Clinical Research Study
Reducing Hospital Toxicity: Impact on Patient Outcomes,✯✯,

https://doi.org/10.1016/j.amjmed.2018.04.013Get rights and content

Abstract

Background

Circadian rhythms are endogenous 24-hour oscillations in biologic processes that drive nearly all physiologic and behavioral functions. Disruption in circadian rhythms can adversely impact short- and long-term health outcomes. Routine hospital care often causes significant disruption in sleep-wake patterns that is further compounded by loss of personal control of health information and health decisions. We wished to evaluate measures directed at improving circadian rhythm and access to daily health information on hospital outcomes.

Methods

We evaluated 3425 consecutive patients admitted to a medical-surgical unit comprised of an intervention wing (n = 1185) or standard control wing (n = 2240) over a 2.5-year period. Intervention patients received measures to improve sleep that included reduction of nighttime noise, delay of routine morning phlebotomy, passive vital sign monitoring, and use of red-enriched lighting after sunset, as well as access to daily health information utilizing an inpatient portal.

Results

Intervention patients accessed the inpatient portal frequently during hospitalization seeking personal health and care team information. Measures impacting the quality and quantity of sleep were significantly improved. Length of stay was 8.6hours less (P = .04), 30- and 90-day readmission rates were 16% and 12% lower, respectively (both P ≤ .02), and self-rated emotional/mental health was higher (69.2% vs 52.4%; P = 0.03) in the intervention group compared with controls.

Conclusions

Modest changes in routine hospital care can improve the hospital environment impacting sleep and access to health knowledge, leading to improvements in hospital outcomes. Sleep-wake patterns of hospitalized patients represent a potential avenue for further enhancing hospital quality and safety.

Introduction

Recovery from hospitalization includes recuperation from the acute illness leading to admission but also recovery from the physiologic disruption created from the environment of hospital care.1 This secondary condition has been called posthospital syndrome and has been defined as an acquired, transient period of vulnerability derived from the allostatic and physiologic stress that patients experience during hospitalization.1 During hospitalization, patients are frequently deprived of sleep, experience disruption of normal circadian rhythms, become deconditioned, and have almost total loss of personal control.

Sleep disruption is well documented and can impact multiple organ systems, including immune function, coagulation, physical function and coordination, cognitive performance, and metabolism.1, 2, 3 Disruption in circadian rhythms impacts daily cellular protein expression and can significantly influence clinical outcomes, from timing of wound healing to surgical outcomes.4, 5, 6

Loss of personal control is common during hospitalization and is so profound that being a hospital patient has been called ‘one of the most disempowering situations one can experience in modern society.’7, 8 In a survey of hospital patients, 90% of respondents wanted to review their hospital medication list, but only 28% were given the opportunity.8, 9 In another study, only 32% of patients could correctly name even one of their hospital physicians.8, 10

The purpose of this investigation was to examine the impact of interventions focused on improvements in the quality and quantity of sleep as well as enhancing the patient's control and understanding of healthcare knowledge and decisions. The outcomes evaluated included length of stay, hospital readmission, intensive care unit (ICU) transfers, and subjective measures of well-being.

Section snippets

Methods

We prospectively evaluated hospital outcomes in 3425 consecutive cardiovascular patients admitted to available beds on a medical-surgical floor consisting of a 15-bed intervention wing (n = 1,185) or a standard 37-bed control wing (n = 2240). All patients were admitted to noncritical care beds capable of telemetry when ordered, and bed selection was based solely on bed availability; bed control had no insight into the care delivery process in either wing. The control wing received standard of

Results

The study cohort consisted of 3425 consecutive patients from March 2015 to October 2017. The mean age of the study cohort was 64 ± 16 years, 57% were male, and geometric mean length of hospital stay was 5.9 days (142 hours). The median Charlson index score was 6.0. Admitting services included cardiology (41.5%), hospital medicine (31.8%), heart failure/heart transplant (22.0%), and surgery (3.2%), with the remaining 1.5% being various other services. Hospital physicians were surveyed, and there

Discussion

There are several key findings from this investigation. First, provided the opportunity, the majority of patients and their families will access information to better identify members of their care team and details about their ongoing medical status including active medications, upcoming schedule of diagnostic testing, and recent test results. Second, improvements in the conditions for sleep, as well as measures to enhance personal control of healthcare knowledge, can be easily implemented in

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  • Funding: None.

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    Conflicts of Interest: None.

    Authorship: All authors had access to the data and a role in writing the manuscript.

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