Sleep Well Project – CNTW NHS Foundation Trust – HC #MHAwards19

The "Sleep Well" service stands out from others by bringing together evidence, research and good practice, and creating a package that can then be delivered by clinical teams to improve sleep on inpatient psychiatric wards. This results in patients receiving better, safer and more reliable care. At the heart of “Sleep Well” is the desire to improve quality and reduce avoidable harm, and it reflects the safety culture in CNTW. The feedback from patients has been very positive.

http://nww1.ntw.nhs.uk/

Highly Commended - #MHAwards19

Co-Production

  • From start: Yes
  • During process: Yes
  • In evaluation: No

Evaluation

  • Peer: No
  • Academic: Yes
  • PP Collaborative: Yes

Find out more

Please briefly describe your project, group, team or service, outlining what you do and why it makes a difference.

The purpose of “Sleep Well” is to improve sleep on inpatient wards. A preliminary study results 95% of inpatients on acute psychiatric wards reported poor subjective sleep quality, and 50% had a mean sleep period of <6 hours /night. Sleep studies implicated nightly observations as a possible cause of some of this sleep disturbance. The level of light and noise on the wards were other factors. In addition some individuals were found to have in diagnosed primary sleep disorders. “Sleep Well” was developed to address this problem and has five active components: 1. The detection of primary sleep disorders; 2. Improving the sleep environment on the wards is improved particularly in regards to light-dark and noise; 3. Modifying night time observations with introduction of protected sleep period when appropriate; 4. Actively monitoring sleep and seeking feedback from patients; 5. Promoting sleep health; 6. Providing CBTi for insomnia; 7. Delivering sleep education. The team has been set up in NTW NHS Foundation Trust and is being hosted in the Positive and Safe Care Department. The approach has involved co-production with input from a service user project co-ordinator, a sleep specialist, psychiatric nurses, psychiatrists, psychologists, occupational therapists and others.

At the centre of the project has been the feedback from service users on the inpatient wards, and objective measurements of light, noise and sleep of the same service users when they were inpatients. This information was used to develop the product. The project is nearing the end of the pilot phase and this has included an evaluation of the impact. The delivery of “Sleep Well” was first to develop the product. Then approval was sought from the Trust board, and then engagement with front line staff. The pilot phase has been on 7 wards and on each ward patients and their carers have been actively engaged.

 

What makes your service stand out from others? Please provide an example of this.

The “Sleep Well” service stands out from others by bringing together evidence, research and good practice, and creating a package that can then be delivered by clinical teams to improve sleep on inpatient psychiatric wards. This results in patients receiving better, safer and more reliable care. At the heart of “Sleep Well” is the desire to improve quality and reduce avoidable harm, and it reflects the safety culture in CNTW. The feedback from patients has been very positive.

 

How do you ensure an effective, safe, compassionate and sustainable workforce?

Education of staff about staff has been an important part of the project. This has included developing a sleep champion on each of the wards, and encouraging these staff to attend local training. There is a two day annual conference which staff are encouraged to attend. In addition the sleep champions and those that are interested can attend local sleep clinics. Improving knowledge about sleep has positive impact on patients, but is also positive for staff, many of who are working night shifts. Information is key to making this project work. The project involves seeking feedback from inpatients on the wards about how they sleep. We know that disturbed sleep is associated with poorer outcomes. Patients feels better both physically and mentally when they sleep well. Obtaining information and feedback enables staff to act on the comments patients are making to improve care. They can also see the effects of improved sleep in the change in presentations the following day. It has been important to develop a culture on the ward whereby sleep is promoted, for example by reducing caffeinated drinks and developing a night time routine, and prompting staff to think about noise. Staff feedback is that the nights shifts are quieter as a result. Staff have been able to bring their own ideas which has resulted in positive outcomes.

 

Who is in your team?

Each of the seven wards have a full multidisciplinary team. In addition the Positive and Safe Care Team have four members of staff who work part time into the team.

 

How do you work with the wider system?

“Sleep Well” has applications across inpatient services within NTW. This includes acute adult wards, older peoples wards (both organic and functional), rehabilitation wards (both psychiatric and neuro-rehabilitation). In time we believe that it will also be applicable to childrens and young peoples inpatient wards and forensic units. The is a possibility that it could be used in acute trusts and in nursing homes.

 

Do you use co-production approaches?

The information and motivation for this improvement came from individual patient feedback. Many individuals reported that the wards were not conducive to sleep – too noisy and the hourly checks were disturbing. For some individuals the act of someone coming into their room at night reminded them of abusive experiences in their childhood. This information was then corroborated by using wrist accelerometers and noise measurements on the wards. When developing the product service user input was provided by the service user lead in Positive and Safe care. On the wards “Sleep Well” is discussed with individuals and their families and the feedback has been used to develop the initiative further.

 

Do you share your work with others? If so, please tell us how.

There has been one publication so far from this work, with another planned. We will be sharing this work with others mental health trusts, and through the Academic Health Science Network. In NTW NHS Foundation Trust we will be using our findings to help inform the design of a new hospital that is being built.

 

What outcome measures are collected, how do you use them and how do they demonstrate improvement?

A range of outcome measures have been used, both qualitative and quantitative. We have used wrist accelerometers as measure of sleep. We have measured the noise levels and the light levels on wards using appropriate instruments. We have data on the use of hypnotic medication and on the number of incidents on the wards before and after “Sleep Well” was introduced. We have obtained feed back from patients and from staff and we are undertaking a thematic analysis on these. We have feedback from patients on how they have slept on the previous night, and we have measured the number of patients who were appropriate for protected sleep periods on each of the wards. Some of the most powerful feedback has been directly from patients about the benefits on protected sleep period between midnight and 6am.

One patient was sleeping in different locations on the ward, moving every night and during the night as he felt suspicious of those checking on him. When he was placed on the protected sleep period he started sleeping on his bed. Another patient had been in hospital before and said that during the most recent admission the protected sleep period helped in her recovery. During the previous admission the hourly checks through the night reminded her of childhood abuse she had experience. Another patient reported that during a previous admission she had been on overnight leave and slept well at home but then returned to the ward and had a disturbed night sleep due to hourly checks. She reported that the protected sleep pattern during the most recent admission was a real improvement and provided more consistency.

 

Has your service been evaluated (by peer or academic review)?

We are involved in ongoing research led by Dr Anderson, Consultant Sleep Specialist and Dr Stuart Watson, Clinical Senior Lecturer at Newcastle University. Our pharmacist Alastair Paterson has been successful in obtaining some funding from the Academic Health Science Network and we are currently investigating the use of hypnotic drugs on the inpatient wards and the impact of “Sleep Well” on prescribing, length of stay and incidents. This evaluation is underway.

 

How will you ensure that your service continues to deliver good mental health care?

We will work with commissioners to promote the importance of sleep but for inpatient wards, but also for individuals when they are back in the community. we believe that sleep assessments such at the STOP-BANG for sleep apnoea should be part of the routine assessments for all inpatients similar to how VTE and Falls Risk Assessments are carried out currently. By demonstrating the effectiveness of the intervention we believe that “Sleep Well” will be adopted and maintained. Staff have been very positive and can see the benefits with wards being quieter and more settled at night, allowing staff to give more time to this most unwell patients. Demonstrating changes in incidents, hypnotic use and length of stay would ensure that the initiative becomes more widely adopted. “Sleep Well” also incorporate CBT for insomnia and this may prove to be one of the most effective uses of CBT. There are two other ways that “Sleep Well” will ensure ongoing delivery of mental health care. The first is that if individuals learn how to improve their sleep whilst in hospital, these skills should be transferrable to the community and will support their long term recovery. Secondly we believe there will be benefits for staff, many of whom work night shifts. Improving the sleep of staff may help reduce sickness and burnout. We will be applying for further funding to assist in the ongoing evaluation and dissemination.

 

What aspects of your service would you share with people who want to learn from you?

– The “Sleep Well” product is a package of evidence based interventions and promotes a culture the values and promotes good sleep. – It needs to involve the whole multidisciplinary team, and needs to operate 24 hours a day. Patients need to get out into the daylight and be as active as possible if they are to sleep well at night. – There needs to be clear links with Estates. Noisy bins, loud alarms, and doors that bang all disturb sleep and Estates need to be active participants. – The policies of the Trust are important and in particular how to safely introduce a protected sleep period, as this is something that patients value greatly.

 

 

How many people do you see?

The “Sleep Well” product is in a pilot phase on 7 wards. These have over 100 beds. So over a period of 12 months there will be over 500 inpatients on these wards. The numbers will increase as the rolls out to other wards.

 

How do people access the service?

All inpatients on the wards are included. All are screen for sleep disorders and are given information about good sleep health. Where it is safe and following an MDT discussion, patients are offered a protected sleep period. Others are offered CBTi.

 

How long do people wait to start receiving care?

The intervention starts on the day of admission. The protected sleep period is not introduced immediately but usually assessed after a period of 72 hours. CBTi is not available on all the wards currently.

 

How do you ensure you provide timely access?

The system for carrying out sleep assessments – STOP-BANG and restless legs needs to be fully embedded and links with the relevant Sleep Clinics are developing in a positive way. The intervention does not have a negative effect on staffing levels, and when working well will release staff time to focus on those most in need at night.

 

 

What is your service doing to identify mental health inequalities that exist in your local area?

Currently the focus is on inpatients. However the plan will be to extend this work into community clinics. The improved identification of sleep disorders will have a positive impact on rates of recovery.

 

What inequalities have you identified regarding access to, and receipt and experience of, mental health care?

This intervention is effective for the full age range and has been implemented on out old peoples wards. We believe it will be relevant to learning disability wards, although these wards were not part of the pilot.

 

What is your service doing to address and advance equality?

By raising awareness of sleep disorders and promoting good sleep, we believe that this will reduce stigma. Improved sleep should also improve the physical health of patients particularly in relation to metabolic syndrome and blood pressure.

 

 

How do you identify the needs of a person using the service (such as their physical, psychological and social needs)?

STOB-BANG, Restless Leg Syndrome assessment, Sleep charts.

 

How do you meet the needs of people using the service and how could you improve on this?

Historically there has been a lack of interest in sleep disorders in psychiatry. By improving detentions and promoting sleep rates of recovery will improve. For example a recent trial in England showed that length of stay on acute wards reduced by 8 days following an intervention to improve sleep.

 

What support do you offer families and carers? (where family/carers are not the service users)

As well as discussing the interventions with individuals, staff also involved families and carers in the discussions. Feedback from families and cares has been positive, and they are also an important source of information about an individual sleep.

 

Have you implemented any of the mental health care pathways developed by the NCCMH (on behalf of NHS England)?

Emergency Mental Health Care

Other:

Inpatient wards

 

 

 

Commissioner and providers

Commissioned by (e.g. name of local authority, CCG, NHS England):

Sunderland CCG, South Tyneside CCG, Gateshead CCG, Newcastle CCG, Northumberland CCG, and North Tyneside CCG

Provided by (e.g. name of NHS trust) or your organisation: NTW NHS Foundation Trust

 

Population details

Brief description of population (e.g. urban, age, socioeconomic status):

The population in the inpatients on seven different inpatient wards including acute adult, older people functional and organic, rehabilitation and neuro-rehabilitation.

Size of population and localities covered:  100+ inpatient beds. Localities: Sunderland, South Tyneside, Gateshead, Newcastle, Northumberland, and North Tyneside

 

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