Development and application of a multi-modal sleep management program for general surgery based on the optimal healing environment model

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Based on these identified factors and leveraging intelligent facilities, we developed a multi-modal sleep management program rooted in the optimal healing environment model. The program included standardizing sleep assessment and intervention processes, fostering a quiet and comfortable ward environment, implementing a medical and nursing behavior modification checklist, enhancing patient awareness of sleep, and cultivating a caring environment. Following the implementation of this program in general surgery wards, the incidence of situational insomnia decreased, noise levels during lunchtime and nighttime reduced, and patient satisfaction significantly improved. The application of a multi-modal sleep management program grounded in the optimal healing environment model can effectively improve sleep quality, expedite postoperative recovery, and enhance patient satisfaction in general surgery settings. Earth and environmental sciences/Environmental social sciences Health sciences/Medical research healing environment sleep disorders enhancedrecoveryaftersurgery general surgery Figures Figure 1 Figure 2 Figure 3 Introduction Promoting patient sleep is one of the key measures in the Enhanced Recovery After Surgery (ERAS) pathway[1]. Clinical studies have shown that approximately 70-80% of perioperative patients suffer from sleep deprivation[2-6]. Sleep disorders are a significant barrier to the recovery of patients[2]. Among perioperative patients, situational insomnia is the most common type of sleep disorder. Literature reports that the main causes of insomnia in hospitalized patients include hospital instrument noise, light, temperature, medication use, hospitalization-related anxiety, postoperative discomfort, lack of attention by medical staff to patients' sleep, and limited sleep awareness among patients and their families. All of these are considered "situational" factors[7]. Therefore, eliminating "situational" factors is essential to improving the sleep of hospitalized patients. The concept of the healing environment was first introduced in the United States in the 1990s, and its core principle is to provide a low-stimulus environment, promoting dignity, meaningful human-computer interactions, and family involvement in care, in order to reduce coercive interventions and bring patients closer to nature[8]. Thus, improving situational insomnia in hospitalized patients based on the concept of healing environments is essential. Jonas et al.[9-10] proposed the concept of the Optimal Healing Environments (OHE) model to guide clinical practice, emphasizing internal, external, and interpersonal environments. Currently, research on the healing environment is still in its infancy in some countries. In this study, we developed a multi-modal sleep management program for general surgery inpatients based on the Optimal Healing Environments model, with the goal of reducing situational insomnia in perioperative patients and promoting recovery. 1 Methodology 1.1 Problem Investigation and Cause Analysis 1.1.1 Establishment of a Research Team The research team consisted of eight members, including one associate chief physician in general surgery, one associate chief physician in mental health, one chief nurse practitioner, two deputy chief nurse practitioners, and three charge nurse practitioners. The research team was responsible for conducting literature searches, preparing, distributing, and collecting questionnaires, analyzing data, and developing the intervention program. 1.1.2 Document Analysis The research team conducted a literature search across both Chinese and English databases, including PubMed, Web of Science, Cochrane Library, China Knowledge Network, China Biomedical Literature Database, VIP Database, and Wanfang Database. The English search terms included "general surgery unit/unit/general surgery/perioperative period,""insomnia/sleep initiation and maintenance disorders/sleep/sleep disorders,""management/nursing care." The Chinese search terms included "surgical ward/unit/general surgery/perioperative period,""insomnia/sleep/sleep management/situational insomnia," and "management/nursing care." The search timeframe extended from the establishment of each database to July 2022. Based on the results of the literature search and expert group discussions, a self-developed questionnaire was created to identify the influencing factors of sleep in general surgery patients. The Pittsburgh Sleep Quality Index Scale and the self-developed questionnaire on sleep influencing factors were administered to patients hospitalized in general surgery wards from July 2022 to August 2022. The inclusion criteria were: patients hospitalized in the general surgery ward with a length of stay of at least 5 days and aged 18 years or older. Exclusion criteria included: patients with cognitive dysfunction or those unable or unwilling to cooperate with the survey due to illness. 1.1.3 Investigation Results and Cause Analysis 1.1.3.1 Evaluation Indices The evaluation indices include the following: ① Prevalence of situational insomnia : The American Academy of Sleep Medicine and the Sleep Research Society agree that adults should sleep 7 hours or more per night[2]. Based on the literature and in consideration of the condition of general surgery patients, situational insomnia is defined as a total sleep duration of less than 7 hours within a 24-hour period, with the cause being linked to "situational" factors. The incidence of situational insomnia is calculated as: (the number of cases of situational insomnia in the general surgery department during the survey period ÷ the total number of cases during the survey period) × 100%. ② Noise dB : A noise-measuring instrument from Chengdu Core Matrix Technology Co., Ltd. was used to monitor noise levels from 12:30 to 13:00 during lunchtime and from 22:00 to 22:30 at night for one week, with the average value calculated. ③ Patient satisfaction : A custom-designed patient satisfaction questionnaire was used, with a total score of 100 points. Satisfaction was categorized into four levels: very satisfied (>90 points), satisfied (80-90 points), general (60-80 points), and dissatisfied (<60 points). 1.1.3.2 Analysis of Survey Results A total of 122 general surgery patients were surveyed, and the results showed that 81 patients (66.4%) experienced situational insomnia. Noise levels were recorded at 65 decibels at lunchtime and 50 decibels at night. Patient satisfaction with ambient noise and room temperature was 62 and 79, respectively. Statistical analysis revealed that 80% of situational insomnia cases were attributable to key influencing factors. To identify the root cause, the group conducted an important factor analysis, followed by field observation and verification through a custom-designed patient sleep diary. The main causes were identified as: symptomatic and psychological factors of the patients, staff talking loudly, low attention to patients' sleep by staff, low sleep awareness among patients and family members, machine alarm sounds, call bell ringing, an unstandardized sleep management process, lack of insomnia treatment protocols in the department, mosquito and insect interference, extreme room temperatures, and overly bright lighting. 1.2 Development of a Multi-Modal Sleep Management Program for General Surgery Patients 1.2.1 Rationale for the Multi-Modal Sleep Management Program The Optimal Healing Environment model (Figure 1) includes the internal, external, and interpersonal environments. The internal environment primarily consists of the conscious development of healing intentions, expectations, and beliefs, along with transformative self-care practices to facilitate the individual's experience of wellness. The external environment primarily includes the core elements of practicing health-promoting behaviors, changing lifestyles, supporting self-healing, and developing social supports; application through collaborative practice approaches that support the healing process; and healing spatial environments that reflect evidence-based design. This emphasizes that creating healing environments hinges on physical design, organizational conditions, interventions, and supports that facilitate the patient's healing experience and other relevant factors influencing healing. The interpersonal environment focuses on fostering healing relationships based on compassion, empathy, and interconnectedness, as well as developing listening and communication skills to promote trust between healthcare professionals and patients [10]. The model provides a scientific and theoretical basis for constructing this intervention program. 1.2.2 Development of a Multi-Modal Sleep Management Program for General Surgery Patients A literature search was conducted using the Optimal Healing Environment model to identify potential measures for improvement. Measures were evaluated by the group, and potential options were identified based on feasibility, cost-effectiveness, and overall impact using a systematic diagram method. A final multi-modal sleep management plan was developed (see Figure 2), which was then gradually implemented from August 2022to May 2023. The plan was continuously optimized based on clinical application outcomes. 1.2.2.1 Option 1: Standardization of Sleep Assessment and Intervention Processes, and Fostering a Compassionate Environment Addressing issues such as the "non-standardized sleep management process,""lack of insomnia intervention procedures in the department,""insufficient awareness of sleep assessment among nurses," and "patients' symptoms and psychological factors," the primary improvement measures include: ① Developing a comprehensive sleep assessment and insomnia intervention process (see Figure 3), which includes basic interventions, environmental/symptomatic/psychological interventions, basic sleep-aid medication, and specialty interventions from the mental health department. Additionally, creating a sleep assessment tool to be displayed in patient rooms. ② Creating a sleep assessment intervention record sheet and including sleep assessment in shift handovers. ③ Implementing a system to notify nurses of patients' birthdays and holidays, including sending birthday greetings, holiday wishes, and encouragement cards. This initiative aims to foster mutual trust and a compassionate relationship between doctors and patients. 1.2.2.2 Option 2: Establishing a Tranquil and Comfortable Healing Environment Addressing issues such as "staff conversations,""family conversations,""ringing phones and machine alarms,""mosquito interference,""excessive facility lighting," and "inappropriate room temperature," the primary improvement measures include: ① Enhancing the intelligent infusion system by incorporating a silent alarm function, eliminating corridor infusion alarms, and transmitting alarm notifications directly to the responsible nurse's PDA (Personal Digital Assistant) and the nursing station’s display board. ② Installing noise monitoring and alerting devices in each ward and nurse station to analyze noise data. The devices will trigger dynamic pattern alerts if noise levels exceed 60 dB during the day or 50 dB at night.③ Installing temperature and humidity sensors in five key areas of the ward to monitor conditions actively. The sensors will automatically record data and issue early warnings to prompt medical staff to take action. ④ Enhancing room door facilities by attaching light-reducing diaphragms to doors and window panes to minimize light intrusion into the wards at night. ⑤ Equipping departments with sleep-promoting kits that include eye masks, earplugs, anti-snoring clips, electric fans, mosquito repellents, and white noise and relaxation music playlists. 1.2.2.3 Option 3: Development of a Healthcare Behavior Modification Checklist Addressing the issue of "low staff attention to patient sleep," the primary improvement measures include:①Implementing the "Noon Quiet Bundle" management system during the 1-hour lunch break (12:30-13:30), which includes: a. Displaying a "nap time" reminder on corridor electronic screens and playing calming music; b. Automatically closing corridor curtains and turning off corridor lights, leaving only the nurse's work light; c. Automaticallylowering the volume of all call bells, phones, and PDAs to below 40 dB; d. Adjusting non-urgent treatments and educating patients’ family members and staff to reduce noise levels; e. Ensuring that team leaders monitor and maintain the quality of the lunch break environment. ② Implementing the "Night Sleep Protocol" from 21:00 to 05:00, which includes the same measures as the "Noon Quiet Bundle" management system, along with additional measures such as checking the room and standardizing the use of floor lamps, ceiling lamps, and bedside lamps in the wards; ③ Requiring nurses to communicate with doctors promptly regarding any unnecessary treatments during the night; ④ Educating medical staff on patient sleep management and creating a WeChat group for tracking and supervising behavior modification among nurses. 1.2.2.4 Option 4: Enhancing Patient Sleep Awareness Through Education Addressing the issue of "low awareness of sleep among patients and families," the primary measures include: (1) Developing a patient sleep management education brochure and an educational board, and instructing nurses to educate patients about sleep during their hospital admission, highlighting the importance of sleep management; (2) Incorporating patient sleep management information into the self-help information system for personalized notifications. 1.2.3 Feasibility Verification In May 2023, a Preliminary experiment was conducted with five patients undergoing hepatobiliary surgery to evaluate the implementation of a specified protocol from the first day after admission through the fifth day postoperatively. Sleep data were collected on the first day after admission, one day before surgery, three days after surgery, and five days after surgery. The retrieval of sleep data was 100% accurate. The results indicated a 98% implementation rate for the sleep assessment and intervention process and a 95% implementation rate for the nurse’s behavior modification checklist, demonstrating the protocol’s feasibility. 2 Results The General Surgery Multi-Modal Sleep Management Program was continuously implemented from July to September 2023, during which sleep data were collected from 194 general surgery patients. Analysis revealed that the incidence of situational insomnia decreased from 66.4% to 35.5%. Noise monitoring showed a reduction in the average midday noise level from 65 dB to 51 dB and a decrease in the average evening noise level from 50 dB to 36 dB. Patient satisfaction with noise management increased from 62 to 86, while satisfaction with room temperature management rose from 79 to 95. 3 Experience 3.1 Significance of Constructing a Multi-Modal Sleep Management Program for General Surgery Based on the Optimal Healing Environment Model Enhanced Recovery After Surgery (ERAS) represents a multi-modal perioperative care pathway designed to minimize surgical stress, expedite recovery, reduce complications, and shorten hospital stays for patients undergoing major surgery [1]. In April and May 2023, the General Office of the National Health Commission (NHC) in China issued directives, including the "Notice of the General Office of the National Health Commission on Further Promoting the Work of Enhanced Recovery After Surgery (ERAS)" [11] and the "Notice on the Theme Activity of Improving the Feeling of Medical Treatment and Enhancing the Patient's Experience" [12]. These directives mandate that hospitals, particularly tertiary hospitals, implement ERAS protocols. Perioperative sleep management, a crucial component of ERAS, is frequently overlooked. Research indicates that the incidence of preoperative sleep disorders in China is as high as 60.6%, with the rate of poor sleep two weeks post-surgery rising to 72.5%, exceeding reported figures for Western patients [13-14]. Additional studies highlight a significant prevalence of situational insomnia among perioperative general surgery patients [4, 15]. Specifically, in hepatobiliary surgery patients, 73.00% experienced perioperative sleep durations of less than 7 hours, suggesting suboptimal perioperative sleep conditions [16]. Situational insomnia is influenced by various factors, including psychological, environmental, and biological sources [7]. Therefore, targeted sleep interventions for general surgery patients are essential. Some researchers in China have developed an orthopedic psychosleep management model based on ERAS, incorporating multidisciplinary teams and graded psychosleep intervention pathways, which have proven effective for perioperative orthopedic patients [2-3]. Other studies have implemented symptom, environmental, and psychological interventions based on comfort theory, effectively reducing sleep disorders [17-18]. The optimal healing environment model emphasizes creating a low-stimulation, evidence-based environment, reflecting a human-centered approach similar to ERAS. This model focuses on enhancing patient experience and facilitating faster recovery. This study identified key factors affecting sleep among general surgery patients through a literature review and clinical research, leading to the development of a multi-modal sleep management program based on this model. The program achieved a situational insomnia incidence of 35.5%, which is lower than reported in similar studies. However, establishing a healing environment incurs high organizational management costs [19]. The optimal healing environment model provides a theoretical foundation for improving organizational management quality and achieving more comprehensive analysis and enhancement. Implementing smart ward construction projects or intelligent facilities offers nurses more convenient resources, does not increase the labor costs of medical staff, and ensures the continuous maintenance of the healing environment [20]. The graded sleep assessment and intervention procedures for general surgery, along with the "Noon Quiet Bundle" checklist, can enhance sleep awareness and improve sleep management among medical personnel. Literature recommendations highlight the clinical significance of quiet moments and sleep aids, such as eye masks, earplugs, stop-snoring clips, and white noise [21-24]. Surgical patients often experience heat and night sweats, making it necessary to provide small electric fans in the ward. In conclusion, the multi-modal sleep management program based on the optimal healing environment model offers valuable new perspectives, though further clinical validation is needed. 3.2 Insights and Limitations of This Study Clinical practice has revealed that patients often lack knowledge about sleep and may mistakenly believe that insomnia does not require intervention or that sleep medications are addictive. Therefore, enhancing patient education on sleep is crucial. In this study, placing a sleep ruler in patient rooms, conducting daily sleep assessments, and installing noise warning devices improved awareness of sleep issues among patients and their families. However, the medical behavior modification checklist and the sleep assessment intervention process necessitate the establishment of a supervision mechanism to ensure ongoing implementation through continuous oversight [25]. Various methods, such as birthday wishes and encouragement cards, were employed to foster trust between doctors and patients and cultivate a healing relationship, representing a novel approach. Clinical practice results indicate that both patients and medical staff highly value these efforts; however, objective data to confirm their effectiveness remains limited. This study employed multiple measures comprehensively but could not individually confirm the clinical effectiveness of each measure in the general surgery ward. While existing evidence supports the clinical significance of these measures, further research is needed. Additionally, the study found that invalid alarm sounds from monitors at night significantly disrupt patient sleep, with no effective solutions provided. Future research should explore the use of advanced, non-inductive monitoring equipment and more precise monitoring methods to minimize unnecessary disturbances [26-27]. The study's reliance on patient questionnaires for sleep data collection may introduce potential data bias. Clinical applications of wearable devices for sleep monitoring, such as the Huawei watch used by the authors' organization, show promise. Further research is necessary to effectively utilize data from wearable devices for objective sleep assessment and the development of early warning functions. Declarations Ethics approval and consent to participate The study was approved by the Ethics Committee of Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University. Signed written informed consents were obtained from the patients and/or guardians. All methods were performed in accordance with the relevant guidelines and regulations. Consent for publication Not applicable. Availability of data and materials All data supporting the findings of this study are available within the paper and its Supplementary Information. Conflict of interest There is no conflict of interest to be declared by any author. Funding This study was supported by Zhejiang medicine and health science and technology project No.2023KY798。 Authors’ contributions (I) Conception and design: H Xu; X Jiang;Y Xu;J Chen;L Cheng;Y Qian; (II) Administrative support: X Liang;H Pan;(III) Provision of study materials or patients: X Jiang;Y Xu; J Chen; Y Qian; (IV) Collection and assembly of data: L Cheng; X Jiang; (V) Data analysis and interpretation: H Xu, Y Xu; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors. 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Cite Share Download PDF Status: Published Journal Publication published 28 Nov, 2025 Read the published version in Scientific Reports → Version 1 posted Editorial decision: Revision requested 24 Mar, 2025 Reviews received at journal 10 Mar, 2025 Reviewers agreed at journal 25 Feb, 2025 Reviews received at journal 11 Jan, 2025 Reviewers agreed at journal 14 Dec, 2024 Reviewers agreed at journal 12 Dec, 2024 Reviewers invited by journal 15 Nov, 2024 Editor assigned by journal 15 Nov, 2024 Editor invited by journal 30 Oct, 2024 Submission checks completed at journal 29 Oct, 2024 First submitted to journal 12 Oct, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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University","correspondingAuthor":false,"prefix":"","firstName":"Qieyi","middleName":"","lastName":"QIAN","suffix":""},{"id":374714823,"identity":"43fa656f-74ca-4ce4-84c0-cceb5b5a0347","order_by":7,"name":"Xiao LIANG","email":"","orcid":"","institution":"Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University","correspondingAuthor":false,"prefix":"","firstName":"Xiao","middleName":"","lastName":"LIANG","suffix":""}],"badges":[],"createdAt":"2024-10-12 12:53:30","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5251547/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5251547/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1038/s41598-025-28981-9","type":"published","date":"2025-11-28T15:57:44+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":69435721,"identity":"c631e7c8-7352-4bf9-ae47-b7622e6573b9","added_by":"auto","created_at":"2024-11-20 10:31:46","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":145282,"visible":true,"origin":"","legend":"\u003cp\u003eThe Optimal Healing EnvironmentModel\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5251547/v1/e6a1dcd21dcd4fa182d843ba.png"},{"id":69437393,"identity":"0c7c202a-80dc-48fd-bb6a-487a4376369f","added_by":"auto","created_at":"2024-11-20 10:47:46","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":207411,"visible":true,"origin":"","legend":"\u003cp\u003eOHE-based multi-modal sleep management program for general surgery patients\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5251547/v1/16d66be45d57fd4cc1e4c25c.png"},{"id":69435719,"identity":"2f59e36d-6b5c-44d3-bea0-fd62a240c9ea","added_by":"auto","created_at":"2024-11-20 10:31:46","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":118105,"visible":true,"origin":"","legend":"\u003cp\u003eA comprehensive sleep assessment and insomnia intervention process\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-5251547/v1/52c0747f5561bb360278d78e.png"},{"id":97179345,"identity":"942712f1-2d57-4a05-a7d1-fc8064fcee4b","added_by":"auto","created_at":"2025-12-01 16:14:53","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1232754,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5251547/v1/5cfa405a-4dc0-4b36-b5fd-80e245bdf0bf.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Development and application of a multi-modal sleep management program for general surgery based on the optimal healing environment model","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePromoting patient sleep is one of the key measures in the Enhanced Recovery After Surgery (ERAS) pathway[1]. Clinical studies have shown that approximately 70-80% of perioperative patients suffer from sleep deprivation[2-6]. Sleep disorders are a significant barrier to the recovery of patients[2]. Among perioperative patients, situational insomnia is the most common type of sleep disorder. Literature reports that the main causes of insomnia in hospitalized patients include hospital instrument noise, light, temperature, medication use, hospitalization-related anxiety, postoperative discomfort, lack of attention by medical staff to patients\u0026apos; sleep, and limited sleep awareness among patients and their families. All of these are considered \u0026quot;situational\u0026quot; factors[7]. Therefore, eliminating \u0026quot;situational\u0026quot; factors is essential to improving the sleep of hospitalized patients.\u003c/p\u003e\n\u003cp\u003eThe concept of the healing environment was first introduced in the United States in the 1990s, and its core principle is to provide a low-stimulus environment, promoting dignity, meaningful human-computer interactions, and family involvement in care, in order to reduce coercive interventions and bring patients closer to nature[8]. Thus, improving situational insomnia in hospitalized patients based on the concept of healing environments is essential. Jonas et al.[9-10] proposed the concept of the Optimal Healing Environments (OHE) model to guide clinical practice, emphasizing internal, external, and interpersonal environments. Currently, research on the healing environment is still in its infancy in some countries. In this study, we developed a multi-modal sleep management program for general surgery inpatients based on the Optimal Healing Environments model, with the goal of reducing situational insomnia in perioperative patients and promoting recovery.\u003c/p\u003e"},{"header":"1 Methodology","content":"\u003ch5\u003e1.1 Problem Investigation and Cause Analysis\u003c/h5\u003e\n\u003cp\u003e\u003cstrong\u003e1.1.1 Establishment of a Research Team\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research team consisted of eight members, including one associate chief physician in general surgery, one associate chief physician in mental health, one chief nurse practitioner, two deputy chief nurse practitioners, and three charge nurse practitioners. The research team was responsible for conducting literature searches, preparing, distributing, and collecting questionnaires, analyzing data, and developing the intervention program.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.1.2 Document Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research team conducted a literature search across both Chinese and English databases, including PubMed, Web of Science, Cochrane Library, China Knowledge Network, China Biomedical Literature Database, VIP Database, and Wanfang Database. The English search terms included \u0026quot;general surgery unit/unit/general surgery/perioperative period,\u0026quot;\u0026quot;insomnia/sleep initiation and maintenance disorders/sleep/sleep disorders,\u0026quot;\u0026quot;management/nursing care.\u0026quot; The Chinese search terms included \u0026quot;surgical ward/unit/general surgery/perioperative period,\u0026quot;\u0026quot;insomnia/sleep/sleep management/situational insomnia,\u0026quot; and \u0026quot;management/nursing care.\u0026quot; The search timeframe extended from the establishment of each database to July 2022.\u003c/p\u003e\n\u003cp\u003eBased on the results of the literature search and expert group discussions, a self-developed questionnaire was created to identify the influencing factors of sleep in general surgery patients. The Pittsburgh Sleep Quality Index Scale and the self-developed questionnaire on sleep influencing factors were administered to patients hospitalized in general surgery wards from July 2022 to August 2022. The inclusion criteria were: patients hospitalized in the general surgery ward with a length of stay of at least 5 days and aged 18 years or older. Exclusion criteria included: patients with cognitive dysfunction or those unable or unwilling to cooperate with the survey due to illness.\u003c/p\u003e\n\u003ch4\u003e1.1.3 Investigation Results and Cause Analysis\u003c/h4\u003e\n\u003ch5\u003e1.1.3.1 Evaluation Indices\u003c/h5\u003e\n\u003cp\u003eThe evaluation indices include the following:\u003cbr\u003e①\u0026nbsp;\u003cstrong\u003ePrevalence of situational insomnia\u003c/strong\u003e: The American Academy of Sleep Medicine and the Sleep Research Society agree that adults should sleep 7 hours or more per night[2]. Based on the literature and in consideration of the condition of general surgery patients, situational insomnia is defined as a total sleep duration of less than 7 hours within a 24-hour period, with the cause being linked to \u0026quot;situational\u0026quot; factors. The incidence of situational insomnia is calculated as: (the number of cases of situational insomnia in the general surgery department during the survey period \u0026divide; the total number of cases during the survey period) \u0026times; 100%.\u003cbr\u003e②\u0026nbsp;\u003cstrong\u003eNoise dB\u003c/strong\u003e: A noise-measuring instrument from Chengdu Core Matrix Technology Co., Ltd. was used to monitor noise levels from 12:30 to 13:00 during lunchtime and from 22:00 to 22:30 at night for one week, with the average value calculated.\u003cbr\u003e③ \u003cstrong\u003ePatient satisfaction\u003c/strong\u003e: A custom-designed patient satisfaction questionnaire was used, with a total score of 100 points. Satisfaction was categorized into four levels: very satisfied (\u0026gt;90 points), satisfied (80-90 points), general (60-80 points), and dissatisfied (\u0026lt;60 points).\u003c/p\u003e\n\u003ch5\u003e1.1.3.2 Analysis of Survey Results\u003c/h5\u003e\n\u003cp\u003eA total of 122 general surgery patients were surveyed, and the results showed that 81 patients (66.4%) experienced situational insomnia. Noise levels were recorded at 65 decibels at lunchtime and 50 decibels at night. Patient satisfaction with ambient noise and room temperature was 62 and 79, respectively. Statistical analysis revealed that 80% of situational insomnia cases were attributable to key influencing factors. To identify the root cause, the group conducted an important factor analysis, followed by field observation and verification through a custom-designed patient sleep diary. The main causes were identified as: symptomatic and psychological factors of the patients, staff talking loudly, low attention to patients\u0026apos; sleep by staff, low sleep awareness among patients and family members, machine alarm sounds, call bell ringing, an unstandardized sleep management process, lack of insomnia treatment protocols in the department, mosquito and insect interference, extreme room temperatures, and overly bright lighting.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.2\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eDevelopment of a Multi-Modal Sleep Management Program for General Surgery Patients\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.2.1\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eRationale for the Multi-Modal Sleep Management Program\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Optimal Healing Environment model (Figure 1) includes the internal, external, and interpersonal environments. The internal environment primarily consists of the conscious development of healing intentions, expectations, and beliefs, along with transformative self-care practices to facilitate the individual\u0026apos;s experience of wellness. The external environment primarily includes the core elements of practicing health-promoting behaviors, changing lifestyles, supporting self-healing, and developing social supports; application through collaborative practice approaches that support the healing process; and healing spatial environments that reflect evidence-based design. This emphasizes that creating healing environments hinges on physical design, organizational conditions, interventions, and supports that facilitate the patient\u0026apos;s healing experience and other relevant factors influencing healing. The interpersonal environment focuses on fostering healing relationships based on compassion, empathy, and interconnectedness, as well as developing listening and communication skills to promote trust between healthcare professionals and patients [10]. The model provides a scientific and theoretical basis for constructing this intervention program.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.2.2\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eDevelopment of a Multi-Modal Sleep Management Program for General Surgery Patients\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA literature search was conducted using the Optimal Healing Environment model to identify potential measures for improvement. Measures were evaluated by the group, and potential options were identified based on feasibility, cost-effectiveness, and overall impact using a systematic diagram method. A final multi-modal sleep management plan was developed (see Figure 2), which was then gradually implemented from August 2022to May 2023. The plan was continuously optimized based on clinical application outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.2.2.1 Option 1:\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eStandardization of Sleep Assessment and Intervention Processes, and Fostering a Compassionate Environment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAddressing issues such as the \u0026quot;non-standardized sleep management process,\u0026quot;\u0026quot;lack of insomnia intervention procedures in the department,\u0026quot;\u0026quot;insufficient awareness of sleep assessment among nurses,\u0026quot; and \u0026quot;patients\u0026apos; symptoms and psychological factors,\u0026quot; the primary improvement measures include: ① Developing a comprehensive sleep assessment and insomnia intervention process (see Figure 3), which includes basic interventions, environmental/symptomatic/psychological interventions, basic sleep-aid medication, and specialty interventions from the mental health department. Additionally, creating a sleep assessment tool to be displayed in patient rooms. ② Creating a sleep assessment intervention record sheet and including sleep assessment in shift handovers. ③ Implementing a system to notify nurses of patients\u0026apos; birthdays and holidays, including sending birthday greetings, holiday wishes, and encouragement cards. This initiative aims to foster mutual trust and a compassionate relationship between doctors and patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.2.2.2 Option 2: Establishing a Tranquil and Comfortable Healing Environment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAddressing issues such as \u0026quot;staff conversations,\u0026quot;\u0026quot;family conversations,\u0026quot;\u0026quot;ringing phones and machine alarms,\u0026quot;\u0026quot;mosquito interference,\u0026quot;\u0026quot;excessive facility lighting,\u0026quot; and \u0026quot;inappropriate room temperature,\u0026quot; the primary improvement measures include: ① Enhancing the intelligent infusion system by incorporating a silent alarm function, eliminating corridor infusion alarms, and transmitting alarm notifications directly to the responsible nurse\u0026apos;s PDA (Personal Digital Assistant) and the nursing station\u0026rsquo;s display board. ② Installing noise monitoring and alerting devices in each ward and nurse station to analyze noise data. The devices will trigger dynamic pattern alerts if noise levels exceed 60 dB during the day or 50 dB at night.③ Installing temperature and humidity sensors in five key areas of the ward to monitor conditions actively. The sensors will automatically record data and issue early warnings to prompt medical staff to take action. ④ Enhancing room door facilities by attaching light-reducing diaphragms to doors and window panes to minimize light intrusion into the wards at night. ⑤ Equipping departments with sleep-promoting kits that include eye masks, earplugs, anti-snoring clips, electric fans, mosquito repellents, and white noise and relaxation music playlists.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.2.2.3 Option 3: Development of a Healthcare Behavior Modification Checklist\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAddressing the issue of \u0026quot;low staff attention to patient sleep,\u0026quot; the primary improvement measures include:①Implementing the \u0026quot;Noon Quiet Bundle\u0026quot; management system during the 1-hour lunch break (12:30-13:30), which includes:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ea. Displaying a \u0026quot;nap time\u0026quot; reminder on corridor electronic screens and playing calming music;\u003cbr\u003e\u0026nbsp;b. Automatically closing corridor curtains and turning off corridor lights, leaving only the nurse\u0026apos;s work light;\u003cbr\u003e\u0026nbsp;c. Automaticallylowering the volume of all call bells, phones, and PDAs to below 40 dB;\u003cbr\u003e\u0026nbsp;d. Adjusting non-urgent treatments and educating patients\u0026rsquo; family members and staff to reduce noise levels;\u003cbr\u003e\u0026nbsp;e. Ensuring that team leaders monitor and maintain the quality of the lunch break environment.\u003c/p\u003e\n\u003cp\u003e② Implementing the \u0026quot;Night Sleep Protocol\u0026quot; from 21:00 to 05:00, which includes the same measures as the \u0026quot;Noon Quiet Bundle\u0026quot; management system, along with additional measures such as checking the room and standardizing the use of floor lamps, ceiling lamps, and bedside lamps in the wards; ③ Requiring nurses to communicate with doctors promptly regarding any unnecessary treatments during the night; ④ Educating medical staff on patient sleep management and creating a WeChat group for tracking and supervising behavior modification among nurses.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.2.2.4 Option 4: Enhancing Patient Sleep Awareness Through Education\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAddressing the issue of \u0026quot;low awareness of sleep among patients and families,\u0026quot; the primary measures include: (1) Developing a patient sleep management education brochure and an educational board, and instructing nurses to educate patients about sleep during their hospital admission, highlighting the importance of sleep management; (2) Incorporating patient sleep management information into the self-help information system for personalized notifications.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.2.3 Feasibility Verification\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn May 2023, a Preliminary experiment was conducted with five patients undergoing hepatobiliary surgery to evaluate the implementation of a specified protocol from the first day after admission through the fifth day postoperatively. Sleep data were collected on the first day after admission, one day before surgery, three days after surgery, and five days after surgery. The retrieval of sleep data was 100% accurate. The results indicated a 98% implementation rate for the sleep assessment and intervention process and a 95% implementation rate for the nurse\u0026rsquo;s behavior modification checklist, demonstrating the protocol\u0026rsquo;s feasibility.\u003c/p\u003e"},{"header":"2 Results","content":"\u003cp\u003eThe General Surgery Multi-Modal Sleep Management Program was continuously implemented from July to September 2023, during which sleep data were collected from 194 general surgery patients. Analysis revealed that the incidence of situational insomnia decreased from 66.4% to 35.5%. Noise monitoring showed a reduction in the average midday noise level from 65 dB to 51 dB and a decrease in the average evening noise level from 50 dB to 36 dB. Patient satisfaction with noise management increased from 62 to 86, while satisfaction with room temperature management rose from 79 to 95.\u003c/p\u003e"},{"header":"3 Experience","content":"\u003cp\u003e\u003cstrong\u003e3.1 Significance of Constructing a Multi-Modal Sleep Management Program for General Surgery Based on the Optimal Healing Environment Model\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEnhanced Recovery After Surgery (ERAS) represents a multi-modal perioperative care pathway designed to minimize surgical stress, expedite recovery, reduce complications, and shorten hospital stays for patients undergoing major surgery [1]. In April and May 2023, the General Office of the National Health Commission (NHC) in China issued directives, including the \"Notice of the General Office of the National Health Commission on Further Promoting the Work of Enhanced Recovery After Surgery (ERAS)\" [11] and the \"Notice on the Theme Activity of Improving the Feeling of Medical Treatment and Enhancing the Patient's Experience\" [12]. These directives mandate that hospitals, particularly tertiary hospitals, implement ERAS protocols.\u003c/p\u003e\n\u003cp\u003ePerioperative sleep management, a crucial component of ERAS, is frequently overlooked. Research indicates that the incidence of preoperative sleep disorders in China is as high as 60.6%, with the rate of poor sleep two weeks post-surgery rising to 72.5%, exceeding reported figures for Western patients [13-14]. Additional studies highlight a significant prevalence of situational insomnia among perioperative general surgery patients [4, 15]. Specifically, in hepatobiliary surgery patients, 73.00% experienced perioperative sleep durations of less than 7 hours, suggesting suboptimal perioperative sleep conditions [16].\u003c/p\u003e\n\u003cp\u003eSituational insomnia is influenced by various factors, including psychological, environmental, and biological sources [7]. Therefore, targeted sleep interventions for general surgery patients are essential. Some researchers in China have developed an orthopedic psychosleep management model based on ERAS, incorporating multidisciplinary teams and graded psychosleep intervention pathways, which have proven effective for perioperative orthopedic patients [2-3]. Other studies have implemented symptom, environmental, and psychological interventions based on comfort theory, effectively reducing sleep disorders [17-18].\u003c/p\u003e\n\u003cp\u003eThe optimal healing environment model emphasizes creating a low-stimulation, evidence-based environment, reflecting a human-centered approach similar to ERAS. This model focuses on enhancing patient experience and facilitating faster recovery. This study identified key factors affecting sleep among general surgery patients through a literature review and clinical research, leading to the development of a multi-modal sleep management program based on this model. The program achieved a situational insomnia incidence of 35.5%, which is lower than reported in similar studies. However, establishing a healing environment incurs high organizational management costs [19]. The optimal healing environment model provides a theoretical foundation for improving organizational management quality and achieving more comprehensive analysis and enhancement. Implementing smart ward construction projects or intelligent facilities offers nurses more convenient resources, does not increase the labor costs of medical staff, and ensures the continuous maintenance of the healing environment [20]. The graded sleep assessment and intervention procedures for general surgery, along with the \"Noon Quiet Bundle\" checklist, can enhance sleep awareness and improve sleep management among medical personnel. Literature recommendations highlight the clinical significance of quiet moments and sleep aids, such as eye masks, earplugs, stop-snoring clips, and white noise [21-24]. Surgical patients often experience heat and night sweats, making it necessary to provide small electric fans in the ward. In conclusion, the multi-modal sleep management program based on the optimal healing environment model offers valuable new perspectives, though further clinical validation is needed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2 Insights and Limitations of This Study\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eClinical practice has revealed that patients often lack knowledge about sleep and may mistakenly believe that insomnia does not require intervention or that sleep medications are addictive. Therefore, enhancing patient education on sleep is crucial. In this study, placing a sleep ruler in patient rooms, conducting daily sleep assessments, and installing noise warning devices improved awareness of sleep issues among patients and their families. However, the medical behavior modification checklist and the sleep assessment intervention process necessitate the establishment of a supervision mechanism to ensure ongoing implementation through continuous oversight [25]. Various methods, such as birthday wishes and encouragement cards, were employed to foster trust between doctors and patients and cultivate a healing relationship, representing a novel approach. Clinical practice results indicate that both patients and medical staff highly value these efforts; however, objective data to confirm their effectiveness remains limited. This study employed multiple measures comprehensively but could not individually confirm the clinical effectiveness of each measure in the general surgery ward. While existing evidence supports the clinical significance of these measures, further research is needed.\u003c/p\u003e\n\u003cp\u003eAdditionally, the study found that invalid alarm sounds from monitors at night significantly disrupt patient sleep, with no effective solutions provided. Future research should explore the use of advanced, non-inductive monitoring equipment and more precise monitoring methods to minimize unnecessary disturbances [26-27]. The study's reliance on patient questionnaires for sleep data collection may introduce potential data bias. Clinical applications of wearable devices for sleep monitoring, such as the Huawei watch used by the authors' organization, show promise. Further research is necessary to effectively utilize data from wearable devices for objective sleep assessment and the development of early warning functions.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Ethics Committee of Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University. Signed written informed consents were obtained from the patients and/or guardians. All methods were performed in accordance with the relevant guidelines and regulations.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data supporting the findings of this study are available within the paper and its Supplementary Information.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere is no conflict of interest to be declared by any author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by Zhejiang medicine and health science and technology project\u0026nbsp;No.2023KY798。\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e(I) Conception and design: H Xu; X Jiang;Y Xu;J Chen;L Cheng;Y Qian; (II) Administrative support: X Liang;H Pan;(III) Provision of study materials or patients: X Jiang;Y Xu; J Chen; Y Qian; (IV) Collection and assembly of data: L Cheng; X Jiang; (V) Data analysis and interpretation: H Xu, Y Xu; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSpecial thanks to all the patients involved in this study, the technical support experts for the project, and the ward nurses who assisted in recruiting subjects and advancing the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eChinese Society of Surgery, Chinese Society of Anesthesiology. 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DOI: 10.19538/j.cjps.issn1005-2208.2023.07.01.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"healing environment, sleep disorders, enhancedrecoveryaftersurgery, general surgery","lastPublishedDoi":"10.21203/rs.3.rs-5251547/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5251547/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThis study aimed to analyze the factors influencing situational insomnia among patients in general surgical wards through a combination of literature review, questionnaire surveys, and group discussions. Based on these identified factors and leveraging intelligent facilities, we developed a multi-modal sleep management program rooted in the optimal healing environment model. The program included standardizing sleep assessment and intervention processes, fostering a quiet and comfortable ward environment, implementing a medical and nursing behavior modification checklist, enhancing patient awareness of sleep, and cultivating a caring environment. Following the implementation of this program in general surgery wards, the incidence of situational insomnia decreased, noise levels during lunchtime and nighttime reduced, and patient satisfaction significantly improved. The application of a multi-modal sleep management program grounded in the optimal healing environment model can effectively improve sleep quality, expedite postoperative recovery, and enhance patient satisfaction in general surgery settings.\u003c/p\u003e","manuscriptTitle":"Development and application of a multi-modal sleep management program for general surgery based on the optimal healing environment model","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-20 10:31:41","doi":"10.21203/rs.3.rs-5251547/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-03-24T06:01:52+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-03-10T13:39:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"221894806123308684272803812993153337837","date":"2025-02-25T07:15:49+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-01-11T09:42:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"21474518724649041353623931805942270238","date":"2024-12-14T08:54:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"26053618863718463665216908913425859815","date":"2024-12-12T05:42:19+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-11-15T18:28:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-11-15T18:21:59+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-10-30T08:38:23+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-10-29T08:58:23+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2024-10-12T12:49:12+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f55563af-7b75-4b3d-9d2c-60cab767717a","owner":[],"postedDate":"November 20th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":39883906,"name":"Earth and environmental sciences/Environmental social sciences"},{"id":39883907,"name":"Health sciences/Medical research"}],"tags":[],"updatedAt":"2025-12-01T16:09:56+00:00","versionOfRecord":{"articleIdentity":"rs-5251547","link":"https://doi.org/10.1038/s41598-025-28981-9","journal":{"identity":"scientific-reports","isVorOnly":false,"title":"Scientific Reports"},"publishedOn":"2025-11-28 15:57:44","publishedOnDateReadable":"November 28th, 2025"},"versionCreatedAt":"2024-11-20 10:31:41","video":"","vorDoi":"10.1038/s41598-025-28981-9","vorDoiUrl":"https://doi.org/10.1038/s41598-025-28981-9","workflowStages":[]},"version":"v1","identity":"rs-5251547","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5251547","identity":"rs-5251547","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}