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Robyn Woidtke MSN,RN, RPSGT,CCP,CCSH OCTOBER 24 KASP 2014 Sleep in the Hospitalized Patient 1 Slide 2 Objectives At the completion of the session, the attendees will: Summarize contributors to sleep loss Describe the impact of sleep loss in the hospitalized patient Explain the rationale for screening for sleep apnea in patients admitted to the hospital Emphasis The perioperative environment The ICU 2 Slide 3 Why is sleep important? Animal models, sleep loss leads to Failure of body temperature regulation Increased metabolism Deterioration of hypothalamic neurons Progressive breakdown of host defenses Death Redeker &McEnany, 2011 3 Slide 4 Functions Conserve energy and metabolism Physiologic systems within homeostatic mechanisms Maintain host defenses Reverse/restore physiologic processes that degrade during wakefulness Memory Consolidation Learning Redeker &McEnany, 2011 4 Slide 5 Factors Contributing to Sleep Loss Voluntary curtailment (social) Environment (i.e. work, technology, etc) Role (new mom, school) Sleep Disorders Medical and psychiatric disorders Redeker &McEnany, 2011 5 Slide 6 Sleep Deprivation Poor job performance Cognition Impaired Lose the ability to make sound judgment; interpretation of events is affected Reduced ability to handle stress Greater alcohol use Higher incidence of drowsy driving Redeker &McEnany, 2011 6 Slide 7 7 Slide 8 Acute Sleep Deprivation 8 Excess diuresis and natriuresis during acute sleep deprivation in healthy adults (Kamperis, 2010). Acute sleep deprivation reduces energy expenditure in healthy men (Benedict, 2011) Increase levels of ghrelin in the morning Declines in neurocognition, increased sympathetic and decreased parasympathetic modulation (Zhong et al., 2004) Slide 9 Outcomes of Disturbed Sleep 9 Alterations in immune function Increased stress hormones (catacholamines) Insulin and glucose regulation Ability to perform activities of daily living Lack of mental processing of self care activities upon discharge Decrease in SWS HGH Alterations in processing and consolidating newly acquired information Slide 10 Correlates and Consequences 10 Sleep Quantity Continuity Diurnal Timing Quality Perceptions Acute Illness Age, Gender, Comorbidity Symptoms Hospital Environment Treatment Sleep Disorders Functional Status Physiologic Status Adapted from Redeker and Hedges, 2002 Slide 11 General Sleep Assessment (1) Challenges Sleep problems typically occur gradually; patients may not be aware or concerned May attribute daytime symptoms to other causes Assessment BEARS (all ages) B-bedtime problems E-Excessive Sleepiness A-Awakenings R- Regularity of sleep S-Sleep disordered breathing Redeker &McEnany, 2011 11 Slide 12 General Sleep Assessment (2) General health Specific Conditions Co-morbid/bi-directionality (heart disease, asthma, diabetes, Parkinsons, pain, depression and anxiety) Anthropometric data HT/Wt (BMI >30), neck circumference (17 m, 16 f) correlate with OSA in adults Waist circumference and BMI>95 th percentile in children Inspection of the profile, oral and nasal cavities Mallampati Cardiovascular (BP, EKG, heart sounds) Pulmonary system (scoliosis, muscle tone) Neuromuscular (restless legs syndrome) Glycemic control Redeker &McEnany, 2011 12 Slide 13 Nursing Staff: Do Not assume While knowledge of findings like these (referring to sleep apnea) have raised my awareness of the dangers of untreated sleep apnea, I can tell you that a majority of the nurses at my hospital, and even those within my own critical care unit still do not aggressively address the issue of having the MD order studies to diagnose and/or treat OSA which has been diagnosed (2012, Personal Communication, Anonymous Critical Care RN, MSN student) Slide 14 Sleep in the ICU Sleep ParameterChanges Total Sleep TimeUnchanged/decreased Sleep LatencyUnchanged/increased Sleep EfficiencyDecreased NREM Stage 1Increased NREM Stage 2Increased NREM Stage 3Decreased REMDecreased Friese, R. (2008) Crit Care Med 14 Slide 15 Environmental and Pathophysiological Factors Sleep Deprivation Noise Lighting Practices Patient Care Activities Diagnostic Procedures Sedatives Analgesics Stress Organ Dysfunction Inflammatory Response PainPsychosis Friese, R. (2008) Crit Care Med 15 Slide 16 ICU Delirium 16 Delirium affects up to 80% of ICU patients, and it is estimated that ICU costs associated with delirium equal between $4 billion and $16 billion annually in the US.(1) This form of acute brain dysfunction is associated with increased length of ICU and hospital stays, time on the ventilator, mortality, and long-term neuropsychological deficits (1) Characteristic features of the syndrome include impaired short- term memory, impaired attention, disorientation, development over a short period of time, and a fluctuating course(2) Caused by a general medical illness, intoxication, or substance withdrawal (2) OSA has been demonstrated as a risk factor (3) 1.American Association of Critical Care Nurses, 2014 2.Cavallazzi, et al., 2012 Annals of Intensive Care 3.Flink, et al.2012 Anesthesology Slide 17 Medications 17 Opioids Increase arousal Precipitate osa Worsen hypoxia Ventilator asynchrony Benzodiazapines Increase theta; reduce SWS Loss of SWS has been shown to increase delirium Dexmedetomidine Reduces ventilator days Reduces delirium Slide 18 Interventions 18 Reduce Effects of Environmental Stimuli Decrease noise Cluster patient care interventions Provide eye masks and ear plugs if appropriate Complementary and Alternative Medicine Relaxation, music and biofeedback White noise may improve sleep quality in cardiac post op patients Massage Meditation Review Drug interactions, understand the consequences Slide 19 Interventions Plan for uninterrupted time for sleep Minimize night time assessments Set monitor alarms down to reasonable loudness Orient patient frequently If possible, cycle light to day/night frequency Sleep may change ventilator synchrony, proportional assist has demonstrated improved ventilatory matching requirements and improved sleep Friese, R. (2008) Crit Care Med 19 "We haven't recognized the importance of prescribing sleep Friese, R 2007 Slide 20 Measuring Sleep Quality Richards-Campbell Sleep Questionnaire Brief validated 5 item questionnaire; visual analog scale (100mm), higher numbers= better Study to determine nurses vs. patients subjective ratings of sleep; inter-rater reliability Johns Hopkins (June-July 2010; 16 bed private room MICU; nurse to patient ratio 1:2; 12 hour shifts); questionnaires completed 30 minutes prior to the end of shift; 33 patients/92 paired assessments Results: Patient/Nurse agreement was slight to moderate; nurses tended to over estimate sleep quality Kamdar et al. (2012) AJCC 20 Slide 21 OSA in the Hospital 21 25% of candidates for elective surgery OSA undiagnosed in 80% at the time of surgery Estimates of OSA in hospitalized patients >50% National Hospital Discharge Survey 5.8% received CPAP with a diagnosis of OSA (Spurr, 2008) Value of a program 50 Analysis of the WestLaw Data base on osa cases 54 cases included in analysis 61% in favor of defendant 12% resolved out of court 9% jury award most frequent factors in litigation Failure to diagnose OSA; failure to use CPAP postoperatively Failure to use CPAP, all cases resolved with payment > 1 million Svider, et al., AAO 2013 Slide 51 Cost of CPAP in the Hospital 51 Prospective cohort study tertiary academic medical center (JH); evaluate costs associated with hospital vs patient provided CPAP All new pt admissions >18 prescribed CPAP as an in-patient (1/1-2/28, 2012) N=162; 1.2% of admissions Cost to provide CPAP to hospitalized patients vs use of home CPAP (avg nights of use 5.35.5) RVUs (110; 8--$2.68) Patient Provided=$0.00 (27.50 for the RT charge) Hospital provided 27.50/day; differential charge = 416.10 (daily rental fee and RT follow ups) for a patient who stayed more than 1 day Avg stay 5.35.5 Cost savings to the hospital and insured can be significant >1.1 million per year Smith et al., 2014, doi.1002/lary.24604 Slide 52 Summary Sleep deprivation can be acute or chronic Both have resulting physiological consequences Sleep in hospitalized patients is disturbed resulting in sleep deprivation. A large proportion of patients who enter the hospital have not been diagnosed with sleep apnea or have CPAP initiated or continued from home Increased awareness of sleep deprivation and sleep apnea can provide for improvement in interventions and early recognition of patients with a potential for adverse consequences Program implementation can have important financial considerations 52 Slide 53 53 Contact Information Robyn.Woidtke@gmail.comRobyn.Woidtke@gmail.com, Office 510-728-0828.