Redesigning the Hospital Environment to Improve Restfulness

Importance: Hospital wards are often not conducive to patient sleep, negatively affecting patient health and experience. Objectives: To assess determinants of in-hospital restfulness and to design and test rest-promoting interventions on the wards in partnership with clinicians, staff, and patients. Design, Setting, and Participants: This rapid-sequential mixed-methods quality improvement study was performed at a large urban academic hospital in St Louis, Missouri, from May 1, 2021, to December 31, 2022, with follow-up through hospitalization. Mixed-methods activities involved purposively selected hospitalized adults on the wards, nurses, hospitalists, and hospital staff. Interventions included all adult hospitalizations on the study wards. Interventions: Sequential stacked bundles of multimodal rest-promoting interventions (general education, focused education on light or noise, safely reducing overnight monitoring or testing, and environmental personalization). Main Outcomes and Measurements: Pre-post comparisons of perceived nighttime quietness (via surveys) and sleep opportunity (coprimary outcomes) as well as clinical interruptions overnight, environmental noise, and adoption and satisfaction. Results: Nine patients (4 female) and 14 staff members (10 female; 3 nurse managers or administrators, 10 nurses, and 1 physician) were interviewed, 38 surveys were collected, and more than 100 hours of observation were performed. Interventions were evaluated for 671 patients (mean SD age, 60 16 years; 336 50% female). Determinants of in-hospital rest included infrastructure, staff attitudes, priorities, culture, and patient experiences of anxiety, uncertainty, and loss of control. Informed by these determinants, codesign workshops yielded 39 potential interventions, from which 9 were selected for testing. Related interventions were organized into bundles, which were tested in sequential 2-week sprints. Perceived nighttime quietness improved nonsignificantly during the project (wards "always" quiet at night: 51% preintervention vs 86% postintervention; P = .09), with excessive noise events decreasing from 0.65 (95% CI, 0.53-0.77) to 0 per 100 patient-nights before the intervention (P = .02). Sleep opportunity improved significantly (mean, 4.94 95% CI, 4.82-5.06 hours per patient-night before the intervention vs 5.10 95% CI, 5.00-5.20 hours per patient-night after the intervention; P = .01). Conclusions and Relevance: In this quality improvement study, a set of feasible, acceptable, and beneficial rest-promoting interventions were developed. After implementation of these interventions on the wards, a significant improvement in nighttime quietness and sleep opportunity was observed. These results demonstrate how human-centered design methods can generate practical and effective strategies for improving an important patient-related outcome and a core element of patient experience.