Sleep in the Hospitalized Patient
Robyn Woidtke MSN,RN, RPSGT,CCP,CCSH
OCTOBER 24
KASP 2014
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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
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The perioperative environment
The ICU
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
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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
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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
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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
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Acute Sleep Deprivation
 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)
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Outcomes of Disturbed Sleep
 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
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Correlates and Consequences
Hospital Environment
Acute Illness
Symptoms
Age, Gender,
Comorbidity
Treatment
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•
•
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Sleep
Quantity
Continuity
Diurnal Timing
Quality
Perceptions
Functional Status
Physiologic Status
Sleep Disorders
Adapted from Redeker and Hedges, 2002
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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
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Redeker &McEnany, 2011
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>95th percentile in children
 Inspection of the profile, oral and nasal cavities
 Mallampati
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Cardiovascular (BP, EKG, heart sounds)
Pulmonary system (scoliosis, muscle tone)
Neuromuscular (restless legs syndrome)
Glycemic control
Redeker &McEnany, 2011
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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)
Sleep in the ICU
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Sleep Parameter
Changes
Total Sleep Time
Unchanged/decreased
Sleep Latency
Unchanged/increased
Sleep Efficiency
Decreased
NREM Stage 1
Increased
NREM Stage 2
Increased
NREM Stage 3
Decreased
REM
Decreased
Friese, R. (2008) Crit Care Med
Environmental and
Pathophysiological Factors
Sedatives
Analgesics
Diagnostic
Procedures
Organ
Dysfunction
Patient Care
Activities
Inflammatory
Response
Lighting
Practices
Noise
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Stress
Pain
Sleep
Deprivation
Psychosis
Friese, R. (2008) Crit Care Med
ICU Delirium
 Delirium affects up to 80% of ICU patients, and it is estimated
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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 shortterm 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
Medications
 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
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Interventions
 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
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Interventions
 Plan for uninterrupted time for sleep
 Minimize night time assessments
 Set monitor alarms down to reasonable loudness
haven't recognized the
 Orient patient"We
frequently
importance of prescribing sleep“
Friese, R 2007
 If possible, cycle light to day/night frequency
 Sleep may change ventilator synchrony,
proportional assist has demonstrated improved
ventilatory matching requirements and improved
sleep
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Friese, R. (2008) Crit Care Med
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
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OSA in the Hospital
 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)
 <20% with a diagnosis of OSA received therapy during
hospitalization (Premier Inc, Database, Memtsoudis, 2013,
NEJM)
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Screening for OSA
 Variety of questionnaires
 Epworth, Berlin, STOP/STOP BANG, Sleep Apnea Clinical
Score
 Pulse Oximetry
 Home sleep testing for all elective surgical procedures
 Full polysomnography
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STOP-BANG
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High STOP-BANG score = higher probability of OSA
 Evaluation of the association between STOP-Bang
scores and the probability of OSA.
 METHODS:
 Patients answered STOP questionnaire and
underwent either laboratory or portable
polysomnography (PSG). PSG recordings were
scored manually. The BMI, age, neck circumference,
and gender (Bang) were documented.
 Over 4 yr, 6369 patients were approached and 1312
(20.6%) consented. Of them, 930 completed PSG,
and 746 patients with complete data on PSG and
STOP-Bang questionnaire were included for data
analysis.
Chung, F. Br. J of Anesthesia doi: 10.1093/bja/aes022
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High STOP-Bang score indicates a high
probability of obstructive sleep apnoea
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 RESULTS:
 The median age of 746 patients was 60 yr, 49% males, BMI 30 kg m(-2), and
neck circumference 39 cm.
 OSA was present in 68.4% with 29.9% mild, 20.5% moderate, and 18.0%
severe OSA.
 STOP-Bang score of 5, the odds ratio (OR) for moderate/severe and severe
OSA was 4.8 and 10.4, respectively.
 STOP-Bang 6, the OR for moderate/severe and severe OSA was 6.3 and
11.6, respectively.
 STOP-Bang 7 and 8, the OR for moderate/severe and severe OSA was 6.9
and 14.9, respectively.
 The predicted probabilities for moderate/severe OSA increased from 0.36
to 0.60 as the STOP-Bang score increased from 3 to 7 and 8.
 CONCLUSIONS:
In the surgical population, a STOP-Bang score of 5-8 identified patients with high
probability of moderate/severe OSA. The STOP-Bang score can help the
healthcare team to stratify patients for unrecognized OSA, practice perioperative
precautions, or triage patients for diagnosis and treatment.
Identification of Patients at Risk for Postoperative
Respiratory Complications Using a Preoperative
Obstructive Sleep Apnea Screening Tool and
Postanesthesia Care Assessment
Gali, et al., Anesthesiology 2009; 110:869–77
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OSA in the Hospitalized Patient
 Why OSA is an important assessment
 Association with MI, arrhythmias, CHF, stroke, sudden cardiac
death
 Sudden death ~ 50% those with OSA compared to 21% without OSA
 Die during the sleep hours (12-6 AM)
 Sudden death related to the AHI, the more severe the higher the risk
 Depressed arousal mechanisms due to sleep fragmentation and
deprivation; acquired arousal failure in obese patients
 Narcotics further delay arousal
Kaw & Mokhlesi (2012) Sleep and Breathing
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Types of patients at high risk for OSA
 CHF
 Obese
 Patients undergoing bariatric surgery
 Atrial Fibrillation
 Refractory Hypertension
 Type 2 diabetes
 Stroke
 Nocturnal cardiac arrhythmia
 Pulmonary Hypertension
AASM Task Force, 2009 JCSM
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Patterns of Unexpected Hospital Death
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ALARM
FATIGUE
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Perioperative Environment -OSA
 Difficulty with intubation
(8 times as often)
 Unanticipated transfers to
ICU
 Overall LOS longer; longer
ICU
 5 fold increase in
intubation and mechanical
ventilation after surgery
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Kaw & Mokhlesi (2012) Sleep and Breathing
Impact of Anesthesia
 Exacerbates the anatomical alterations which result in
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pharyngeal collapse
Blunt the arousal mechanisms
Reduce tone of the upper airway
Depress ventilation
Diminish ventilatory response to carbon dioxide
 In children, apneic episodes were increased 50% after
modest doses of fentenyl (0.5µg/Kg)
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Perioperative Outcomes-Other
 Higher rates of
 Hypercapnia
 Oxygen desaturations
 Cardiac arrhythmias
 Myocardial injury
 Delirium
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Adesanya, et al. 2012 CHEST
Key Take Away
 OSA patients live in a state
of perpetual “arousal
dependent survival” (Lynn &
Curry,2011)
 Acquired arousal failure
 Nursing staff may not be
educated
 Protocols may/may not be
in place or followed
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Mitigating Risk
Studies demonstrate that patients who
are treated for OSA have reduced
complications and improved
outcomes
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2 Relevant Joint Commission Directives
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Clinical Practice Guidelines
“The consultants agree that, in the absence of a sleep study,
a presumptive diagnosis of OSA may be made based on
consideration of the following criteria: increased body
mass index, a weight or body mass index greater than 95th
percentile for age (pediatric patients), increased neck
circumference, snoring, congenital airway abnormalities,
daytime hypersomnolence, inability to visualize the soft
palate, and tonsillar hypertrophy. They strongly agree that
observed apnea during sleep is an additional criterion.”
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New Guidelines
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Post Operative
 Postoperative concerns in the management of patients with
OSA include (1) analgesia, (2) oxygenation, (3) patient
positioning, and (4) monitoring.
 Risk factors for respiratory depression include the systemic
and neuraxial administration of opioids, administration of
sedatives, site and invasiveness of surgical procedure, and the
underlying severity of the sleep apnea.
 In addition, exacerbation of respiratory depression may occur
on the third or fourth postoperative day as sleep patterns are
reestablished and “REM rebound” occurs.
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Pre-operative Evaluation
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Extended Stay PACU Protocol
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Risk Management
The Perils of Litigation
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ADVOCATE, ADMIT and MONITOR…….
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Value of a program
 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
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Cost of CPAP in the Hospital
 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 5.3±5.5)
 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 5.3±5.5
 Cost savings to the hospital and insured can be significant >1.1 million
per year
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Smith et al., 2014,
doi.1002/lary.24604
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
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Contact Information
Robyn.Woidtke@gmail.com, Office 510-728-0828
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