The Effect of a Quality Improvement Intervention on Perceived Sleep Quality and Cognition in a Medical ICU*

Abstract

Objective To determine if a quality improvement (QI) intervention improves sleep and delirium/cognition. Design Observational, pre-post design. Setting A tertiary academic hospital in the US. Patients 300 medical ICU (MICU) patients. Interventions This MICU-wide project involved a “usual care” baseline stage, followed by a QI stage incorporating multi-faceted sleep-promoting interventions implemented with the aid of daily reminder checklists for ICU staff. Measurements and Main Results Primary ICU outcomes were perceived sleep quality and noise ratings (measured on a 0-100 scale using the valid and reliable Richards-Campbell Sleep Questionnaire [RCSQ]) and delirium/coma-free days. Secondary outcomes included ICU and hospital length of stay and mortality. Post-ICU measures of cognition and perceived sleep quality were evaluated in an ICU patient subset. During the baseline and sleep QI stages there were 122 and 178 patients, respectively, with >1 night in the ICU, accounting for 634 and 826 patient-days. Within the groups, 78 (63.9%) and 83 (46.6%) patients received mechanical ventilation. Over the 826 patient-day QI period, checklist item completion rates ranged from 86-94%. In multivariable regression analysis of the QI vs. baseline stages, improvements in overall RCSQ sleep quality ratings did not reach statistical significance, but there were significant improvements in daily noise ratings (mean ± standard deviation: 65.9 ± 26.6 vs. 60.5 ± 26.3, P=0.001), incidence of delirium/coma (odds ratio: 0.46; 95% confidence interval, 0.23-0.89; P=0.02), and daily delirium/coma-free status (odds ratio: 1.64; 95% confidence interval, 1.04-2.58; P=0.03). Improvements in secondary ICU outcomes and post-ICU outcomes did not reach statistical significance. Conclusions An ICU-wide QI intervention to improve sleep and delirium is feasible and associated with significant improvements in perceived nighttime noise, incidence of delirium/coma, and daily delirium/coma-free status. Improvement in perceived sleep quality did not reach statistical significance.

Delirium in the Cardiac Intensive Care Unit

“…By enacting a series of nonpharmacologic interventions (closing doors, decreased alarm volumes, ear plugs, eye masks, and timed “lights off”) to improve sleep in the ICU, Patel et al were able to reduce the incidence of delirium compared with the nonintervention arm (33% versus 14%, P <0.001) 48. Similarly, in a quality improvement initiative, Kamder et al found that implementing a 3‐stage strategy to improve sleep decreased the incidence of delirium/coma (OR: 0.46; 95% CI, 0.23–0.89; P =0.02) 49. In this study, stage 1 focused on reducing sleep disruptions by minimizing overhead pages, turning off patient televisions, dimming hallway lights, and grouping care activities 49.…”

“…Stage 2 used nonpharmacological sleep aids such as earplugs, eye masks and soothing music for nondelirious patients. For patients unable to sleep despite the stages 1 and 2 interventions, pharmacological agents were initiated (stage 3) 49. Benzodiazepines, opiates, and diphenhydramine were avoided.…”

Cuidados multiprofissionais para pacientes em delirium em terapia intensiva: revisão integrativa

“…Kamdar BB, King LM, Collop NA, Sakamuri S, Colantuoni E, Neufeld KJ, et al (22) Observational study, pre-post. 2c…”

“…The guidelines for pain, agitation and delirium do not recommend the use of a pharmacological protocol for the treatment and prevention of delirium, since pharmacological evidences in reducing the incidence of this neurological disorder has not yet shown definitive results (1,14,(21)(22) .…”

“…All of them used haloperidol, three associated an atypical antipsychotic (olanzapine, risperidone or quetiapine) in the presence of elongated QT in the patients. Of these, only one study described the dose of haloperidol used: 0.5 to 1mg every 8 hours orally or parenterally (21) the others reported only the use of a "low dose" (1,(22)(23)(24) .…”