No More Counting Sheep How Nurses Can Help Improve Their Patients’ Sleep

Susan Derby RN, MA, GNP-BC, ACHPN & Heidi Yulico RN, MS, GNP-BC Michelle Cavuoto RN, Eileen Collins RN, Melody DeSanto RN, Sarah Fellhauer RN, Catherine Finlayson RN, Joshua Halpert RN, Pamela Harris RN,

Alysha Lawson RN, Amy Lowery Ph.D., Stephanie McEneaney RN, Patrice Mockler RN, Nina Sohn-Bachman RN Memorial Sloan-Kettering Cancer Center, Medicine, New York, NY

BACKGROUND & SIGNIFICANCE • Prevalent Symptoms in Cancer Patients:

•Insomnia (31%-75%) •Severe fatigue (44%-61%) •Pain (65%-90%) •Excessive sleepiness (28%) •Leg restlessness (41%)

•Effects of Sleep Disturbances: •Excessive daytime sleepiness •Delayed reaction time •Reduced cognitive performance •Increase fall risk •Decreased immune function •Increased cortisol levels •Impaired wound healing •Chronic pain •Hypertension •Anxiety / Depression •Delirium

• 50-70 million Americans with chronic sleep disorders • Causes of Sleep Disturbance in Hospitalized Patients:

•Environmental noise / light •Uncontrolled symptoms •Medication administration •Daytime naps •Sleep apnea •Restless legs

• Sleep disorders are a common problem but often neglected during clinical oncology practice

PROJECT GOALS • To identify the most common symptoms and their level of severity in the

hospitalized older adult at MSKCC • To develop a quality improvement project to address above findings.

METHODS: PART 1 • One day survey Wednesday June 22, 2011 using the CMSAS (Condensed

Memorial Symptom Assessment Scale) • All inpatients > 75

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hospital medicine.2010:5(3) E20-E24.

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Boonstra L, et al., Sleep disturbance in hospitalized recipients of stem cell transplantation. Clinical journal of oncology nursing.2011:15(3)271-76.

Eyigor S, et al., Assessment of pain, fatigue, sleep and quality of life (QoL) in elderly hospitalized cancer patients. Archives of gerontology and geriatrics 2010:51:e57=e61.

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Kadies S, Ali N. Sleep in the intensive care unit. Sleep Med Clinics.2008

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Langford D, et al., Sleep disturbance interventions in oncology patients and family caregivers: A comprehensive review and meta-analysis. Sleep medicine reviews. 2011, doi:10.1016/j.smrv.2011.07.002.

LaReau R, et al., Examining the feasibility of implementing specific nursing interventions to promote sleep in hospitalized elderly patients. Geriatric nursing.2008:29(3)197-206.

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Missildine K, Sleep and the sleep environment of older adults in acute care settings. Journal of gerontological nursing 2008:34(6):15-21.

Missildine K, et al., Sleep in hospitalized elders: A pilot study. Geriatric nursing.2010:31(4)263-71.

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Webster RA, Thompson DR, Sleep in Hospital. Journal of Advanced Nursing. 1986: 11. 447-57.

FUTURE PLANS • Ongoing staff education about sleep hygiene, relaxation

techniques, and nursing interventions that promote sleep

• Collaboration with the Patient Volunteer Department to implement the interventions as outlined in the newly developed Patient Fact Card

• Ongoing evaluation of the success of the program utilizing the CMSAS

RESULTS

CMSAS

0%

10%

20%

30%

40%

50%

60%

70%

•46 patients from all adult floors (M5, M7, M8, M10, M12, M14, M16, M17, M18, M19)

METHODS: PART 2 • What’s preventing our patients from sleeping? • Convenience survey conducted by Geriatric Resource Nurses on their floor

INPATIENT SLEEP SURVEY 1. Are you having trouble sleeping in the hospital? 2. If yes, can you tell me if it is getting to sleep or staying asleep? 3. Can you tell me the reason?

Noise, disturbance on the floor Roommate issues - noise, telephone Interruptions by staff (for temperature taking, blood pressure) Pain, anxiety or other symptoms Other…

4. Is there anything we can do to help solve this problem?

SLEEP PROBLEMS

Staying Asleep 75

Falling Asleep 9

Both 21

RESULTS •169 patients surveyed (M5, M8, M10, M12, M15, M16) •Average age 60 •104 (61.5%) reported trouble sleeping •Only 12 patients >75 (50% complained of problems sleeping)

Floor % Trouble Sleeping M5 48% M8 100%

M10 59% M12 79% M15 44% M16 73%

0 10 20 30 40

INTERRUPTIONS TO SLEEP

SUGGESTIONS FROM 50 PATIENTS

0 5

10 15 20 25 30

DEVELOPMENT OF A PATIENT EDUCATION FACT CARD

NURSING INTERVENTIONS Daytime: • Raise shades-keep lights on • Encourage activity • Up to chair and ambulating as tolerates • Limit naps to 30-45 minute periods • Encourage patient to contact Integrative Medicine for relaxation therapies • For overly anxious patients –consider referral to Social Worker • Adjust medication schedule to preserve sleep • Suggestions to LIP:

•Dose diuretics early in the day •Avoid evening and overnight blood products if possible •Order medication TID, QID, or BID instead of q6, q8, q12

Evening: • Encourage patients to complete dinner 3 hours before bedtime • Remind patients to avoid caffeine in the afternoon • Offer sleep medication, if prescribed, 1 hour before patient wants to go to

bed • Encourage patient to verbalize/ list concerns so they are not thinking

about them all night •Keep a notebook to write down questions to ask the LIPs on AM rounds

Bedtime Rounds: • Toilet patient • Assess for symptoms which may interfere with sleep and intervene as

necessary (pain, nausea, diarrhea, anxiety) • Lower blackout shades, turn off TV and computer screens • Offer warm blanket, straighten bed linens • Encourage visitors to leave at 8PM • Encourage patients to silence cell phones, use earphones for music • Lead patient in a relaxation exercise or deep breathing exercise Overnight: • Coordinate Care

•Bundle care with PCTs (vitals, weights, hanging IVs, ect.)

• Allow patients at least 2 hour blocks of uninterrupted sleep • Consult with LIP about:

•Reducing IV fluids overnight in patients without foley catheters •Skipping 2AM vitals in noncritical patients