Physiologic stress is being needlessly inflicted on patients because, despite their education and expertise, some doctors are reluctant to shed traditions. But any hospital, regardless of size or budget, can do better to promote healing.
Being an inpatient is already stressful enough, for obvious reasons.
Yet, many hospitals make the experience worse— and potentially dangerous—by needlessly subjecting patients to longstanding, but outmoded protocols that can result in food and sleep deprivation.
"My patients were telling me that this was an issue," Makary told me. "Any doctor will tell you that patients routinely talk about sleep interruptions, difficulty sleeping, and asking when they can eat."
Although feeding patients and allowing them to rest seem obvious, Makary says these basic needs can be overlooked in hospital patient safety programs that focus on reducing adverse events. In addition, sleep and food deprivation can be hard to spot because they are dynamic and can vary greatly from patient to patient.
"Traditional medicine has never really measured physiologic stress," Makary says. "Nobody has measured the complication rate in a normal body versus the complication rate in a fatigued, starved body. Is that complication rated doubled? Quadrupled? No one knows."
The variability between patients and the fact that food and sleep deprivation can't be well measured, has kept the issue "off the radar," Makary says. "It's off the radar because physicians like things that are actionable—things that we can fix."
Despite their education and expertise, some doctors are reluctant to shed traditions, no matter how outdated.
"Doctors have been frustrated by the strong traditions in medicine that govern patient care that are even stronger than the science," Makary says. "For example, we have a tradition in surgery that patients should not eat anything eight hours before an operation. That is dogma. It's a tradition, and it's considered a standard of care. If we really ask where that number came from, it was haphazardly chosen in the wisdom of the doctors of that era, who thought it was a safe period which would allow someone to empty their stomach and reduce the risk of aspiration."
The timeframe was debunked by science more than a decade ago, Makary says, and the rule of thumb now is that patients shouldn't eat within six hours or drink within two hours of an operation. "We are learning that if we actually feed the patients high-carbohydrate drinks two hours before the operation they feel better going in and they're less-starved coming out," he says.
Makary says hospitals must examine their protocols because the ramifications of sleep and food deprivation can be severe. Even a younger, relatively healthy person at home and without illness can become physiologically stressed and immunocompromised after 24-hours of fasting and a poor night's sleep.
Martin Makary, MD
In older, frail patients, already stressed by a hospital stay, food and sleep deprivation can worsen complications and overwhelm a patient's physiological reserves.
"Coming out of surgery, not only has your body undergone a physiological stress, now your body, if it's been without food, is in a vulnerable state, even without surgery," he says. "So, when we scratch our heads and ask 'how can we lower our infection rates' or 'how can we improve patient satisfaction?' Well, we know patients are happier and healthier when they're eating and sleeping."
On the subject of sleep deprivation, Makary once again listened to his patients.
Archaic Protocols Amidst a Cacophony
"One thing the patients told me at Johns Hopkins—and I have seen this at every hospital I have worked at— is 'they come in at 2AM and stick a needle in me and draw my labs,'" he says. "The people ordering the labs say they have to do that because they need the lab results before 5AM, which is when the youngest residents come in and pre-route and get all the information together to pass on to the chief resident. Then the chief resident uses all the information from their 6:30AM rounds and passes it on to the head surgeon at 7:30AM. So, there is this communication cascade that is archaic, burdensome, and technologically immature that results in patients' sleep getting interrupted at night."
Beyond the early morning wake-up calls, hospitals are a cacophony of sound, with overhead pages, phones ringing, loud conversations, and monitors beeping. Makary says Johns Hopkins has eliminated overhead pages on clinical units, ended overnight lab draws, and provides private rooms for most patients.
"We are learning more and more that many of these labs are not needed, and we can work with the patients to learn when they're planning on going to bed and do the labs just beforehand," he says. "We got rid of overhead pages after recognizing that there are better technological forms of communicating that do not need to wake up or alarm patients."
Makary also suggests that hospitals provide patients with eye masks, pipe in soft music, and display artwork that encourages relaxation and sleep.
Every Hospital Can Do Better
Makary's recommendations are particularly appealing because every hospital can do it, regardless of size or budget. There really is no excuse not to.
"Hospital leaders are having great success putting together groups of doctors and nurses who are asking how they can reduce noise, how they can change the time for lab testing, and how can they insure that patients are given better information about eating and drinking before surgery," he says.
A renewed emphasis on the importance of rest is overdue.
"We're supposed to promote health, but we create these hostile environments," Makary says. "There is a long tradition in medicine that rest is still good medicine. That's been under-represented in the litany of treatments that we have memorized and compartmentalized as doctors."
"We in medicine often don't have the methods and vehicles to study treatments because every patient is different and studies are labor intensive," he says. "As a result, we rely heavily on tradition. We rely heavily on consensus wisdom. And that reliance is so strong that even when there is science, it can't overcome the tradition."
John Commins is a content specialist and online news editor for HealthLeaders, a Simplify Compliance brand.