Providing Evidence-Based Care, Day and Night: A Quality Improvement Initiative to Improve Intensive Care Unit Patient Sleep Quality

Abstract

Objective: Evidence-based guidelines recommend promoting sleep in the Intensive Care Unit (ICU), yet many patients experience poor sleep quality. We sought to engage allied health staff and patient families to determine barriers to sleep promotion, to measure sleep quality for ICU patients, and to evaluate the improvement in sleep quality after implementation of nursing morning report protocol and a doorway poster. Design: The study followed an interrupted time-series framework of quality improvement. Qualitative diagnostics included focus groups and interviews with patients, families, and allied health care workers, analyzed by qualitative descriptive analysis. Quantitative diagnostics included direct observation of nurses and patients overnight. Analysis of primary outcome data used statistical process control methodology. Patients: Patients included were >18 years old, admitted overnight to a Canadian tertiary academic ICU, with a Richards Agitation Sedation Scale (RASS) ≥−2. Interventions: Sleep quality was measured using the Richards Campbell Sleep Questionnaire (RCSQ). Two interventions were developed: sleep quality in morning nursing report, and a doorway poster. Main results: A total of 2332 patient nights across 7 consecutive months were included for analysis. Baseline sleep in the ICU was poor (mean RCSQ 53.7/100). Root cause-analysis identified the most prominent sleep barriers as nurse stigma associated with less active management of patients and lack of physician engagement. No significant improvement occurred over the sleep quality improvement initiative (mean RCSQ 59.5/100). Sleep quality was better among non-delirious patients compared with delirious patients (mean RCSQ 62.7 vs 53.3). Conclusion: The intervention of a nursing morning report protocol and sleep posters did not improve the quality of ICU patient sleep in this study. Structured interviews revealed potential sleep barriers to be addressed such as nursing stigma and inappropriate awakenings. Nursing stigma has not been previously linked to sleep quality.

The Impact of a Pharmacist-Driven Multicomponent Sleep-Promoting Protocol on Delirium in Critically Ill Patients

“…Patients in the post-protocol group were more likely to receive MV compared to patients in the preprotocol group (55.7% vs 36.1%; P < .001). MV days were similar between the 2 groups (5 (3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15) pre-protocol vs 4 (3-9) post-protocol; P = .053).…”

“…4 Polysomnography demonstrates that critically ill adults experience increased sleep fragmentation and daytime sleep, decreased restorative sleep, frequent arousals and awakenings, and abnormal sleep architecture. 5 Common barriers to sleep in the ICU include frequent awakenings for procedures, vital sign checks, medication administration, mechanical ventilation (MV), inappropriate and artificial light, increased noise levels, anxiety, and pain. 1 Sleep-enhancing medications lack safety and efficacy data in the critically ill population and may increase the risk for polypharmacy and delirium rather than actually promote sleep.…”

Sedation, sleep-promotion, and non-verbal and verbal communication techniques in critically ill intubated or tracheostomized patients: results of a survey

“…In the tracheostomized subjects, melatonin and neuroleptic agents were preferred each in about 20% of patients. Other investigators have reported a very variable use of sleep medication in 13% to 58% of ICU-patients [ 12 , 22 , 39 ].…”