Sleep-Promotion Bundle Development, Implementation, and Evaluation in Critically Ill Adults: Roles for Pharmacists

Abstract

Objective: To review evidence for intensive care unit (ICU) sleep improvement bundle use, identify preferred sleep bundle components and implementation strategies, and highlight the role for pharmacists in developing and evaluating bundle efforts. Data Sources: Multiple databases were searched from January 1, 1990, to September 1, 2021, using the MeSH terms sleep, intensive care or critical care, protocol or bundle to identify comparative studies evaluating ICU sleep bundle implementation. Study Selection and Data Extraction: Study screening, data extraction, and risk-of-bias evaluation were conducted in tandem. The ICU quality improvement literature and Institute for Healthcare Improvement bundle improvement guidance were also reviewed to identify recommended strategies for successful sleep bundle use. Data Synthesis: Nine studies (3 randomized, 1 quasi-experimental, 5 before-and-after) were identified. Bundle elements varied and were primarily focused on nonpharmacological interventions designed to be performed during either the day or night; only 2 studies included a medication-based strategy. Five studies were associated with reduced delirium; 2 studies were associated with improved total sleep time and 2 with improved patient-perceived sleep. Pharmacists were involved directly in 4 studies. Relevance to Patient Care and Clinical Practice: Sleep improvement bundles are recommended for use in all critically ill adults; specific bundle elements and ICU team member roles should be individualized at the institution/ICU level. Pharmacists can help lead bundle development efforts and routinely deliver key elements. Conclusions: Pharmacists can play an important role in the development and implementation of ICU sleep bundles. Further research regarding the relative benefit of individual bundle elements on relevant patient outcomes is needed.

Nighttime medication administration and patient perception of sleep in the intensive care unit

“…The 2018 PADIS guidelines recommend the use of bundles with a focus on sleep promotion. Bundles have been shown to improve sleep and/or other patient outcomes by providing a framework for care measures 6,13,30,36,39,40 . A systematic review article by Louzon et al identified nine studies assessing sleep‐promotion bundles in the ICU 13 .…”

“…Risks for ICU delirium were either based on the patient's past medical history or exposures during the ICU stay. Data on potential confounders for delirium were also collected since there may be a bidirectional relationship between delirium and sleep disruption 13–16 …”

“…On a larger scale, such changes may manifest as respiratory drive abnormalities, blood pressure deviations, unnecessary inflammatory responses, insulin resistance, and decreased pain thresholds, all of which are detrimental to the critically ill patient 1,4,5,12 . Critically ill patients with sleep and circadian disruption may also be at an increased risk of developing delirium 13–16 . A diagnosis of delirium during hospitalization increases risk of cognitive impairment at 3‐ and 12‐months post‐discharge 17–20 .…”

Causes, Consequences, and Treatments of Sleep and Circadian Disruption in the ICU: An Official American Thoracic Society Research Statement

“…Numerous studies have explored interventions to control the environment, cluster bedside care delivery patterns, or combine elements of both ( 186 ). In fact, multicomponent sleep promotion bundles are guideline recommended for ICU patients ( 46 , 187 ). Environmental control interventions reduce disturbances including noise, light, and care interruptions ( 78 , 188 – 191 ); however, not all studies have been successful ( 192 , 193 ), and when reduced, sound levels continue to exceed recommendations ( 78 , 188 ).…”

Sleep in the intensive care unit

“…Given the multifactorial nature of sleep disruption in the ICU, there is increasing interest in developing multicomponent sleep improvement bundles [31,34 ▪ ,35]. By implementing a multifaceted sleep-promoting bundle for 300 general medical-surgical ICU patients, Kamdar et al [36] showed a reduction in delirium incidence in the postimplementation phase as compared to baseline.…”