SAUSALITO, CA (ASRN.ORG) -- During nursing school, I remember my first clinical instructor initiating us into one of the paradoxical truths of health care: “You don’t come to the hospital to sleep.”
Patients need to sleep — for emotional health, for wound healing, to maintain a strong immune system — and yet the drama of fractured and broken sleep plays out night after night in hospitals around the country.
Recently, a patient was set to be discharged the next day. But he needed a transfusion of platelets before we could remove the intravenous line that had been used to deliver chemotherapy. Thinking through the timing, the physician assistant realized that to get everything done, and to get the patient discharged on time, his treatment would have to start early in the morning. She scheduled the transfusion for 4 a.m, which meant the patient had to be woken at 3:30 a.m. to take the medications required before a transfusion.
For practical reasons, it made sense. But the patient didn’t see it that way.
“Can’t it be later so that I can sleep?” he asked.
I started explaining why the transfusion had to be at 4 in the morning, but the patient wasn’t buying it. A kind and gentle man, he had had enough of being woken in the middle of the night. After several weeks in the hospital, he was tired. He wanted to sleep.
And there was no way for him to doze through this particular procedure. For starters, we would turn on the lights in his darkened room, and two nurses would begin reading the medical record number on his wristband. We would take a set of vital signs, connect the platelets to his intravenous line and take another set of vitals in 15 minutes. In roughly an hour the transfusion would be over, at which time the pump would start to beep annoyingly. The nurse would disconnect the I.V. line and get another set of vitals.
But the timing of the process was dictated by the need to discharge the patient early in the morning. Delaying the platelets until 8 a.m. would mean the line couldn’t be pulled until 10 a.m. or later, delaying the discharge until at least noon.
Delaying a treatment for a few hours in exchange for needed sleep may not sound like a big tradeoff, but hospitals depend on “flow” and limiting a patient’s “length of stay.” They do this not only to accommodate new patients but also to make money. If a room that could empty at 10 a.m. does not empty until 2 p.m., that’s four extra hours a patient has to wait in the emergency department or a lengthy wait time for a patient with a scheduled admission. Perhaps more important to the hospital, a room that could be generating payment from a new patient isn’t earning anything from a patient who is simply waiting to leave.
There are other reasons nurses are continually required to wake patients in the dead of night. Doctors make rounds early in the morning, so we need to have the results of daily laboratory tests available by the time they get there. As a result, we start our “morning labs” at 4 a.m. Sometimes vital signs need to be taken every four hours to make sure a patient is stable. Antibiotics may be scheduled every six or eight hours, so we have to go into the patient’s room in the middle of the night, scan the wristband and sign on to the computer in the room before we can hang the bags that feed the I.V. line.
We try to bundle nighttime patient care, so we disturb the patient only once, but it’s not always possible. We try to be quiet, but some patients startle easily and can’t get back to sleep. Most of the time, we have no choice but to turn on a light. The alarm on the I.V. pump can wake a patient who then will need pain medication to fall asleep again.
And sometimes, even the best-laid plans for sleep can go awry. One of my patients had chronic insomnia and asked for an intravenous sleep drug at 4 a.m., hoping it would help him get four solid hours of sleep. No problem, I thought. But on my way to get the drug, another patient, who was physically big and unsteady on his feet, needed to go to the bathroom and wouldn’t use a bedpan. He also wanted his damp bed completely remade because he had been sweating during the night. I changed his linens, cleaned him up after he used the commode, and got him safely back into bed.
I was on my way to retrieve the sleep drug when a patient in another room, who was growing increasingly delirious, called out that she was going to be sick. I ran into the room, grabbed a basin and held it while I patted her back. In time the feeling passed, and she settled back into bed.
All that took 45 minutes, delaying my return to the bedside of the patient with insomnia. He was unhappy and complained to the aide, who was busily taking nighttime vitals, that I was very late, and that sleep still eluded him.
Nurses are taught to always think in terms of priorities. A patient who could fall going to the bathroom is a very high priority. Monitoring and comforting a delirious patient who is nauseated is a high priority, too. Sleep, unfortunately, has fallen far down on the list of priorities.
Is there a way to meet the many demands of the hospital system, while still giving our patients a good night’s sleep? If there is, I haven’t found it.
“Macbeth does murder sleep,’’ laments Shakespeare’s title character, realizing that killing his king did real violence to his own ability to get a good night’s rest.
“Methought I heard a voice cry ‘Sleep no more!’ ” he imagines after killing King Duncan.
For hospital patients, the nurse is often the dreaded voice crying “Sleep no more!” That was certainly the case for the poor man who needed the 4 a.m. transfusion.
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