledge the enthusiastic support of the Occupational Therapy Division staff at the University of Michigan Health System. We are indebted to our trained study staff, especially Mary Barber, Christelle David, Sandy Fogarty, Brittany Gappy, Bridget Higgins, Steven Heidt, Melissa Johnson, Julia Meireles, and Zainab Rasheed.

      Appendix A Control Group Script

      (Following Signed Consent and Randomization)

      Introduction

      Thank you for consenting to participate in this study. Our research team includes occupational therapists, anesthesiologists, and a cardiologist with an interest in sleep. As you know, we are interested in how problems sleeping affect you while you are in the hospital. Simply being in the hospital can lead to sleep disruption. And regardless of age, this disruption of sleep can create a negative impact on your quality of life, mood, and alertness.

      Background

      Even though the ability to sleep becomes more difficult as we age, the need does not decrease with age. Humans sleep about a third of their life. Yet most of us know very little about sleep. Although its exact function has yet to be defined, sleep is a universal need for all of us. In fact, absence of sleep has serious consequences. For instance, about 20% of all car crashes in the general population are associated with driver drowsiness, and this figure is independent of alcohol. It is estimated that between 50 and 70 million Americans have disorders of sleep or wakefulness, which have negative effects on daytime functioning.
      As we learn about sleep problems, it is important to understand some of the types of insomnias. There are multiple kinds of sleep disruptions or “insomnias.” Transient Insomnia can last up to 1 week and is usually brought on by a new stressor in your life, like a new job or deadline. Short-term insomnia can last up to 6 months and is usually associated with a more significant stress, like the loss of a loved one, illness, or even environmental factors such as noise. Chronic Insomnia lasts more than 6 months and can be the result of a number of other health conditions.
      In Psychophysiological Insomnia, people have a cycle of trying harder and harder to sleep, which results in them becoming more tense and unable to sleep. Idiopathic Insomnia is a neurological abnormality of the sleep-wake cycle. Sleep State Misperception is when a person feels that they have experienced insomnia, but there is no evidence of actually having a disrupted sleep cycle; therefore, it appears to be more of a perception of their sleep quality or quantity, more than the actual sleep quality and quantity that occurred.
      It is also important to understand the role that melatonin has in sleep. Melatonin is a hormone that is produced in the pineal gland, which is in the brain. Melatonin can also be found in trace amounts in some foods that we eat. Melatonin affects our sleep by helping our body to sleep. Melatonin is produced when the body is in darkness; therefore, when we go to sleep in a dark room, melatonin is produced. Because light affects how much melatonin is produced, many environmental factors can affect it, both indoor and outdoor light. Some people find even the light from an alarm clock can be disruptive to their sleep, and others find that they are easily awakened upon the sunrise; this is likely due to the role that melatonin plays with our wake-sleep cycle, or as we also call it, our “circadian rhythm.” It has also been reported that our melatonin levels decrease as we age, which may lead to more difficulty with sleep in the older adult population.
      In understanding Insomnias, it is important to learn that people don't have the same type of impaired sleep. For example, some have “Initial Insomnia,” which is the difficulty of falling asleep. Others experience “Middle Insomnia,” which is classified by waking during the night. Terminal Insomnia is defined as waking up earlier than their needed time. Initial insomnia is usually reported more by people who experience anxiety. Middle insomnia has been reported to occur with medical problems and pain. Terminal insomnia has been linked to major depression and menopause.
      Some people experience other sleep problems that are not related to the lack of sleep. For example, Hypersomnia can be described as a person who has abnormal amounts of daytime sleepiness.
      There are 3 major causes of sleep disorders and insomnias. When impaired, medical conditions, psychological conditions, and environmental conditions can all play a primary role in negatively affecting our sleep.

      Disturbed Sleep

      People with sleep deprivation or sleep disorders are linked with a variety of health conditions including an increased risk of diabetes, hypertension, obesity, depression, and stroke. The exact reasons for these effects are not known but give support to the theory that sleep is vital for our body to rest and heal. Sleep—it turns out—is a very complex process and is considered a vital part of happiness, which is one of the best forms of preventative medicine!

      Your Health Care Team Cares About Your Sleep

      We'd like to see you sleep better here and after you go home. Eliminating or reducing your sleep problems are important to your health and well-being. The first step is to establish a routine. Go to sleep at the same time every day. And wake up at a regular time. Also, establish a relaxing pre-sleep routine. Give yourself some “wind down” time, such as brushing your teeth or read a book. Avoid caffeine within 6 hours of bedtime. Caffeine is a stimulant and can disrupt or fragment your sleep. Do not watch the clock. This action may make it impossible to sleep. If you need to urinate in the middle of the night, try to limit your intake of liquids at least 90 minutes prior to your bedtime.
      It is also important to note the timing of your sleep disruptions. Do you have difficulty falling asleep, staying asleep, or are you waking earlier than necessary? Sleep schedules should also be tracked; do you wake up at the same time each morning and go to bed at the same time each day?
      Sleep environments are also something you can track. What is the temperature of your room, do you have increased noise and light levels that could be affecting your sleep routine?
      Some people find it helpful to keep a sleep diary for approximately 2 weeks in order to establish exactly what kinds of sleep problems they are experiencing so that they can begin to tackle the actual problem at hand. There are different types of therapy, for example, cognitive behavioral therapy for people who have anxiety that is disrupting their sleep. Sleep Restriction Training can be used if you find yourself sleeping at various times. For example, the weekend or vacation is not necessarily a “time to sleep in” or “take naps,” as these activities can actually impair your sleep. Sleep restriction training focuses on getting to bed at the same time and awakening at the same time every day to improve your sleep.
      There are many causes of sleep impairment, and oftentimes it can be multifactorial. It is important to follow up with your doctor if you have sleep impairments.

      Final Reminder and Thank You

      As part of this study, you can store this tray of equipment provided anywhere you would like in the room. The white noise machine, mask, and ear plugs you may take at the end of your stay.
      Again, thanks for your participation in this study. And now I want you to complete a few questions about your sleep, pain, and fatigue. Remember, you'll be asked these same questions every day as a part of this study.

      Appendix B Intervention Group Script

      Sleeping Tools INTERVENTION Subject Script
      (Following Signed Consent and Randomization)

      Introduction

      Thank you for consenting to participate in this study. Our research team includes occupational therapists, anesthesiologists, and a cardiologist with an interest in sleep. As you know, we are interested in how problems sleeping affect you while you are in the hospital. And regardless of age, this disruption of sleep can create a negative impact on your quality of life, mood, and alertness.

      Background

      Even though the ability to sleep becomes more difficult as we age, the need does not decrease with age. Humans sleep about a third of their life. Yet most of us know very little about sleep. Although its exact function has yet to be defined, sleep is a universal need for all of us. In fact, absence of sleep has serious consequences. For instance, about 20% of all car crashes in the general population are associated with driver drowsiness, and this figure is independent of alcohol. It is estimated that between 50 and 70 million Americans have disorders of sleep or wakefulness, which have negative effects on daytime functioning.

      Disturbed Sleep

      People with sleep deprivation or sleep disorders are linked with a variety of health conditions including an increased risk of diabetes, hypertension, obesity, depression, and stroke. The exact reasons for these effects are not known but give support to the theory that sleep is vital for our body to rest and heal. Sleep—it turns out—is a very complex process and is considered a vital part of happiness, which is one of the best forms of preventative medicine!

      Your Health Care Team Cares About Your Sleep

      We'd like to see you sleep better here and after you go home. The first step to better sleep is to establish a routine. Go to sleep at the same time and wake up at a regular time, EACH DAY. Also, establish a relaxing pre-sleep routine. Give yourself some “wind down” time, such as brushing your teeth or read a book. Avoid coffee within 6 hours of bedtime, because caffeine is a stimulant and can disrupt or fragment your sleep. Do not watch the clock. This action may make it impossible to sleep. If you need to urinate in the middle of the night, try to limit your intake of liquids at least 90 minutes prior to your bedtime.

      Demonstration of Tools

      Simply being in the hospital can lead to sleep disruption. The causes are many. Most common are noise and light. So we have a few tools to improve your sleep, by reducing noise and light.
      • 1.
        The first tool I want to show you are earplugs. They are designed to fit snug in your ears. They can be reused and are yours to keep at discharge. (DEMONSTRATE) Gently place them in your ear at bedtime and remove in the morning. For your information, these plugs can attenuate audible frequencies by 20 to 40 decibels. These may be especially useful if the noise from the hallway or the nurse's station or people talking distracts you while you are trying to fall asleep. Let me make sure you know how to put them in and take them out. (DEMONSTRATE)
      • 2.
        The second tool is the mask that comfortably covers your eyes. (DEMONSTRATE) It can shield your eyes from exposure to light, one of the most important factors that makes it difficult to fall asleep. Our natural desire to sleep comes with the cycle of light and dark during the day and night. So if you have trouble falling asleep while the light shines through the window or if lights in your room are on when nursing checks on you, this mask may help you to remain asleep. It may also help if the sun shines into the window first thing in the morning, waking you up. Again, this mask is for you to keep when you are discharged from the hospital. Let me make sure you know how to put it on and take it off. (DEMONSTRATE)
      • 3.
        The third tool is a white noise machine. These machines have been shown to reduce the number of arousals from sleep when used in the Intensive Care Units but have not been studied on a monitored Cardiology floor like 7C. Have you ever heard of a person needing a fan to fall asleep? It is speculated that reducing the difference between background noise and peak noise makes waking up or an arousal less likely. (DEMONSTRATE) There are many settings to choose from, including noises that sound like a soft thunderstorm, ocean waves, a babbling brook, summer night sounds with crickets, rain, or white noise. You can adjust the volume to your liking as well. You could try it for 15 or 30 minutes then it will automatically turn off; however, we recommend leaving it on the entire night to help diffuse the hospital noises. Let us have you turn it on and see if you can hear the different settings and make sure you know how to use it. (DEMONSTRATE)

      Final Reminder and Thank You

      You can store the equipment anywhere you would like in the room. The white noise machine, mask, and earplugs you may take at the end of your stay. You can start using these tools tonight.
      Again, thanks for your participation in this study. And now I want you to complete a few questions about your sleep, pain, and fatigue. Remember you will be asked these same questions every day as a part of this study.

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