Although potentially life saving, blood‐product transfusion is costly and associated with transfusion‐related adverse events, including death on rare occasions. Studies in varied patient populations have demonstrated that a restrictive red blood cell transfusion strategy reduces the number of transfusion‐related adverse effects and can result in improved short‐term survival.[1, 2, 3] In 2011, more than 20 million blood products were transfused in the United States, which resulted in more than 50,000 transfusion‐related adverse reactions (0.24%).[4] With a mean cost of greater than $50 per unit of plasma and $500 per unit of apheresis platelets,[4] the cost of blood transfusion is well in excess of $1 billion per year. Blood‐product transfusion is the most frequent inpatient procedure,[5] and inpatient blood‐product transfusion contributes to the bulk of transfusions nationwide. To study the utilization of blood‐product transfusion in the inpatient population, we studied the temporal trend of inpatient blood‐product transfusions in the United States from 2002 to 2011 using data from the Nationwide Inpatient Sample (NIS), Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality.[4] The NIS, the largest inpatient care database in the United States, includes approximately a 20% stratified sample of US community hospital admissions and is weighted at discharge level to permit population‐level estimates.[6] We utilized this database to identify the total number of blood‐product transfusions and discharges between 2002 and 2011. We calculated the rate of all blood‐product transfusions, which include packed red blood cell, platelets, and other blood components, using the International Classification of DiseasesNinth Revision, Clinical Modification Procedural Clinical Classification Software code 222.[7] Trend analysis and calculation of average annual percent change were done using the Joinpoint Regression Program version 4.0.4 (National Cancer Institute, Bethesda, MD).[8] This software uses trend data and calculates the best fit lines to create the simplest joinpoint model that the data allow. The model can be expressed as a figure where several different multisegmented trend lines are connected together at the joinpoints. Trend over a fixed prespecified interval was computed as average annual percent change, and the Monte Carlo permutation method was used to test for apparent change in the trends.[9, 10] The study was exempted by the institutional review board of the University of Nebraska Medical Center.

Between 2002 and 2011, there were a total of 24,641,581 blood‐product transfusions among 389,761,571 hospitalizations. The rate of transfusion per 100 hospitalizations increased by 2.9% from 2002 to 2011 (4.6% in 2002 [n=1,767,111] to 7.5% in 2011 [n=2,929,312]) (Figure 1). The average annual percent change from 2002 to 2011 was 5.6% (95% confidence interval [CI]: 3.7‐7.6), which was statistically significant at P<0.05. A statistically significant change in trend (joinpoint) was observed in 2004. The annual percent change was 11.2% (95% CI: 0.323.4) from 2002 to 2004 and 4.1% (95% CI: 3.05.1) from 2004 to 2011, both of which were statistically significant at P<0.05 (Figure 2).

Figure 1

Figure 2

Our study demonstrates an overall increasing trend in the inpatient blood‐product transfusions over the past decade. However, the rate of increase seems to have slowed down since 2004. The National Blood Collection and Utilization Survey[4] demonstrated a decrease of 11.6% in the total number of all components transfused in the United States between 2008 and 2011. Our data are different from the survey, which also included blood transfusions in outpatient settings, emergency departments, and pediatric patients. The rising proportion of aging population with multiple comorbidities and cancers, increases in hematopoietic stem cell/solid organ transplants and chemotherapy, as well as widespread availability of blood products presumably contributed to the continued increase observed in our inpatient data after 2004. Nevertheless, the declining trend in the rate of the increased blood‐product transfusion usage seen after 2004 is encouraging. Increased awareness of restrictive transfusion strategy, coupled with efforts by professional bodies to improve the adoption of restrictive strategies, is most likely responsible for this.[3, 11, 12] As the clinical classification software procedure code 222 lumps together all the different types of blood products, we were unable to study the transfusion trend among each different type of blood products. In conclusion, further efforts need to be directed at increasing the awareness of clinicians, especially hospitalists, about the benefits of a restrictive transfusion policy and decreasing the rate of blood product use in the inpatient service. Furthermore, studies elaborating the patient population who are being transfused and the factors influencing the transfusion trends can provide useful insights to optimize blood‐product utilization and control resource consumption.

Although potentially life saving, blood‐product transfusion is costly and associated with transfusion‐related adverse events, including death on rare occasions. Studies in varied patient populations have demonstrated that a restrictive red blood cell transfusion strategy reduces the number of transfusion‐related adverse effects and can result in improved short‐term survival.[1, 2, 3] In 2011, more than 20 million blood products were transfused in the United States, which resulted in more than 50,000 transfusion‐related adverse reactions (0.24%).[4] With a mean cost of greater than $50 per unit of plasma and $500 per unit of apheresis platelets,[4] the cost of blood transfusion is well in excess of $1 billion per year. Blood‐product transfusion is the most frequent inpatient procedure,[5] and inpatient blood‐product transfusion contributes to the bulk of transfusions nationwide. To study the utilization of blood‐product transfusion in the inpatient population, we studied the temporal trend of inpatient blood‐product transfusions in the United States from 2002 to 2011 using data from the Nationwide Inpatient Sample (NIS), Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality.[4] The NIS, the largest inpatient care database in the United States, includes approximately a 20% stratified sample of US community hospital admissions and is weighted at discharge level to permit population‐level estimates.[6] We utilized this database to identify the total number of blood‐product transfusions and discharges between 2002 and 2011. We calculated the rate of all blood‐product transfusions, which include packed red blood cell, platelets, and other blood components, using the International Classification of DiseasesNinth Revision, Clinical Modification Procedural Clinical Classification Software code 222.[7] Trend analysis and calculation of average annual percent change were done using the Joinpoint Regression Program version 4.0.4 (National Cancer Institute, Bethesda, MD).[8] This software uses trend data and calculates the best fit lines to create the simplest joinpoint model that the data allow. The model can be expressed as a figure where several different multisegmented trend lines are connected together at the joinpoints. Trend over a fixed prespecified interval was computed as average annual percent change, and the Monte Carlo permutation method was used to test for apparent change in the trends.[9, 10] The study was exempted by the institutional review board of the University of Nebraska Medical Center.

Between 2002 and 2011, there were a total of 24,641,581 blood‐product transfusions among 389,761,571 hospitalizations. The rate of transfusion per 100 hospitalizations increased by 2.9% from 2002 to 2011 (4.6% in 2002 [n=1,767,111] to 7.5% in 2011 [n=2,929,312]) (Figure 1). The average annual percent change from 2002 to 2011 was 5.6% (95% confidence interval [CI]: 3.7‐7.6), which was statistically significant at P<0.05. A statistically significant change in trend (joinpoint) was observed in 2004. The annual percent change was 11.2% (95% CI: 0.323.4) from 2002 to 2004 and 4.1% (95% CI: 3.05.1) from 2004 to 2011, both of which were statistically significant at P<0.05 (Figure 2).

Figure 1

Figure 2

Our study demonstrates an overall increasing trend in the inpatient blood‐product transfusions over the past decade. However, the rate of increase seems to have slowed down since 2004. The National Blood Collection and Utilization Survey[4] demonstrated a decrease of 11.6% in the total number of all components transfused in the United States between 2008 and 2011. Our data are different from the survey, which also included blood transfusions in outpatient settings, emergency departments, and pediatric patients. The rising proportion of aging population with multiple comorbidities and cancers, increases in hematopoietic stem cell/solid organ transplants and chemotherapy, as well as widespread availability of blood products presumably contributed to the continued increase observed in our inpatient data after 2004. Nevertheless, the declining trend in the rate of the increased blood‐product transfusion usage seen after 2004 is encouraging. Increased awareness of restrictive transfusion strategy, coupled with efforts by professional bodies to improve the adoption of restrictive strategies, is most likely responsible for this.[3, 11, 12] As the clinical classification software procedure code 222 lumps together all the different types of blood products, we were unable to study the transfusion trend among each different type of blood products. In conclusion, further efforts need to be directed at increasing the awareness of clinicians, especially hospitalists, about the benefits of a restrictive transfusion policy and decreasing the rate of blood product use in the inpatient service. Furthermore, studies elaborating the patient population who are being transfused and the factors influencing the transfusion trends can provide useful insights to optimize blood‐product utilization and control resource consumption.

Although potentially life saving, blood‐product transfusion is costly and associated with transfusion‐related adverse events, including death on rare occasions. Studies in varied patient populations have demonstrated that a restrictive red blood cell transfusion strategy reduces the number of transfusion‐related adverse effects and can result in improved short‐term survival.[1, 2, 3] In 2011, more than 20 million blood products were transfused in the United States, which resulted in more than 50,000 transfusion‐related adverse reactions (0.24%).[4] With a mean cost of greater than $50 per unit of plasma and $500 per unit of apheresis platelets,[4] the cost of blood transfusion is well in excess of $1 billion per year. Blood‐product transfusion is the most frequent inpatient procedure,[5] and inpatient blood‐product transfusion contributes to the bulk of transfusions nationwide. To study the utilization of blood‐product transfusion in the inpatient population, we studied the temporal trend of inpatient blood‐product transfusions in the United States from 2002 to 2011 using data from the Nationwide Inpatient Sample (NIS), Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality.[4] The NIS, the largest inpatient care database in the United States, includes approximately a 20% stratified sample of US community hospital admissions and is weighted at discharge level to permit population‐level estimates.[6] We utilized this database to identify the total number of blood‐product transfusions and discharges between 2002 and 2011. We calculated the rate of all blood‐product transfusions, which include packed red blood cell, platelets, and other blood components, using the International Classification of DiseasesNinth Revision, Clinical Modification Procedural Clinical Classification Software code 222.[7] Trend analysis and calculation of average annual percent change were done using the Joinpoint Regression Program version 4.0.4 (National Cancer Institute, Bethesda, MD).[8] This software uses trend data and calculates the best fit lines to create the simplest joinpoint model that the data allow. The model can be expressed as a figure where several different multisegmented trend lines are connected together at the joinpoints. Trend over a fixed prespecified interval was computed as average annual percent change, and the Monte Carlo permutation method was used to test for apparent change in the trends.[9, 10] The study was exempted by the institutional review board of the University of Nebraska Medical Center.

Between 2002 and 2011, there were a total of 24,641,581 blood‐product transfusions among 389,761,571 hospitalizations. The rate of transfusion per 100 hospitalizations increased by 2.9% from 2002 to 2011 (4.6% in 2002 [n=1,767,111] to 7.5% in 2011 [n=2,929,312]) (Figure 1). The average annual percent change from 2002 to 2011 was 5.6% (95% confidence interval [CI]: 3.7‐7.6), which was statistically significant at P<0.05. A statistically significant change in trend (joinpoint) was observed in 2004. The annual percent change was 11.2% (95% CI: 0.323.4) from 2002 to 2004 and 4.1% (95% CI: 3.05.1) from 2004 to 2011, both of which were statistically significant at P<0.05 (Figure 2).

Figure 1

Figure 2

Our study demonstrates an overall increasing trend in the inpatient blood‐product transfusions over the past decade. However, the rate of increase seems to have slowed down since 2004. The National Blood Collection and Utilization Survey[4] demonstrated a decrease of 11.6% in the total number of all components transfused in the United States between 2008 and 2011. Our data are different from the survey, which also included blood transfusions in outpatient settings, emergency departments, and pediatric patients. The rising proportion of aging population with multiple comorbidities and cancers, increases in hematopoietic stem cell/solid organ transplants and chemotherapy, as well as widespread availability of blood products presumably contributed to the continued increase observed in our inpatient data after 2004. Nevertheless, the declining trend in the rate of the increased blood‐product transfusion usage seen after 2004 is encouraging. Increased awareness of restrictive transfusion strategy, coupled with efforts by professional bodies to improve the adoption of restrictive strategies, is most likely responsible for this.[3, 11, 12] As the clinical classification software procedure code 222 lumps together all the different types of blood products, we were unable to study the transfusion trend among each different type of blood products. In conclusion, further efforts need to be directed at increasing the awareness of clinicians, especially hospitalists, about the benefits of a restrictive transfusion policy and decreasing the rate of blood product use in the inpatient service. Furthermore, studies elaborating the patient population who are being transfused and the factors influencing the transfusion trends can provide useful insights to optimize blood‐product utilization and control resource consumption.

Interprofessional collaborative care (IPCC) involves members from different professions working together to enhance communication, coordination, and healthcare quality.[1, 2, 3] Because several current healthcare policy initiatives include financial incentives for increased quality of care, there has been resultant interest in the implementation of IPCC in healthcare systems.[4, 5] Unfortunately, many hospitals have found IPCC difficult to achieve. Hospital‐based medicine units are complex, time‐constrained environments requiring a high degree of collaboration and mutual decision‐making between nurses, physicians, therapists, pharmacists, care coordinators, and patients. In addition, despite recommendations for interprofessional collaborative care, the implementation and assessment of IPCC within this environment has not been well studied.[6, 7]

On academic internal medicine services, the majority of care decisions occur during rounds. Although rounds provide a common structure, the participants, length, location, and agenda of rounds tend to vary by institution and individual physician preference.[8, 9, 10, 11] Traditionally, ward rounds occur mostly in hallways and conference rooms rather than the patient's bedside.[12] Additionally, during rounds, nurse‐physician collaboration occurs infrequently, estimated at <10% of rounding time.[13] Recently, an increased focus on quality, safety, and collaboration has inspired the investigation and implementation of new methods to increase interprofessional collaboration during rounds, but many of these interventions occurred away from the patient's bedside.[14, 15] One trial of bedside interprofessional rounds (BIRs) by Curley et al. suggested improvements in patient‐level outcomes (cost and length of stay) versus traditional physician‐based rounds.[16] Although interprofessional nurse‐physician rounds at patients' bedsides may represent an ideal process, limited work has investigated this activity.[17]

A prerequisite for successful and sustained integration of BIRs is a shared conceptualization among physicians and nurses regarding the process. Such a shared conceptualization would include perceptions of benefits and barriers to implementation.[18] Currently, such perceptions have not been measured. In this study, we sought to evaluate perceptions of front‐line care providers on inpatient units, specifically nursing staff, attending physicians, and housestaff physicians, regarding the benefits and barriers to BIRs.

METHODS

RESULTS

Of the 171 surveys sent, 149 participants completed surveys (response rate 87%). Responses were received from 53/58 nursing staff (91% response), 21/28 attending physicians (75% response), and 75/85 housestaff physicians (88% response). Table 1 describes the participant response demographics.

DISCUSSION

In this study, we sought to compare perceptions of nurses and physicians on the benefits and barriers to BIRs. Nursing staff ranked each benefit higher than physicians, though rank orders of specific benefits were highly correlated. Highest‐ranked benefits related to coordination and communication more than quality or process benefits. Across groups, the highest‐ranked barriers to BIRs were related to time, whereas the lowest‐ranked factors were related to provider and patient discomfort. These results highlight important similarities and differences in perceptions between front‐line providers.

The highest‐ranked benefits were related to improved interprofessional communication and coordination. Combining interprofessional team members during care delivery allows for integrated understanding of daily care plans and clinical issues, and fosters collaboration and a team‐based atmosphere.[1, 20, 26] The lowest‐ranked benefits were related to more tangible measures, including length of stay, timely consultations, and judicious laboratory ordering. This finding contrasts with the limited literature demonstrating increased efficiency in general medicine units practicing IPCC.[16] These rankings may reflect a poor understanding or self‐assessment of outcome measures by healthcare providers, representing a potential focus for educational initiatives. Future investigations using objective assessment methods of outcomes and collaboration will provide a more accurate understanding of these findings.

The highest‐ranked barriers were related to time and systems issues. Several studies of physician‐based bedside rounds have identified systems‐ and time‐related issues as primary limiting barriers.[22, 24] In units without colocalization of patients and providers, finding receptive times for BIRs can be difficult. Although time‐related issues could be addressed by decreasing patient‐provider ratios, these changes require substantial investment in resources. A reasonable degree of improvement in efficiency and coordination is expected following acclimation to BIRs or by addressing modifiable systems factors to increase this activity. Less costly interventions, such as tailoring provider schedules, prescheduling patient rounding times, and geographic colocalization of patients and providers may be more feasible. However, the clinical microsystems within which medicine patients are cared for are often chaotic and disorganized at the infrastructural and cultural levels, which may be less influenced by surface‐level interventions. Such interventions may be ward specific and require customization to individual team needs.

The lowest‐ranked barriers to BIRs were related to provider‐ and patient‐related factors, including comfort level of patients and providers. Prior work on bedside rounds has identified physicians who are apprehensive about performing bedside rounds, but those who experience this activity are more likely to be comfortable with it.[12, 28] Our results from a culture where BIRs occur on nearly two‐thirds of patients suggest provider discomfort is not a predominant barrier.[22, 29] Additionally, educators have raised concerns about patient discomfort with bedside rounds, but nearly all studies evaluating patients' perspectives reveal patient preference for bedside case presentations over activities occurring in alternative locations.[30, 31, 32] Little work has investigated patient preference for BIRs as per our definition; our participants do not believe patients are discomforted by BIRs, building upon evidence in the literature for patient preferences regarding bedside activities.

Nursing staff perceptions of the benefits and culture related to BIRs were more positive than physicians. We hypothesize several reasons for this disparity. First, nursing staff may have more experience with observing and understanding the positive impact of BIRs and therefore are more likely to understand the positive ramifications. Alternatively, nursing staff may be satisfied with active integration into traditional physician‐centric decisions. Additionally, the professional culture and educational foundation of the nursing culture is based upon a patient‐centered approach and therefore may be more aligned with the goals of BIRs. Last, physicians may have competing priorities, favoring productivity and didactic learning rather than interprofessional collaboration. Further investigation is required to understand differences between nurses and physicians, in addition to other providers integral to BIRs (eg, care coordinators, pharmacists). Regardless, during the implementation of interprofessional collaborative care models, our findings suggest initial challenges, and the focus of educational initiatives may necessitate acclimating physician groups to benefits identified by front‐line nursing staff.

There are several limitations to our study. We investigated the perceptions of medicine nurses and physicians in 1 teaching hospital, limiting generalizability to other specialties, other vital professional groups, and nonteaching hospitals. Additionally, BIRs has been a focus of our hospital for several years. Therefore, perceived barriers may differ in BIRs‐nave hospitals. Second, although pilot‐tested for content, the construct validity of the instrument was not rigorously assessed, and the instrument was not designed to measure benefits and barriers not explicitly identified during pilot testing. Last, although surveys were anonymous, the possibility of social desirability bias exists, thereby limiting accuracy.

For over a century, physician‐led rounds have been the preferred modality for point‐of‐care decision making.[10, 15, 32, 33] BIRs address our growing understanding of patient‐centered care. Future efforts should address the quality of collaboration and current hospital and unit structures hindering patient‐centered IPCC and patient outcomes.

Interprofessional collaborative care (IPCC) involves members from different professions working together to enhance communication, coordination, and healthcare quality.[1, 2, 3] Because several current healthcare policy initiatives include financial incentives for increased quality of care, there has been resultant interest in the implementation of IPCC in healthcare systems.[4, 5] Unfortunately, many hospitals have found IPCC difficult to achieve. Hospital‐based medicine units are complex, time‐constrained environments requiring a high degree of collaboration and mutual decision‐making between nurses, physicians, therapists, pharmacists, care coordinators, and patients. In addition, despite recommendations for interprofessional collaborative care, the implementation and assessment of IPCC within this environment has not been well studied.[6, 7]

On academic internal medicine services, the majority of care decisions occur during rounds. Although rounds provide a common structure, the participants, length, location, and agenda of rounds tend to vary by institution and individual physician preference.[8, 9, 10, 11] Traditionally, ward rounds occur mostly in hallways and conference rooms rather than the patient's bedside.[12] Additionally, during rounds, nurse‐physician collaboration occurs infrequently, estimated at <10% of rounding time.[13] Recently, an increased focus on quality, safety, and collaboration has inspired the investigation and implementation of new methods to increase interprofessional collaboration during rounds, but many of these interventions occurred away from the patient's bedside.[14, 15] One trial of bedside interprofessional rounds (BIRs) by Curley et al. suggested improvements in patient‐level outcomes (cost and length of stay) versus traditional physician‐based rounds.[16] Although interprofessional nurse‐physician rounds at patients' bedsides may represent an ideal process, limited work has investigated this activity.[17]

A prerequisite for successful and sustained integration of BIRs is a shared conceptualization among physicians and nurses regarding the process. Such a shared conceptualization would include perceptions of benefits and barriers to implementation.[18] Currently, such perceptions have not been measured. In this study, we sought to evaluate perceptions of front‐line care providers on inpatient units, specifically nursing staff, attending physicians, and housestaff physicians, regarding the benefits and barriers to BIRs.

METHODS

RESULTS

Of the 171 surveys sent, 149 participants completed surveys (response rate 87%). Responses were received from 53/58 nursing staff (91% response), 21/28 attending physicians (75% response), and 75/85 housestaff physicians (88% response). Table 1 describes the participant response demographics.

DISCUSSION

In this study, we sought to compare perceptions of nurses and physicians on the benefits and barriers to BIRs. Nursing staff ranked each benefit higher than physicians, though rank orders of specific benefits were highly correlated. Highest‐ranked benefits related to coordination and communication more than quality or process benefits. Across groups, the highest‐ranked barriers to BIRs were related to time, whereas the lowest‐ranked factors were related to provider and patient discomfort. These results highlight important similarities and differences in perceptions between front‐line providers.

The highest‐ranked benefits were related to improved interprofessional communication and coordination. Combining interprofessional team members during care delivery allows for integrated understanding of daily care plans and clinical issues, and fosters collaboration and a team‐based atmosphere.[1, 20, 26] The lowest‐ranked benefits were related to more tangible measures, including length of stay, timely consultations, and judicious laboratory ordering. This finding contrasts with the limited literature demonstrating increased efficiency in general medicine units practicing IPCC.[16] These rankings may reflect a poor understanding or self‐assessment of outcome measures by healthcare providers, representing a potential focus for educational initiatives. Future investigations using objective assessment methods of outcomes and collaboration will provide a more accurate understanding of these findings.

The highest‐ranked barriers were related to time and systems issues. Several studies of physician‐based bedside rounds have identified systems‐ and time‐related issues as primary limiting barriers.[22, 24] In units without colocalization of patients and providers, finding receptive times for BIRs can be difficult. Although time‐related issues could be addressed by decreasing patient‐provider ratios, these changes require substantial investment in resources. A reasonable degree of improvement in efficiency and coordination is expected following acclimation to BIRs or by addressing modifiable systems factors to increase this activity. Less costly interventions, such as tailoring provider schedules, prescheduling patient rounding times, and geographic colocalization of patients and providers may be more feasible. However, the clinical microsystems within which medicine patients are cared for are often chaotic and disorganized at the infrastructural and cultural levels, which may be less influenced by surface‐level interventions. Such interventions may be ward specific and require customization to individual team needs.

The lowest‐ranked barriers to BIRs were related to provider‐ and patient‐related factors, including comfort level of patients and providers. Prior work on bedside rounds has identified physicians who are apprehensive about performing bedside rounds, but those who experience this activity are more likely to be comfortable with it.[12, 28] Our results from a culture where BIRs occur on nearly two‐thirds of patients suggest provider discomfort is not a predominant barrier.[22, 29] Additionally, educators have raised concerns about patient discomfort with bedside rounds, but nearly all studies evaluating patients' perspectives reveal patient preference for bedside case presentations over activities occurring in alternative locations.[30, 31, 32] Little work has investigated patient preference for BIRs as per our definition; our participants do not believe patients are discomforted by BIRs, building upon evidence in the literature for patient preferences regarding bedside activities.

Nursing staff perceptions of the benefits and culture related to BIRs were more positive than physicians. We hypothesize several reasons for this disparity. First, nursing staff may have more experience with observing and understanding the positive impact of BIRs and therefore are more likely to understand the positive ramifications. Alternatively, nursing staff may be satisfied with active integration into traditional physician‐centric decisions. Additionally, the professional culture and educational foundation of the nursing culture is based upon a patient‐centered approach and therefore may be more aligned with the goals of BIRs. Last, physicians may have competing priorities, favoring productivity and didactic learning rather than interprofessional collaboration. Further investigation is required to understand differences between nurses and physicians, in addition to other providers integral to BIRs (eg, care coordinators, pharmacists). Regardless, during the implementation of interprofessional collaborative care models, our findings suggest initial challenges, and the focus of educational initiatives may necessitate acclimating physician groups to benefits identified by front‐line nursing staff.

There are several limitations to our study. We investigated the perceptions of medicine nurses and physicians in 1 teaching hospital, limiting generalizability to other specialties, other vital professional groups, and nonteaching hospitals. Additionally, BIRs has been a focus of our hospital for several years. Therefore, perceived barriers may differ in BIRs‐nave hospitals. Second, although pilot‐tested for content, the construct validity of the instrument was not rigorously assessed, and the instrument was not designed to measure benefits and barriers not explicitly identified during pilot testing. Last, although surveys were anonymous, the possibility of social desirability bias exists, thereby limiting accuracy.

For over a century, physician‐led rounds have been the preferred modality for point‐of‐care decision making.[10, 15, 32, 33] BIRs address our growing understanding of patient‐centered care. Future efforts should address the quality of collaboration and current hospital and unit structures hindering patient‐centered IPCC and patient outcomes.

Interprofessional collaborative care (IPCC) involves members from different professions working together to enhance communication, coordination, and healthcare quality.[1, 2, 3] Because several current healthcare policy initiatives include financial incentives for increased quality of care, there has been resultant interest in the implementation of IPCC in healthcare systems.[4, 5] Unfortunately, many hospitals have found IPCC difficult to achieve. Hospital‐based medicine units are complex, time‐constrained environments requiring a high degree of collaboration and mutual decision‐making between nurses, physicians, therapists, pharmacists, care coordinators, and patients. In addition, despite recommendations for interprofessional collaborative care, the implementation and assessment of IPCC within this environment has not been well studied.[6, 7]

On academic internal medicine services, the majority of care decisions occur during rounds. Although rounds provide a common structure, the participants, length, location, and agenda of rounds tend to vary by institution and individual physician preference.[8, 9, 10, 11] Traditionally, ward rounds occur mostly in hallways and conference rooms rather than the patient's bedside.[12] Additionally, during rounds, nurse‐physician collaboration occurs infrequently, estimated at <10% of rounding time.[13] Recently, an increased focus on quality, safety, and collaboration has inspired the investigation and implementation of new methods to increase interprofessional collaboration during rounds, but many of these interventions occurred away from the patient's bedside.[14, 15] One trial of bedside interprofessional rounds (BIRs) by Curley et al. suggested improvements in patient‐level outcomes (cost and length of stay) versus traditional physician‐based rounds.[16] Although interprofessional nurse‐physician rounds at patients' bedsides may represent an ideal process, limited work has investigated this activity.[17]

A prerequisite for successful and sustained integration of BIRs is a shared conceptualization among physicians and nurses regarding the process. Such a shared conceptualization would include perceptions of benefits and barriers to implementation.[18] Currently, such perceptions have not been measured. In this study, we sought to evaluate perceptions of front‐line care providers on inpatient units, specifically nursing staff, attending physicians, and housestaff physicians, regarding the benefits and barriers to BIRs.

METHODS

RESULTS

Of the 171 surveys sent, 149 participants completed surveys (response rate 87%). Responses were received from 53/58 nursing staff (91% response), 21/28 attending physicians (75% response), and 75/85 housestaff physicians (88% response). Table 1 describes the participant response demographics.

DISCUSSION

In this study, we sought to compare perceptions of nurses and physicians on the benefits and barriers to BIRs. Nursing staff ranked each benefit higher than physicians, though rank orders of specific benefits were highly correlated. Highest‐ranked benefits related to coordination and communication more than quality or process benefits. Across groups, the highest‐ranked barriers to BIRs were related to time, whereas the lowest‐ranked factors were related to provider and patient discomfort. These results highlight important similarities and differences in perceptions between front‐line providers.

The highest‐ranked benefits were related to improved interprofessional communication and coordination. Combining interprofessional team members during care delivery allows for integrated understanding of daily care plans and clinical issues, and fosters collaboration and a team‐based atmosphere.[1, 20, 26] The lowest‐ranked benefits were related to more tangible measures, including length of stay, timely consultations, and judicious laboratory ordering. This finding contrasts with the limited literature demonstrating increased efficiency in general medicine units practicing IPCC.[16] These rankings may reflect a poor understanding or self‐assessment of outcome measures by healthcare providers, representing a potential focus for educational initiatives. Future investigations using objective assessment methods of outcomes and collaboration will provide a more accurate understanding of these findings.

The highest‐ranked barriers were related to time and systems issues. Several studies of physician‐based bedside rounds have identified systems‐ and time‐related issues as primary limiting barriers.[22, 24] In units without colocalization of patients and providers, finding receptive times for BIRs can be difficult. Although time‐related issues could be addressed by decreasing patient‐provider ratios, these changes require substantial investment in resources. A reasonable degree of improvement in efficiency and coordination is expected following acclimation to BIRs or by addressing modifiable systems factors to increase this activity. Less costly interventions, such as tailoring provider schedules, prescheduling patient rounding times, and geographic colocalization of patients and providers may be more feasible. However, the clinical microsystems within which medicine patients are cared for are often chaotic and disorganized at the infrastructural and cultural levels, which may be less influenced by surface‐level interventions. Such interventions may be ward specific and require customization to individual team needs.

The lowest‐ranked barriers to BIRs were related to provider‐ and patient‐related factors, including comfort level of patients and providers. Prior work on bedside rounds has identified physicians who are apprehensive about performing bedside rounds, but those who experience this activity are more likely to be comfortable with it.[12, 28] Our results from a culture where BIRs occur on nearly two‐thirds of patients suggest provider discomfort is not a predominant barrier.[22, 29] Additionally, educators have raised concerns about patient discomfort with bedside rounds, but nearly all studies evaluating patients' perspectives reveal patient preference for bedside case presentations over activities occurring in alternative locations.[30, 31, 32] Little work has investigated patient preference for BIRs as per our definition; our participants do not believe patients are discomforted by BIRs, building upon evidence in the literature for patient preferences regarding bedside activities.

Nursing staff perceptions of the benefits and culture related to BIRs were more positive than physicians. We hypothesize several reasons for this disparity. First, nursing staff may have more experience with observing and understanding the positive impact of BIRs and therefore are more likely to understand the positive ramifications. Alternatively, nursing staff may be satisfied with active integration into traditional physician‐centric decisions. Additionally, the professional culture and educational foundation of the nursing culture is based upon a patient‐centered approach and therefore may be more aligned with the goals of BIRs. Last, physicians may have competing priorities, favoring productivity and didactic learning rather than interprofessional collaboration. Further investigation is required to understand differences between nurses and physicians, in addition to other providers integral to BIRs (eg, care coordinators, pharmacists). Regardless, during the implementation of interprofessional collaborative care models, our findings suggest initial challenges, and the focus of educational initiatives may necessitate acclimating physician groups to benefits identified by front‐line nursing staff.

There are several limitations to our study. We investigated the perceptions of medicine nurses and physicians in 1 teaching hospital, limiting generalizability to other specialties, other vital professional groups, and nonteaching hospitals. Additionally, BIRs has been a focus of our hospital for several years. Therefore, perceived barriers may differ in BIRs‐nave hospitals. Second, although pilot‐tested for content, the construct validity of the instrument was not rigorously assessed, and the instrument was not designed to measure benefits and barriers not explicitly identified during pilot testing. Last, although surveys were anonymous, the possibility of social desirability bias exists, thereby limiting accuracy.

For over a century, physician‐led rounds have been the preferred modality for point‐of‐care decision making.[10, 15, 32, 33] BIRs address our growing understanding of patient‐centered care. Future efforts should address the quality of collaboration and current hospital and unit structures hindering patient‐centered IPCC and patient outcomes.

Sleep is known to be poor among hospitalized patients for many reasons.[1] Patients may have pain, dyspnea, or other discomforts that prevent sleep. Diagnostic and therapeutic procedures, including medication administration and routine nursing care, may take place during normal sleep times. Environmental factors such as noise and light frequently remain at daytime levels during normal sleep times.[2] In response, patients frequently request pharmacological sleep aids. Unfortunately, the use of sleep medications has been linked to clinically relevant and detrimental outcomes such as delirium and falls, particularly in the elderly. For example, in the landmark study by Inouye et al., a multicomponent intervention was used to successfully reduce delirium in older (>70 years) hospitalized patients.[3] One of the successful components was nonpharmacological sleep promotion, which reduced the use of pharmacological sleep aids from 46% to 35% of patients. Most recently, Kolla and colleagues found zolpidem tartrate use to be a risk factor (odds ratio 4.37) for inpatient falls, a known risk factor for morbidity and increased healthcare costs.[4]

The scope of recent pharmacological sleep aid use in the inpatient setting is not well described. Frighetto and colleagues described the pattern of in‐hospital drug use more than 12 years ago, before the concerns above were described, with 29% of patients receiving a medication for sleep, mostly benzodiazepines.[5] In 2008, Bartick and colleagues also found a very high rate of sleep aid use (42% of patients), but additionally described in 2010 an intervention to minimize sleep disruption that successfully reduced sleep aid use by 38%.[6] Both concerns over side effects and sleep promotion efforts might have reduced the current rate of medication use. Therefore, we sought to evaluate the prescription and administration of pharmacological sleep aids in general medical and surgical inpatients at our institution. Using our electronic medical records, including preadmission and discharge medication records, we assessed new and continued usage of medications for sleep complaints following hospital admission.

METHODS

RESULTS

Patients

During the 59‐day study period, there were 642 patients admitted to the study units. Two hundred seventy‐six patients received 1 of the monitored medications; however, 106 patients received the medication for an indication other than insomnia/difficulty sleeping. In 2 patients, incomplete records prevented ascertainment of the motivation for using the monitored medication. Thus, 168 patients (26.2%) were determined to have received a medication for sleep complaints and were included in the study analysis (Figure 1). Table 1 lists the characteristics of the 168 patients, of whom 10 had a prior documented sleep disorder such as insomnia (6 patients), restless leg syndrome (1 patient), and obstructive sleep apnea (3 patients). The rate of sleep medication use was lower, though not drastically so, in patients 65 years of age compared to those <65 years of age.

Figure 1

Table 1.Demographic and Clinical Characteristics of Patients Receiving a Sleep Aid (N=168)

Patients	Value
NOTE a Data presented as meanstandard deviation.
Age, y	57.919.8a
Age 65 years	70 (41.7)
Age 64 years	98 (58.3)
Female, n (%)	97 (57.7)
Ethnicity, n (%)
Caucasian	114 (67.9)
Black	18 (10.7)
Hispanic	13 (7.7)
Other	23 (13.7)
Admitted to floor from:
Emergency department	95 (56.5)
Operating room	30 (17.9)
Transferred from outside hospital	35 (20.8)
Intensive care unit	8 (4.8)
Admission service, n (%)
Medical	109 (64.9)
Surgical	59 (35.1)
Hospital length of stay	10.516.0a
Known sleep disorder
Insomnia	6 (3.6)
Restless leg syndrome	1 (0.6)
Obstructive sleep apnea	3(1.8)

Medication Administration Characteristics

Sleep medications were prescribed most frequently as standing orders (63.7%), rather than x1 (17.7%) or PRN (18.6%). Although the majority of sleep medications were administered between the hours of 9 _pm and 12 _am, more than 35% of doses were given outside of this range (Figure 2).

Figure 2

DISCUSSION

Our results confirm the continued frequent use of pharmacological sleep aids in the hospital setting, even in the elderly, despite recent concerns regarding the use of certain sleep medications. Additional, novel findings of our study are: (1) medications used for sleep complaints in the hospital are frequently those without a formal indication for sleep, (2) medications for sleep complaints are frequently administered too early or too late at night to be consistent with good sleep hygiene, and (3) many patients never previously on a medication for insomnia are discharged with a prescription for a sleep aid.

Despite recent warnings regarding side effects especially in the elderly, our rate of medication use has only slightly improved from prior reports from more than a decade ago.[3, 5] This high rate of use is likely due to a combination of patient, clinician, and environmental factors. In our sample, the sleep aid orders were not part of an order set; thus, the orders were either the result of patient request or in response to a patient report of poor sleep. Patients and clinicians may perceive medications for sleep as highly effective and safe, despite evidence to the contrary. Another factor is that both patients and clinicians may be unaware of nonpharmacological interventions that might improve sleep. Similarly, hospital environmental factors (noise, light) may be so disruptive as to preclude these interventions or opportunities for adequate sleep. Thus, the continued high use of medication for sleep is due in part to the lack of patient and clinician education and the difficulty in changing the hospital environment and culture, especially with only limited data on the value of sleep during recovery from illness.

Clinicians typically receive little training regarding sleep or its importance. In fact, most clinicians do not assess or communicate about the patient's quality of sleep.[11] Many may not know that there is little evidence of benefit of pharmacological sleep aids in the hospital. For example, a recent report found, in contrast to the authors' hypothesis, no changes in sleep architecture or duration using 10 mg of zolpidem tartrate in postoperative patients.[12] In our study, we found that some patients required an increase in the dose of their medications or were transitioned to a different sleep aid class (suggesting that sleep aids were ineffective). Alternatively, some patients' sleep aids were discontinued during hospital admission, again, likely due to perceived ineffectiveness or perhaps side effects. It is possible that the effectiveness of these medications might be influenced by timing of administration. This too was variable in our study. Proper clinician education around sleep hygiene might prevent early medication administration (which might lead to middle‐of‐the‐night awakenings) or delayed administration (which will delay the sleep phase), as was frequently seen in our cohort.

Despite emerging evidence of the importance of sleep in maintaining adequate immune, cardiovascular, and cognitive function, there are limited data regarding the benefits of sleep during acute illness.[13, 14, 15, 16] In the absence of compelling data, promoting sleep in the hospital has been difficult. The successful interventions used by Inouye and Bartick and their colleagues to minimize sedative hypnotic use included: a bedtime routine (eg, milk or herbal tea, relaxation tapes or music, back massage, toilet at bedtime), unit‐wide noise‐reduction strategies (eg, silent pill crushers, vibrating beepers, quiet hallways, and noise‐monitoring equipment that alerted staff above a certain decibel level), and schedule adjustments to allow sleep (eg, rescheduling of medications, intravenous fluids, and procedures), all of which require substantial clinician care or may not be possible in more acutely ill patients. Although such changes might be costly, sleep promotion and minimization of sleep aids continues to be part of a strategy that reduces delirium, hospital costs, and hospital length of stay.[16] From a patient perspective, many are interested in nondrug alternatives, especially those who have never used medications before, but few are told of them.[17]

Novel findings of our study include the types of medications used for sleep in the hospital. We found that a variety of medications and classes of medications were prescribed by clinicians for sleep complaints during hospitalization. This variability is due to a number of factors including the lack of rigorous data in this area, well‐established guidelines, or clinician education. We speculate that the high rates of use of nonbenzodiazepine and non‐ gamma‐aminobutyric acid (GABA)ergic agents, such as trazodone and quetiapine, reflect concerns about the use of medications such as zolpidem. Conversely, this means patients are increasingly treated with medications without formal FDA labeling for sleep. It does appear at least that the median doses of medication prescribed were lower in those over age 65 years compared to younger patients, although we cannot determine whether this reflects physician awareness or effective decision support used during computerized order entry. The geriatric decision support recommends a reduced dose for some (eg, trazodone, haloperidol) but not all (eg, quetiapine, lorazepam) of the monitored medications.

We found that many patients, even those who were never previously known to have insomnia, were discharged with a prescription for a sleep medication. Our study design is limited in assessing whether this prescription was needed or not, that is, whether or not the patient will have insomnia (sleep difficulty despite adequate opportunity for sleep) after hospital discharge. However, other studies have suggested that acute illness can be a precipitant for insomnia. Some of this literature has focused on patients in the intensive care unit, but it seems reasonable that patients on general medical and surgical wards (not having come through the intensive care units) might also be at risk for insomnia.[18] A study by Zisberg and colleagues in an elderly Israeli cohort found hospitalization (even without intensive care unit stay) to be both a starting point and a stopping point for chronic sleep medication use.[19] Alternatively, patients may not continue to suffer from insomnia after discharge, and thus the prescription for a sleep aid is inappropriate, as it is likely to have no benefit but may carry risk.[20] Regardless of whether hospital‐acquired insomnia persists past discharge, our findings suggest that some patients will start on chronic medication use for insomnia. Importantly, these patients may have limited understanding of the reason for their prescription, medication risks and benefits, and are unlikely to receive guidance on sleep hygiene or referral to a sleep specialist if needed. In our case, the high rate of prescriptions likely reflects the way in which inpatient medications can be added as a discharge medication automatically. This represents an area for improvement at our institution.

CONCLUSIONS

Despite increasing evidence of risks such as delirium or falls, pharmacological sleep aid use in hospitalized patients, even the elderly, remains common. A variety of medications are used, with variable administration times, which likely reflects the few rigorous studies or guidelines for the use of pharmacological sleep aids in hospitalized patients. Many patients not known to be on medications for sleep before admission leave the hospital with a sleep aid prescription. Our results suggest the need to better understand the factors that contribute to the high rate of sleep aid use in hospitalized patients. Clinician education regarding sleep, and nonpharmacological strategies to improve sleep in the hospital, are also needed.

Disclosure: Nothing to report.

Sleep is known to be poor among hospitalized patients for many reasons.[1] Patients may have pain, dyspnea, or other discomforts that prevent sleep. Diagnostic and therapeutic procedures, including medication administration and routine nursing care, may take place during normal sleep times. Environmental factors such as noise and light frequently remain at daytime levels during normal sleep times.[2] In response, patients frequently request pharmacological sleep aids. Unfortunately, the use of sleep medications has been linked to clinically relevant and detrimental outcomes such as delirium and falls, particularly in the elderly. For example, in the landmark study by Inouye et al., a multicomponent intervention was used to successfully reduce delirium in older (>70 years) hospitalized patients.[3] One of the successful components was nonpharmacological sleep promotion, which reduced the use of pharmacological sleep aids from 46% to 35% of patients. Most recently, Kolla and colleagues found zolpidem tartrate use to be a risk factor (odds ratio 4.37) for inpatient falls, a known risk factor for morbidity and increased healthcare costs.[4]

The scope of recent pharmacological sleep aid use in the inpatient setting is not well described. Frighetto and colleagues described the pattern of in‐hospital drug use more than 12 years ago, before the concerns above were described, with 29% of patients receiving a medication for sleep, mostly benzodiazepines.[5] In 2008, Bartick and colleagues also found a very high rate of sleep aid use (42% of patients), but additionally described in 2010 an intervention to minimize sleep disruption that successfully reduced sleep aid use by 38%.[6] Both concerns over side effects and sleep promotion efforts might have reduced the current rate of medication use. Therefore, we sought to evaluate the prescription and administration of pharmacological sleep aids in general medical and surgical inpatients at our institution. Using our electronic medical records, including preadmission and discharge medication records, we assessed new and continued usage of medications for sleep complaints following hospital admission.

METHODS

RESULTS

Patients

During the 59‐day study period, there were 642 patients admitted to the study units. Two hundred seventy‐six patients received 1 of the monitored medications; however, 106 patients received the medication for an indication other than insomnia/difficulty sleeping. In 2 patients, incomplete records prevented ascertainment of the motivation for using the monitored medication. Thus, 168 patients (26.2%) were determined to have received a medication for sleep complaints and were included in the study analysis (Figure 1). Table 1 lists the characteristics of the 168 patients, of whom 10 had a prior documented sleep disorder such as insomnia (6 patients), restless leg syndrome (1 patient), and obstructive sleep apnea (3 patients). The rate of sleep medication use was lower, though not drastically so, in patients 65 years of age compared to those <65 years of age.

Figure 1

Table 1.Demographic and Clinical Characteristics of Patients Receiving a Sleep Aid (N=168)

Patients	Value
NOTE a Data presented as meanstandard deviation.
Age, y	57.919.8a
Age 65 years	70 (41.7)
Age 64 years	98 (58.3)
Female, n (%)	97 (57.7)
Ethnicity, n (%)
Caucasian	114 (67.9)
Black	18 (10.7)
Hispanic	13 (7.7)
Other	23 (13.7)
Admitted to floor from:
Emergency department	95 (56.5)
Operating room	30 (17.9)
Transferred from outside hospital	35 (20.8)
Intensive care unit	8 (4.8)
Admission service, n (%)
Medical	109 (64.9)
Surgical	59 (35.1)
Hospital length of stay	10.516.0a
Known sleep disorder
Insomnia	6 (3.6)
Restless leg syndrome	1 (0.6)
Obstructive sleep apnea	3(1.8)

Medication Administration Characteristics

Sleep medications were prescribed most frequently as standing orders (63.7%), rather than x1 (17.7%) or PRN (18.6%). Although the majority of sleep medications were administered between the hours of 9 _pm and 12 _am, more than 35% of doses were given outside of this range (Figure 2).

Figure 2

DISCUSSION

Our results confirm the continued frequent use of pharmacological sleep aids in the hospital setting, even in the elderly, despite recent concerns regarding the use of certain sleep medications. Additional, novel findings of our study are: (1) medications used for sleep complaints in the hospital are frequently those without a formal indication for sleep, (2) medications for sleep complaints are frequently administered too early or too late at night to be consistent with good sleep hygiene, and (3) many patients never previously on a medication for insomnia are discharged with a prescription for a sleep aid.

Despite recent warnings regarding side effects especially in the elderly, our rate of medication use has only slightly improved from prior reports from more than a decade ago.[3, 5] This high rate of use is likely due to a combination of patient, clinician, and environmental factors. In our sample, the sleep aid orders were not part of an order set; thus, the orders were either the result of patient request or in response to a patient report of poor sleep. Patients and clinicians may perceive medications for sleep as highly effective and safe, despite evidence to the contrary. Another factor is that both patients and clinicians may be unaware of nonpharmacological interventions that might improve sleep. Similarly, hospital environmental factors (noise, light) may be so disruptive as to preclude these interventions or opportunities for adequate sleep. Thus, the continued high use of medication for sleep is due in part to the lack of patient and clinician education and the difficulty in changing the hospital environment and culture, especially with only limited data on the value of sleep during recovery from illness.

Clinicians typically receive little training regarding sleep or its importance. In fact, most clinicians do not assess or communicate about the patient's quality of sleep.[11] Many may not know that there is little evidence of benefit of pharmacological sleep aids in the hospital. For example, a recent report found, in contrast to the authors' hypothesis, no changes in sleep architecture or duration using 10 mg of zolpidem tartrate in postoperative patients.[12] In our study, we found that some patients required an increase in the dose of their medications or were transitioned to a different sleep aid class (suggesting that sleep aids were ineffective). Alternatively, some patients' sleep aids were discontinued during hospital admission, again, likely due to perceived ineffectiveness or perhaps side effects. It is possible that the effectiveness of these medications might be influenced by timing of administration. This too was variable in our study. Proper clinician education around sleep hygiene might prevent early medication administration (which might lead to middle‐of‐the‐night awakenings) or delayed administration (which will delay the sleep phase), as was frequently seen in our cohort.

Despite emerging evidence of the importance of sleep in maintaining adequate immune, cardiovascular, and cognitive function, there are limited data regarding the benefits of sleep during acute illness.[13, 14, 15, 16] In the absence of compelling data, promoting sleep in the hospital has been difficult. The successful interventions used by Inouye and Bartick and their colleagues to minimize sedative hypnotic use included: a bedtime routine (eg, milk or herbal tea, relaxation tapes or music, back massage, toilet at bedtime), unit‐wide noise‐reduction strategies (eg, silent pill crushers, vibrating beepers, quiet hallways, and noise‐monitoring equipment that alerted staff above a certain decibel level), and schedule adjustments to allow sleep (eg, rescheduling of medications, intravenous fluids, and procedures), all of which require substantial clinician care or may not be possible in more acutely ill patients. Although such changes might be costly, sleep promotion and minimization of sleep aids continues to be part of a strategy that reduces delirium, hospital costs, and hospital length of stay.[16] From a patient perspective, many are interested in nondrug alternatives, especially those who have never used medications before, but few are told of them.[17]

Novel findings of our study include the types of medications used for sleep in the hospital. We found that a variety of medications and classes of medications were prescribed by clinicians for sleep complaints during hospitalization. This variability is due to a number of factors including the lack of rigorous data in this area, well‐established guidelines, or clinician education. We speculate that the high rates of use of nonbenzodiazepine and non‐ gamma‐aminobutyric acid (GABA)ergic agents, such as trazodone and quetiapine, reflect concerns about the use of medications such as zolpidem. Conversely, this means patients are increasingly treated with medications without formal FDA labeling for sleep. It does appear at least that the median doses of medication prescribed were lower in those over age 65 years compared to younger patients, although we cannot determine whether this reflects physician awareness or effective decision support used during computerized order entry. The geriatric decision support recommends a reduced dose for some (eg, trazodone, haloperidol) but not all (eg, quetiapine, lorazepam) of the monitored medications.

We found that many patients, even those who were never previously known to have insomnia, were discharged with a prescription for a sleep medication. Our study design is limited in assessing whether this prescription was needed or not, that is, whether or not the patient will have insomnia (sleep difficulty despite adequate opportunity for sleep) after hospital discharge. However, other studies have suggested that acute illness can be a precipitant for insomnia. Some of this literature has focused on patients in the intensive care unit, but it seems reasonable that patients on general medical and surgical wards (not having come through the intensive care units) might also be at risk for insomnia.[18] A study by Zisberg and colleagues in an elderly Israeli cohort found hospitalization (even without intensive care unit stay) to be both a starting point and a stopping point for chronic sleep medication use.[19] Alternatively, patients may not continue to suffer from insomnia after discharge, and thus the prescription for a sleep aid is inappropriate, as it is likely to have no benefit but may carry risk.[20] Regardless of whether hospital‐acquired insomnia persists past discharge, our findings suggest that some patients will start on chronic medication use for insomnia. Importantly, these patients may have limited understanding of the reason for their prescription, medication risks and benefits, and are unlikely to receive guidance on sleep hygiene or referral to a sleep specialist if needed. In our case, the high rate of prescriptions likely reflects the way in which inpatient medications can be added as a discharge medication automatically. This represents an area for improvement at our institution.

CONCLUSIONS

Despite increasing evidence of risks such as delirium or falls, pharmacological sleep aid use in hospitalized patients, even the elderly, remains common. A variety of medications are used, with variable administration times, which likely reflects the few rigorous studies or guidelines for the use of pharmacological sleep aids in hospitalized patients. Many patients not known to be on medications for sleep before admission leave the hospital with a sleep aid prescription. Our results suggest the need to better understand the factors that contribute to the high rate of sleep aid use in hospitalized patients. Clinician education regarding sleep, and nonpharmacological strategies to improve sleep in the hospital, are also needed.

Disclosure: Nothing to report.

Sleep is known to be poor among hospitalized patients for many reasons.[1] Patients may have pain, dyspnea, or other discomforts that prevent sleep. Diagnostic and therapeutic procedures, including medication administration and routine nursing care, may take place during normal sleep times. Environmental factors such as noise and light frequently remain at daytime levels during normal sleep times.[2] In response, patients frequently request pharmacological sleep aids. Unfortunately, the use of sleep medications has been linked to clinically relevant and detrimental outcomes such as delirium and falls, particularly in the elderly. For example, in the landmark study by Inouye et al., a multicomponent intervention was used to successfully reduce delirium in older (>70 years) hospitalized patients.[3] One of the successful components was nonpharmacological sleep promotion, which reduced the use of pharmacological sleep aids from 46% to 35% of patients. Most recently, Kolla and colleagues found zolpidem tartrate use to be a risk factor (odds ratio 4.37) for inpatient falls, a known risk factor for morbidity and increased healthcare costs.[4]

The scope of recent pharmacological sleep aid use in the inpatient setting is not well described. Frighetto and colleagues described the pattern of in‐hospital drug use more than 12 years ago, before the concerns above were described, with 29% of patients receiving a medication for sleep, mostly benzodiazepines.[5] In 2008, Bartick and colleagues also found a very high rate of sleep aid use (42% of patients), but additionally described in 2010 an intervention to minimize sleep disruption that successfully reduced sleep aid use by 38%.[6] Both concerns over side effects and sleep promotion efforts might have reduced the current rate of medication use. Therefore, we sought to evaluate the prescription and administration of pharmacological sleep aids in general medical and surgical inpatients at our institution. Using our electronic medical records, including preadmission and discharge medication records, we assessed new and continued usage of medications for sleep complaints following hospital admission.

METHODS

RESULTS

Patients

During the 59‐day study period, there were 642 patients admitted to the study units. Two hundred seventy‐six patients received 1 of the monitored medications; however, 106 patients received the medication for an indication other than insomnia/difficulty sleeping. In 2 patients, incomplete records prevented ascertainment of the motivation for using the monitored medication. Thus, 168 patients (26.2%) were determined to have received a medication for sleep complaints and were included in the study analysis (Figure 1). Table 1 lists the characteristics of the 168 patients, of whom 10 had a prior documented sleep disorder such as insomnia (6 patients), restless leg syndrome (1 patient), and obstructive sleep apnea (3 patients). The rate of sleep medication use was lower, though not drastically so, in patients 65 years of age compared to those <65 years of age.

Figure 1

Table 1.Demographic and Clinical Characteristics of Patients Receiving a Sleep Aid (N=168)

Patients	Value
NOTE a Data presented as meanstandard deviation.
Age, y	57.919.8a
Age 65 years	70 (41.7)
Age 64 years	98 (58.3)
Female, n (%)	97 (57.7)
Ethnicity, n (%)
Caucasian	114 (67.9)
Black	18 (10.7)
Hispanic	13 (7.7)
Other	23 (13.7)
Admitted to floor from:
Emergency department	95 (56.5)
Operating room	30 (17.9)
Transferred from outside hospital	35 (20.8)
Intensive care unit	8 (4.8)
Admission service, n (%)
Medical	109 (64.9)
Surgical	59 (35.1)
Hospital length of stay	10.516.0a
Known sleep disorder
Insomnia	6 (3.6)
Restless leg syndrome	1 (0.6)
Obstructive sleep apnea	3(1.8)

Medication Administration Characteristics

Sleep medications were prescribed most frequently as standing orders (63.7%), rather than x1 (17.7%) or PRN (18.6%). Although the majority of sleep medications were administered between the hours of 9 _pm and 12 _am, more than 35% of doses were given outside of this range (Figure 2).

Figure 2

DISCUSSION

Our results confirm the continued frequent use of pharmacological sleep aids in the hospital setting, even in the elderly, despite recent concerns regarding the use of certain sleep medications. Additional, novel findings of our study are: (1) medications used for sleep complaints in the hospital are frequently those without a formal indication for sleep, (2) medications for sleep complaints are frequently administered too early or too late at night to be consistent with good sleep hygiene, and (3) many patients never previously on a medication for insomnia are discharged with a prescription for a sleep aid.

Despite recent warnings regarding side effects especially in the elderly, our rate of medication use has only slightly improved from prior reports from more than a decade ago.[3, 5] This high rate of use is likely due to a combination of patient, clinician, and environmental factors. In our sample, the sleep aid orders were not part of an order set; thus, the orders were either the result of patient request or in response to a patient report of poor sleep. Patients and clinicians may perceive medications for sleep as highly effective and safe, despite evidence to the contrary. Another factor is that both patients and clinicians may be unaware of nonpharmacological interventions that might improve sleep. Similarly, hospital environmental factors (noise, light) may be so disruptive as to preclude these interventions or opportunities for adequate sleep. Thus, the continued high use of medication for sleep is due in part to the lack of patient and clinician education and the difficulty in changing the hospital environment and culture, especially with only limited data on the value of sleep during recovery from illness.

Clinicians typically receive little training regarding sleep or its importance. In fact, most clinicians do not assess or communicate about the patient's quality of sleep.[11] Many may not know that there is little evidence of benefit of pharmacological sleep aids in the hospital. For example, a recent report found, in contrast to the authors' hypothesis, no changes in sleep architecture or duration using 10 mg of zolpidem tartrate in postoperative patients.[12] In our study, we found that some patients required an increase in the dose of their medications or were transitioned to a different sleep aid class (suggesting that sleep aids were ineffective). Alternatively, some patients' sleep aids were discontinued during hospital admission, again, likely due to perceived ineffectiveness or perhaps side effects. It is possible that the effectiveness of these medications might be influenced by timing of administration. This too was variable in our study. Proper clinician education around sleep hygiene might prevent early medication administration (which might lead to middle‐of‐the‐night awakenings) or delayed administration (which will delay the sleep phase), as was frequently seen in our cohort.

Despite emerging evidence of the importance of sleep in maintaining adequate immune, cardiovascular, and cognitive function, there are limited data regarding the benefits of sleep during acute illness.[13, 14, 15, 16] In the absence of compelling data, promoting sleep in the hospital has been difficult. The successful interventions used by Inouye and Bartick and their colleagues to minimize sedative hypnotic use included: a bedtime routine (eg, milk or herbal tea, relaxation tapes or music, back massage, toilet at bedtime), unit‐wide noise‐reduction strategies (eg, silent pill crushers, vibrating beepers, quiet hallways, and noise‐monitoring equipment that alerted staff above a certain decibel level), and schedule adjustments to allow sleep (eg, rescheduling of medications, intravenous fluids, and procedures), all of which require substantial clinician care or may not be possible in more acutely ill patients. Although such changes might be costly, sleep promotion and minimization of sleep aids continues to be part of a strategy that reduces delirium, hospital costs, and hospital length of stay.[16] From a patient perspective, many are interested in nondrug alternatives, especially those who have never used medications before, but few are told of them.[17]

Novel findings of our study include the types of medications used for sleep in the hospital. We found that a variety of medications and classes of medications were prescribed by clinicians for sleep complaints during hospitalization. This variability is due to a number of factors including the lack of rigorous data in this area, well‐established guidelines, or clinician education. We speculate that the high rates of use of nonbenzodiazepine and non‐ gamma‐aminobutyric acid (GABA)ergic agents, such as trazodone and quetiapine, reflect concerns about the use of medications such as zolpidem. Conversely, this means patients are increasingly treated with medications without formal FDA labeling for sleep. It does appear at least that the median doses of medication prescribed were lower in those over age 65 years compared to younger patients, although we cannot determine whether this reflects physician awareness or effective decision support used during computerized order entry. The geriatric decision support recommends a reduced dose for some (eg, trazodone, haloperidol) but not all (eg, quetiapine, lorazepam) of the monitored medications.

We found that many patients, even those who were never previously known to have insomnia, were discharged with a prescription for a sleep medication. Our study design is limited in assessing whether this prescription was needed or not, that is, whether or not the patient will have insomnia (sleep difficulty despite adequate opportunity for sleep) after hospital discharge. However, other studies have suggested that acute illness can be a precipitant for insomnia. Some of this literature has focused on patients in the intensive care unit, but it seems reasonable that patients on general medical and surgical wards (not having come through the intensive care units) might also be at risk for insomnia.[18] A study by Zisberg and colleagues in an elderly Israeli cohort found hospitalization (even without intensive care unit stay) to be both a starting point and a stopping point for chronic sleep medication use.[19] Alternatively, patients may not continue to suffer from insomnia after discharge, and thus the prescription for a sleep aid is inappropriate, as it is likely to have no benefit but may carry risk.[20] Regardless of whether hospital‐acquired insomnia persists past discharge, our findings suggest that some patients will start on chronic medication use for insomnia. Importantly, these patients may have limited understanding of the reason for their prescription, medication risks and benefits, and are unlikely to receive guidance on sleep hygiene or referral to a sleep specialist if needed. In our case, the high rate of prescriptions likely reflects the way in which inpatient medications can be added as a discharge medication automatically. This represents an area for improvement at our institution.

CONCLUSIONS

Despite increasing evidence of risks such as delirium or falls, pharmacological sleep aid use in hospitalized patients, even the elderly, remains common. A variety of medications are used, with variable administration times, which likely reflects the few rigorous studies or guidelines for the use of pharmacological sleep aids in hospitalized patients. Many patients not known to be on medications for sleep before admission leave the hospital with a sleep aid prescription. Our results suggest the need to better understand the factors that contribute to the high rate of sleep aid use in hospitalized patients. Clinician education regarding sleep, and nonpharmacological strategies to improve sleep in the hospital, are also needed.

Disclosure: Nothing to report.