Delirium in the ICU has been well studied and is associated with poor patient outcomes. Other studies have suggested that few patients in the ICU get adequate sleep for a variety of reasons. The link between lack of sleep and delirium, however, has not been evaluated in ICU patients. Additionally, most studies to improve sleep quality have been small or adopted a single-faceted approach.
Taking a Multifaceted Approach
For a study published in Critical Care Medicine, my colleagues and I implemented a multifaceted intervention to improve sleep quality—and therefore reduce delirium—in the medical ICU. Perceived sleep quality was assessed daily for every patient during a usual care stage and during three intervention stages:
Stage 1: Environmental interventions. At night, ICU staff was encouraged to turn off room and hallway lights, turn off televisions, minimize unnecessary alarms, pull curtains, close doors, and minimize unnecessary patient room visits. Overhead paging was virtually eliminated by encouraging clerks to deliver messages face-to-face. Daytime interventions to maintain circadian rhythms included raising blinds, encouraging patient mobilization, and minimizing caffeine in the late afternoon.
Stage 2: Non-pharmacologic interventions. Ear plugs, eye masks, and tranquil music were used to promote sleep but only in patients who willingly accepted these interventions.
Stage 3: Pharmacologic guideline. A guideline was developed and provided to physicians and nurses encouraging use of medications that could promote restorative sleep. The guideline also discouraged use of drugs that could impair restorative sleep and precipitate delirium.
Findings from our analysis showed that perceived sleep quality improved, but not to a statistically significant degree. However, the sleep-promoting interventions led to significant improvements in perceived nighttime noise, incidence of delirium/coma, and daily delirium/coma-free status. More research is needed to determine whether the sleep-promoting interventions were directly associated with the observed improvements; nevertheless, it is clear that sleep promotion on an ICU-wide level is feasible and may be beneficial. Most importantly, the interventions used in our study were well-accepted and easily adopted by ICU staff.
After pain and anxiety, poor sleep has been identified as one of the top complaints of patients who survive ICU stays. Any efforts by providers to assist with sleep can only improve patients’ overall experiences. An added benefit is that a good night’s rest helps patients feel more energetic, think clearer, and heal more quickly.
Readings & Resources (click to view)
Kamdar B, King L, Collop N, et al. The effect of a quality improvement intervention on perceived sleep quality and cognition in a medical ICU. Crit Care Med. 2012;41:800-809.
Kamdar B, Needham D, Collop N, et al. Sleep deprivation in critical illness: its role in physical and psychological recovery. J Intensive Care Med. 2012;27:97-111.
Desai S, Law T, Needham D, et al. Long-term complications of critical care. Crit Care Med. 2011;39:371-379.
Black M, Schorr C, Levy M, et al. Knowledge translation and the multifaceted intervention in the intensive care unit. Crit Care Med. 2012;40:1324-1328.