Final Deliverable for Healthcare QI Project

1. Implementation of a Non-Pharmacological Sleep Hygiene
Program to Improve Sleep Quality on a Transitional Care
Unit in a Rehab/CCC Hospital
Sadaf Fatima1, Kelvin Yam1, Rahul Bhundhoo1, Sally Twin1,
Nishita Kamath2, Mallory Drost2, Agnes Tong2
1University of Toronto, 2Sinai Health System

2. Background
2
➢Older adults experience sleep disturbances due to age-related
changes1
➢Sedatives prescribed to address sleep disturbances are associated
with cognitive impairment and increased risk of falls2-4
➢Non-pharmacological sleep hygiene interventions offer alternative
to sedatives5-9

3. Aim Statement
Co-design, implement and evaluate a non-
pharmacological sleep hygiene program to
improve sleep quality by 25% on one
Transitional Care Unit by June 2019.
3

4. 4
Methodology
Experience Based Co-DesignPlan - Do - Study - Act (PDSA) Cycles
Figure 2: Experienced Based Co-Design, Adapted from NHS Guidelines
Figure 1: PDSA Cycles

5. 5
Methodology - EBCD
Experience Based Co-Design Process Mapping
Figure 3: Tool to capture patient experience

6. 6
Methodology - EBCD
Experience Based Co-Design Cause & Effect Analysis to Understand the Experience
Figure 4: Root Cause Analysis of Poor Sleep on Transitional Care Unit

7. 7
Methodology - EBCD
Experience Based Co-Design
Figure 5: Collaboration with
Patients and Staff to Co-Design
Intervention
Figure 6: Standardized Sleep
Hygiene Routine Co-Designed
as Intervention to Improve
Sleep Quality

8. 8
Methodology - EBCD
Experience Based Co-Design
Figure 7: Visual Sleep Scale

9. PDSA Cycle 2PDSA Cycle 1
April 23 April 28
Methodology - PDSA Cycles
May 06 May 21
➢ Optimization of
reminder tool required
➢ Further training and
education of Clinical
Team required
➢ Successful implementation of intervention
➢ Accurate collection of qualitative and quantitative data
○ Qualitative data: Clinical Team’s observations of patients’ sleep
disturbances
○ Quantitative data: Post-intervention sleep scores
Intervention: Implementation of Standardized Sleep Hygiene Routine

10. 10
Results
Process Measure:
Proportion of evenings when at least
70% of standardized bedtime activities
were completed
Outcome Measure:
Patient reported sleep score
Balancing Measure:
Clinical team satisfaction on
completing the standardized bedtime
activities
Quantitative Results:
● Sleep quality improved by 100%
Qualitative Results:
● Patient and clinical team experiences were captured
○ “I feel rested upon waking.” - Patient
○ “I like when the nurses pulls the blinds before I go to bed.” - Patient
○ “The standardized bedtime routine is important for a good night’s sleep.” - Team
Table 1: Summary of Post-Intervention Results Tabulated for Patients A, B, and C

11. 11
Results
Figures 8,9,10 (Left to Right): Run Charts Depicting Results of Patients A,B, and C

12. Conclusions & Next Steps
➢ Standardized bedtime routine showed early and promising improvements
to sleep quality for three patients
➢ Next Steps:
1. Identifying opportunities to optimize the routine as it spreads to additional
patients on the unit.
2. Co-designing a visual management tool in the form of a poster.
3. Encouraging patients and caregivers to participate in all bedtime activities.
4. Spreading the routine to other units across the hospital
12

13. References
1. McDowell JA, et al. A nonpharmacologic sleep protocol for hospitalized older patients. J Am Geriatr Soc.
1998;46(6):700-705.
2. Pek EA, et al. High Prevalence of Inappropriate Benzodiazepine and Sedative Hypnotic Prescriptions among
Hospitalized Older Adults. Journal of Hospital Medicine. 2017; 12(5): 310-6.
3. Westley C. Sleep: geriatric self-learning module. Medsurg Nurs. 2004; 13(5): 291-5.
4. Glass J, et al. Sedative hypnotics in older people with insomnia: meta-analysis of risks and benefits. BMJ.
2005;331(7526):1169.
5. Elliott R, McKinley S. The development of a clinical practice guideline to improve sleep in intensive care
patients: a solution focused approach. Intensive Crit Care Nurs. 2014;30(5):246-56.
6. Lareau, et al. Examining the feasibility of implementing specific nursing interventions to promote sleep in
hospitalized elderly patients. Geriatr Nurs. 2008;29:197–206.
7. Foley DJ, et al. Sleep complaints among elderly persons: an epidemiologic study of three communities.
Sleep 1995; 18(6):425-32.
8. Alparslan G. B., et al. Assessment of Sleep Quality and Effects of Relaxation Exercise on Sleep Quality in
Patients Hospitalized in Internal Medicine Services in a University Hospital: The Effect of Relaxation Exercises
in Patients Hospitalized. Holistic Nursing Practice. 2016;30(3):155-65.
9. de Niet G, et al. Applicability of two brief evidence-based interventions to improve sleep quality in inpatient
mental health care. Int J Ment Health Nurs. 2011.

14. Acknowledgements
Thank you to Bridgepoint Active Healthcare, Sinai Health Foundation
for sponsoring this QI Project.
Our sincerest gratitude to our Project Champions:
Agnes Tong and Nishita Kamath.
Thank you to the Patient Partner and Clinical Staff from 7th North
TCU.
Thank you to UofT IHI for the Opportunity.
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15. Questions?

16. Cause and Effect Diagram

17. 17
Methodology - Initial Iteration of Reminder
Tool

18. Methodology - Second Iteration of Reminder Tool