PICO Presentation: For hospitalized patients, does the use of hypnotic agents as compared with non-pharmaceutical sleep aids improve sleep?

Danielle EloreCOHP 450Ferris State UniversityPICO Presentation:For hospitalized patients, does the use of hypnotic agents as compared with non-pharmaceutical sleep aids improve sleep?

Hello, my name is Danielle Elore. The PICO question that I proposed is For hospitalized patients, does the use of hypnotic agents as compared with non-pharmaceutical sleep aids improve sleep? I am a registered nurse that works twelve hour night shifts. I have many patients that take hypnotic sedatives chronically for insomnia. I also have many patients that do not, but often complain of the lack of sleep they are receiving on their hospital stay and request something to help them sleep. I often try to cluster my care to disturb them less and I offer ear plugs, eye masks, headphones, but some patients refuse these and want some sort of medication to put them to sleep. Much of the time patients that do not regularly take hypnotic sleep agents complain that the medication did not work. Also, patients that do take the opportunity to use the earplugs, eye masks, etc. thank me for making their stay more comfortable. The purpose of this presentation is to compare research on this subject so that I can become more educated on this subject, since it is something I often deal with. 1Using FLITE, I searched CINAHL, which is a nursing database.Search words included: Hypnotics sleep, hospitalized patients sleep, and noise reduction hospitalsHypnotics sleep: search produced a good research article about hypnotic sedatives prescribed for sleepHospitalized patients sleep and noise reduction hospitals did not produce adequate resultsUsing Google, I was able to find an article on the National Institutes of Health Website.Search words included: noise reduction hospital setting and noise reduction hospital patients sleepNoise reduction hospital setting did not provide adequate resultsNoise reduction hospital patients sleep produced a good research article about noise reduction strategies and the impact of noise on hospitalized patients sleep

Literature search results

I used Ferris State Universitys FLITE library to search CINAHL which is a nursing database powered by EbscoHost. I used multiple search words. Some searches provided no results, others provided very few results with none of them adequate for this presentation. I did however find a decent research article about hypnotic sedatives prescribed for sleep using hypnotics sleep as the search words. I also did a Google search. I weeded out the inappropriate articles for this presentation and found a good research article from the National Institutes of Health website. The search words I used were noise reduction hospital patients sleep. The article I found is about noise reduction strategies and the impact of noise on hospitalized patients sleep. 2Moloney, M.E., Konrad, T.R. & Zimmer, C.R. (2011). The medicalization of sleeplessness: A public health concern. American Journal of Public Health, 8, 1429-1433. doi: 10.2105/AJPH.2010.300014Xie, H., Kang, J. & Mills, G.H. (2009). Clinical review: The impact of noise on patients sleep and the effectiveness of noise reduction strategies in intensive care units. Critical Care, 13(2), 208-215. doi: 10.1186/cc7154Literature search results

The first research study I found for this presentation is from American Journal of Public Health and is called The Medicalization of sleeplessness: A public health concern. The second research study I found for this presentation is from Critical Care and is called Clinical review: The impact of noise on patients sleep and the effectiveness of noise reduction strategies in intensive care units. Both articles are cited in the American Psychological Association or APA format on this slide. 3The Medicalization of Sleeplessness: A Public Health ConcernThis article is research on benzodiazepines and hypnotic sedatives prescribed for sleep. I chose this one because the article researches the increase in people being prescribed these agents and often do not have a medical diagnosis of insomnia.

Clinical Review: The Impact of Noise on Patients Sleep and the Effectiveness of Noise Reduction Strategies in Intensive Care UnitsThis article is research on the impact noise has on hospitalized patients sleep and the non-pharmaceutical measures taken to provide sleep by reducing noise.

Literature Search results

I chose the first article the medicalization of sleeplessness: a public health concern for this presentation because the research the article provides is geared towards how often benzodiazepines and hypnotic sedatives are being prescribed for sleep. This article is not about hospitalized patients, but does show how there is a growing concern for over prescribing these medications, especially in patients where an insomnia diagnosis is not given by a physician. These medications have many side effects and benzodiazepines can be highly addictive. So why would we want to give them to hospitalized patients who are being treated for something else entirely. I chose to use the second article clinical review: the impact of noise on patients sleep and the effectiveness of noise reduction strategies in intensive care units because this article provide research on non-pharmaceutical ways to produce sleep in hospitalized patients. The research also provides information on the effectiveness of the non-pharmaceutical ways to produce sleep. 4Medicalization of SleeplessnessQuantitativeStudy Design: Cross-sectional survey, retrospective Sample: Adults 18+ 1993 to 2007Variables: Sleeplessness, insomnia diagnosis, Benzodiazepine/NBSH prescriptionStatistical Analysis: SVY commands, bivariate linear model, descriptive statisticsClinical Review: Noise ReductionQuantitativeStudy design: Literature Review, retrospectiveSample: Hospitalized ICU patientsVariables: Hospital noise, noise reduction interventionsStatistical Analysis: Descriptive Statistics, Cochrane CollaborationResearch study evaluation

Both articles are quantitative studies. The first article has a retrospective cross-sectional survey study design. The authors used the National Ambulatory Medical Care Survey which is an annual population based survey of US office based physician visits and uses 3000 randomly chosen physicians per year. The sample was based on adults 18 years and older that were patients in those office visits in the years 1993 to 2007. Variables that were used include patient complaints of sleeplessness, physician diagnosis of insomnia and benzodiazepine or nonbenzodiazpine sedative hypnotic prescription. In the second article the study design was a retrospective literature review that used cochrane collaboration which is a group that puts retrospective medical research into data. The sample used was hospitalized ICU patients. Variables included hospital noise and noise reduction interventions. 5Medicalization of Sleeplessness ResultsNBSH prescriptions grew 21 times more rapidly than sleeplessness complaints and 5 times more rapidly than insomnia diagnosesAges 18-65 outpaced 65+ on all sleeplessness related measuresVery large rise in number of sleeplessness complaints in 2006-2007NBSH increase sleep time by less than 12 minutes on averageSide effects include sleep driving, sleep eating, sleep walking and short term amnesia. Also, NBSH are risky for patients who take multiple medications, have a history of drug abuse or mental illness and those that are at risk for falls. Proven nondrug treatments exist: sleep hygiene and environmental modifications. Research study evaluation

Results from the first article The Medicalization of sleeplessness: a public health concern are shown on this slide. Nonbenzodiazepine sedative hypnotics prescriptions, including ambien and sonata, grew much more rapidly than sleeplessness complaints or insomnia diagnoses. This means that over time medications for sleep are being prescribed at a much faster rate than complaints of sleeplessness are increasing over time. There was a very large rise in number of sleeplessness complaint in 2006 to 2007. The authors contribute this to multiple things including more awareness of insomnia and how it is not always secondary to a mental illness, also including more awareness to how important good sleep is to health and the increase of advertising for sleep aids. The side effects of sedative hypnotics can be detrimental to the health of a patient, however the average increase in sleep time is less than 12 minutes. The proven nondrug treatments includes sleep hygiene which are things such as diet and exercise and environmental modifications which includes temperature, noise and light. 6Clinical Review: Noise Reduction ResultsNoise is just one of a number of factors that may disrupt sleep of an ICU patientStaff conversation and alarms are regarded as the most disturbing noises for patients sleep in the ICU.Four interventions exist for sleep improvement including: earplugs, behavioral modification, sound masking and acoustic absorption.Sound absorbing treatment is an effective noise strategySound masking is the most effective technique for improving sleep. Research study evaluation

The results from the second article Clinical review: The impact of noise on patients sleep and the effectiveness of noise reduction strategies in intensive care units are shown on this slide. Sleep disturbance plays a role in causing hospital delirium. Drugs used in the hospital may aggravate the levels and appropriateness as well as timing of either wakefulness or sleep, which has a lot to do with our natural circadian rhythm. Also, on withdrawal of these medications a rebound increase in REM sleep may be precipitated which can cause nightmares, hypertension, tachycardia and hypoventilation, according to Xie, Kang and Mills (2009) . All of which are not good especially for the hospitalized patient. Staff conversations and alarms are the most disturbing noises for patients sleep according to this research. The four interventions for sleep improvement include earplugs, behavioral modification which involves providing a dark and quiet environment which will in turn make patients, visitors and hospital staff quiet, sound masking would include playing music or white noise to mask disturbing sounds, acoustic absorption would be like having special ceiling tiles to absorb the disturbing sounds. In the research provided, all interventions to decrease noise decreased noise in all results. 7Medicalization of SleeplessnessUsed National Ambulatory Medical Care Survey (NAMCS) conducted by the National Center for Health Statistics (NCHS). http://www.cdc.gov/nchs/about.htm Clinical Review: Noise ReductionDid a literature review of other research studies using specific search engines. Found 167 studies, used 23 that included key criteria. Gave credit to each study used within this literature review. Ethical Considerations

The authors of The medicalization of sleeplessness: a public health concern did not specifically state anywhere in their article about ethical considerations. However, the privacy of the sample population is implied because of their use of a survey conducted by the National Center for Health Statistics. Upon my research of the NCHS, I found their website which is a part of the Centers for Disease Control website. I have added the link to that website on this slide. The website has a link about how they protect our privacy by following federal law and using good statistical laws. The authors of the second article did a literature review. Throughout their article they often cited other authors for using their information, so by doing this they gave credit and recognition and did not plagiarize. 8Medicalization of SleeplessnessPeer ReviewedAdequate background for researchThreat to external validityLevel of Measure: Ratio data

StrengthQualityCredibility

Research study evaluation

The article The Medicalization of Sleeplessness: a public health concern is a peer reviewed article. The authors state that sleeplessness is a normal part of humanity and that there is a problem if people are taking medicine to provide sleep. This provide adequate background for the research study. The authors do state that all the information was taken from doctors offices. This may exclude people with a lower socioeconomic background and/or people without insurance who use the emergency department of hospitals as their primary source of health care. The level of measure in this study is ratio data which is consistent with descriptive statistics which is the type of analysis used in this study. This research study is a strong, credible and quality source. 9Clinical Review: Noise ReductionPeer ReviewedAdequate background for researchNo threats to validityLevel of measure: Nominal data

StrengthQualityCredibility

Research study evaluation

In the article Clinical review: The impact of noise on patients sleep and the effectiveness of noise reduction strategies in intensive care units I was unable to tell if it was peer reviewed. Upon discovering the journals website which states that articles are usually reviewed by at least 2-3 peers, I have decided the article is peer reviewed. The authors state in the background for this article that disturbing noise is very common for ICU patients. In the past research, all research has been on noise reduction. The hopes of these authors were to put a correlation between noise reduction and improving sleep. This information is adequate for research. I did not find any threats to validity, other than the authors use other research studies to compile their research. The level of measure is nominal in the research studies used which is compatible with descriptive statistics. 10Medicalization of SleeplessnessThis article can contribute to EBPComplaints of sleeplessness and/or diagnoses of insomnia should increase with prescriptions of sedative hypnoticsClinical Review: Noise ReductionThis article can contribute to EBPMore emphasis should be placed on nondrug interventions to promote sleep as they are proven to help without the side effects. Evidence based practice contributions

Both articles can contribute to evidence based practice. It is important to know that the number of people complaining of sleeplessness or getting an insomnia diagnosis from their physician is not increasing that much over time. However the use of sedative hypnotics are increasing rapidly over time. Sedative hypnotics are not very effective and can produce potentially detrimental side effects. On the other hand in the second article, nondrug interventions to reduce noise are proven to help promote sleep. 11Medicalization of SleeplessnessThis research can be used in practice at the professional level. Information and statistics on sedative hypnotics is important to know when educating patients on these drugsEducate patients on sleeplessness and insomnia as well. Clinical Review: Noise ReductionThis research can be used in practice at the professional level. Results found when using nondrug interventions to promote sleep are in favor of using nondrug interventions vs. sedative hypnotics. Relevance to practice

Both research articles can be used at the professional level by people like me, nurses. The first article provides a lot of facts on sedative hypnotics. The fact that the average increase of sleep by taking these drugs is only 12 minutes is pretty staggering to me. They can be addictive, have what could be detrimental side effects and are not very effective. This is all information that can be used in practice because we have an obligation to educate our patients. The second article had a lot of statistics about noise reduction interventions. The fact that all patients who used one of the interventions stated their was a reduction of noise and according to the research, half of patients complaining of sleeplessness stated noise was the reason they received inadequate sleep. Since this is research of hospitalized patients, it can be used in practice. Nurses can promote their noise reduction interventions to patients and have research to back it up. 12Pharmaceutical CompaniesThey will continue to produce sedative hypnotics. They are expensive and they make the company money. They will continue to advertise about these medications.

PhysiciansPhysicians have pharmaceutical companies promoting these drugs. Physicians have patients asking for these drugs. Physicians know the risks and low effectiveness, yet they prescribe them anyways.

Potential barriers

Pharmaceutical companies make a ton of money. They invent drugs for everything. Even though these drugs are fairly expensive, they are still readily available and multiple advertisements exist promoting these drugs. This is a potential barrier that exists for the utilization of this research. Physicians are also potential barriers. They know the side effects and the low effectiveness of these drugs, but they are still prescribed. Also, some patients are pretty insistent upon having a medication to solve their problems instead of making life style changes or trying nondrug interventions. 13For patients with a history of drug abuse, does the use of sedative hypnotics as compared with no sedative hypnotics produce addictive tendencies?For elderly patients with an unsteady gait, does the use of sedative hypnotics as compared with no sedative hypnotics increase the risk of falls?For hospitalized patients, does the use of earplugs/headphones as compared with music/white noise increase sleep?For hospitalized patients, does the hospital noise/staff communication as compared with reason for hospital stay decrease sleep?

Additional PICO questions

This slide portrays additional PICO questions that could be researched. 14For hospitalized patients, does the use of hypnotic agents as compared with non-pharmaceutical sleep aids improve sleep?Both articles are credible resources that can be used to contribute to EBP and can be used in current practice.Based on the research provided in this presentation:Sedative hypnotics are ineffective. Sedative hypnotics have potentially harmful side effects.Sedative hypnotics are over-prescribed by physicians, especially when there is not a diagnosis for insomnia. At least half of hospitalized patients state noise is the reason for inadequate sleep.Noise reduction interventions work.Other nondrug interventions available.

Conclusion

In conclusion, for this presentation I used the PICO question: for hospitalized patients, does the use of hypnotic agents as compared with non-pharmaceutical sleep aids improve sleep? Both articles are credible sources that can be used to contribute to evidence based practice and can be used in current practice. It is important as a nurse to educate our patients. That is one of our biggest jobs. All the information found in these two research articles can be shared with our patients so that they can be informed about their health and can also make informed decisions about their health. Thank you. 15