Increase patient safety by creating a quieter hospital environment

Individualized sleep promotion in acute care hospitals: managing specific factors that affect patient sleep

BACKGROUND

Improving sleep for hospitalized patients is an essential clinical need. Compared to the traditional "one-size-fits-all" interventions designed by clinicians for all patients, an individualized strategy engaging patients to identify salient sleep disruptors and seek their input how to address these disruptors are more likely to succeed. Followed by our work of developing the Factors Affecting Inpatient Sleep (FAIS) scale, in this report we developed a set of icons illustrating 14 common sleep disruptors on the FAIS scale, and proposed behavioral sleep promotion tips addressing each sleep disruptor. The set of icons and sleep promotion tips were built into the mobile health (mHealth) tool SLEEPKit, which was the start of our endeavor using mHealth technology to support individualized sleep promotion.

METHODS

A participatory iterative approach including feedbacks from patients, family members, and clinicians was used to develop and refine the icons and sleep promotion tips. Focus groups were used to inform the initial development and to brainstorm for the refinement of the icons. Individual interviews with patients and clinicians were conducted to validate each version of the icons using a standardized Content Validity Index (CVI) on a 4-point Likert scale, and offered comments and suggestions for improvement. Strategies of sleep promotion were first identified by the literature review, and then enriched by the summary of data from our previous work. Focus groups were conducted in order to learn empirically if the sleep promotion tips on the current version were acceptable to both patients and clinicians, and how they could be improved.

RESULTS

Six focus groups were conducted and achieved saturation in suggestions for improvement. A total of 5 patients and 3 family members who served on the Patient/ Family Advisory Council, and 42 nurses who served on the interdisciplinary professional practice committees participated in the focus groups. A total of 75 patients and 50 clinicians offered individual feedback and the CVI test for the icons. Successive two or four phases of iterative icon evaluation and refinement were carried out until the average CVI ratings for each icon achieved 3 and above. The sleep promotion tips were created to demonstrate a collaborative effort between patients and clinicians. To empower patients for bedside communication related to their sleep, examples of communication starters ("Try saying") were included in the tips for patients.

CONCLUSIONS

By using the participatory iterative approach, these icons for common sleep disturbing factors were understandable by both patients and clinicians, and the sleep promotion tips were perceived to be feasible and effective in the acute care hospital setting. This work moved the individualized sleep promotion forward, and supported the development of a novel mHealth tool for inpatient sleep promotion tailored to individual patient's needs.

Individualized sleep promotion in acute care hospitals: Identifying factors that affect patient sleep

BACKGROUND/AIM

One major challenge of inpatient sleep promotion is that there is no "one-size-fits-all" intervention as patients' sleep may be bothered by different factors. A tool evaluating factors that disturb patient sleep is greatly needed as a foundation for generating a personalized action plan to address the patient's specific need for sleep. Unfortunately such tools are currently unavailable in clinical practice. In this study we developed and psychometrically evaluated a brief assessment tool for sleep disruptors important for hospitalized patients, the Factors Affecting Inpatient Sleep (FAIS) scale.

METHODS

The FAIS items were developed by literature review and validated by content validity testing. A survey collected from 105 hospitalized patients was used to select the most significant sleep disruptors. Psychometric evaluation using survey data included item analysis, principal components analysis, and internal consistency reliability.

RESULTS

The final FAIS scale included 14 items in three subscales explaining 56.4% of the total variance: 1) emotional or physical impairment due to illness or hospitalization; 2) sleep disturbance due to discomfort or care plan schedule; 3) sleep interruption due to hospital environment or medical care. The Cronbach's alpha coefficient for the FAIS scale was 0.87, and the reliability of the subscales ranged from 0.72 to 0.81.

CONCLUSION

The FAIS is a brief tool assessing sleep disruptors important for patients, and is empirically grounded, judged to have content validity, and has demonstrated psychometric adequacy. The FAIS scale can be used to guide the development of an individualized patient-centered sleep promotion plan.

Benefits of quiet time interventions in the intensive care unit: a literature review

Sleep disturbance is a significant issue for patients in intensive care units (ICUs), which can affect their health and recovery from illness. Therefore, it is important to consider ways to address sleep disturbance in these settings. One strategy that has been suggested is the use of 'quiet time' interventions, which involve a defined period where there is a reduction in controllable light and sound, and where interruptions at the patient's bedside are minimised.

AIM

To determine the effectiveness of quiet time interventions in improving patients' sleep quality in ICUs; to investigate other potential clinical benefits of quiet time interventions; and to consider the effect of incorporating open visitation when implementing quiet time interventions.

METHOD

The author conducted a literature review of qualitative and quantitative studies that investigated the effects of quiet time interventions as a primary intervention in adult ICUs, with sleep quality as the outcome. Three databases were searched electronically for articles that met the inclusion criteria, and narrative synthesis was used to identify themes from these articles.

FINDINGS

A total of seven articles were included in this literature review. Overall, the evidence indicated that quiet time interventions can be effective in improving patients' sleep quality; however, the study findings were variable and inconsistent. Quiet time interventions also appeared to provide some physiological benefits for patients, as demonstrated by reductions in respiratory rates, the administration of sedatives and the incidence of delirium, suggesting that patients are experiencing restfulness. Additionally, nurses reported an increasingly satisfying workplace environment following quiet time interventions.

CONCLUSION

Quiet time interventions can improve patients' sleep quality and have positive physiological effects for patients, such as improved restfulness. Quiet time interventions may also promote a healthier workplace environment and increase patient and family satisfaction. Considering the potential benefits and lack of evidence of harm, the author recommends that quiet time interventions are implemented in ICUs as part of routine practice.

The nocturnal acoustical intensity of the intensive care environment: an observational study

BACKGROUND

The intensive care unit (ICU) environment exposes patients to noise levels that may result in substantial sleep disruption. There is a need to accurately describe the intensity pattern and source of noise in the ICU in order to develop effective sound abatement strategies. The objectives of this study were to determine nocturnal noise levels and their variability and the related sources of noise within an Australian tertiary ICU.

METHODS

An observational cross-sectional study was conducted in a 24-bed open-plan ICU. Sound levels were recorded overnight during three nights at 5-s epochs using Extech (SDL 600) sound monitors. Noise sources were concurrently logged by two research assistants.

RESULTS

The mean recorded ambient noise level in the ICU was 52.85 decibels (dB) (standard deviation (SD) 5.89), with a maximum noise recording at 98.3 dB (A). All recorded measurements exceeded the WHO recommendations. Noise variability per minute ranged from 9.9 to 44 dB (A), with peak noise levels >70 dB (A) occurring 10 times/hour (SD 11.4). Staff were identified as the most common source accounting for 35% of all noise. Mean noise levels in single-patient rooms compared with open-bed areas were 53.5 vs 53 dB (p = 0.37), respectively.

CONCLUSION

Mean noise levels exceeded those recommended by the WHO resulting in an acoustical intensity of 193 times greater than the recommended and demonstrated a high degree of unpredictable variability, with the primary noise sources coming from staff conversations. The lack of protective effects of single rooms and the contributing effects that staffs have on noise levels are important factors when considering sound abatement strategies.

Ambulatory Voice Biofeedback: Relative Frequency and Summary Feedback Effects on Performance and Retention of Reduced Vocal Intensity in the Daily Lives of Participants With Normal Voices

Purpose

Ambulatory voice biofeedback has the potential to significantly improve voice therapy effectiveness by targeting carryover of desired behaviors outside the therapy session (i.e., retention). This study applies motor learning concepts (reduced frequency and delayed, summary feedback) that demonstrate increased retention to ambulatory voice monitoring for training nurses to talk softer during work hours.

Method

Forty-eight nurses with normal voices wore the Voice Health Monitor (Mehta, Zañartu, Feng, Cheyne, & Hillman, 2012) for 6 days: 3 baseline days, 1 biofeedback day, 1 short-term retention day, and 1 long-term retention day. Participants were block-randomized into 3 different biofeedback groups: 100%, 25%, and Summary. Performance was measured in terms of compliance time below a participant-specific vocal intensity threshold.

Results

All participants exhibited a significant increase in compliance time (Cohen's d = 4.5) during biofeedback days compared with baseline days. The Summary feedback group exhibited statistically smaller performance reduction during both short-term (d = 1.14) and long-term (d = 1.04) retention days compared with the 100% feedback group.

Conclusions

These findings suggest that modifications in feedback frequency and timing affect retention of a modified vocal behavior in daily life. Future work calls for studying the potential beneficial impact of ambulatory voice biofeedback in participants with behaviorally based voice disorders.

The Effectiveness of Measures Aimed at Noise Reduction in an Intensive Care Unit

Noise is a significant problem for both hospitalized patients and health care workers. This study aimed to determine the effectiveness of noise reduction strategies in an intensive care unit. Noise was measured in two phases. In the first phase, the unit’s present level of noise was established over 3 weeks between January 1, 2012, and February 1, 2012. During the month following initial measurements, noise reduction interventions, including staff education and physical space arrangement, were initiated, and device alarms were checked. The second phase of measurement was conducted during another 3-week period (between June 1, 2012, and July 1, 2012). The noise levels before and after noise reduction interventions were calculated as 67.6 dB-A and 56 dB-A; the difference between the two levels was statistically significant ( p < .05). The interventions were effective in reducing noise in intensive care units; the interventions are relatively easy and low cost.

The influence of "quiet time" for patients in critical care

The primary aim was to examine the influence of "quiet time" in critical care. A dual-unit, nonrandomized, uncontrolled trial of a quiet time (QT) protocol was completed. A sample of adult patients from the Neurosciences Intensive Care Unit (NICU) and Cardiovascular Intensive Care Unit (CVICU) participated. Environmental stressors were reduced and patient rest promoted prior to QT. One hundred twenty-nine patients participated in 205 QTs. A one-way, repeated measure analysis of covariance (ANCOVA) was calculated comparing Richards-Campbell Sleep Questionnaire scores, pain and anxiety over three consecutive QTs. No significant statistical effect was found. However, patients rated sleep higher and anxiety levels decreased over consecutive QTs. Ninety-three percent of patients reported QT mattered to them. The combined efforts of nursing, medicine, and ancillary staff are necessary to foster periods of uninterrupted rest, thereby optimizing patient care. Further research is needed to determine if successive QTs positively influence patient outcomes.

Benefits of quiet time for neuro-intensive care patients

The primary mission of any intensive care unit (ICU) is to provide critically ill patients with high-quality care and an atmosphere in which to recuperate. However, all too often, the intensive environment, which is often busy, chaotic, and noisy, may contribute to just the opposite. Patients overstimulated with noise, lights, and other distractions often suffer from sleep deprivation. Research in medicine and nursing has shown that sleep deprivation can have detrimental effects on an ailing patient. Therefore, a quiet time program was developed in the neuro-ICU to reduce noise and light levels, with the ultimate goal to allow sleep. Quiet time, a period of reduced controllable noise and light, took place twice daily coinciding with circadian rhythms. The study included 50 neuro-ICU patients, 35 observed during day hours and 15 observed during night hours. Noise and light levels were measured at multiple locations before, during, and after quiet time hours. Patients' sleep behavior was recorded every half hour, beginning 1/2 hour before quiet time until 30 minutes after. Analysis of data, adjusted for multiple testing and repeated measures on patients, demonstrated significantly lower noise and light levels during day shift quiet time. In addition, patients were significantly more likely to be observed sleeping during day shift quiet time hours.