Nocturnal Care Interactions with Patients in Critical Care Units

Effects of dim light at night in C57BL/6 J mice on recovery after spinal cord injury

Spinal cord injury (SCI) can cause long-lasting locomotor deficits, pain, and mood disorders. Anatomical and functional outcomes are exacerbated by inflammation after SCI, which causes secondary damage. One promising target after SCI is manipulating the circadian system, which optimizes biology and behavior for time of day - including neuroimmune responses and mood-related behaviors. Circadian disruption after SCI is likely worsened by a disruptive hospital environment, which typically includes dim light-at-night (dLAN). Here, we hypothesized that mice subjected to SCI, then placed in dLAN, would exhibit worsened locomotor deficits, pain-like behavior, and anxiety-depressive-like symptoms compared to mice maintained in light days with dark nights (LD). C57BL/6 J mice received sham surgery or moderate T9 contusion SCI, then were placed permanently in LD or dLAN. dLAN after SCI did not worsen locomotor deficits; rather, SCI-dLAN mice showed slight improvement in open-field locomotion at the final timepoint. Although dLAN did not alter SCI-induced heat hyperalgesia, SCI-dLAN mice exhibited an increase in mechanical allodynia at 13 days post-SCI compared to SCI-LD mice. SCI-LD and SCI-dLAN mice had similar outcomes using sucrose preference (depressive-like) and open-field (anxiety-like) tests. At 21 dpo, SCI-dLAN mice had reduced preference for a novel juvenile compared to SCI-LD, implying that dLAN combined with SCI may worsen this mood-related behavior. Finally, lesion size was similar between SCI-LD and SCI-dLAN mice. Therefore, newly placing C57BL/6 J mice in dLAN after SCI had modest effects on locomotor, pain-like, and mood-related behaviors. Future studies should consider whether clinically-relevant circadian disruptors, alone or in combination, could be ameliorated to enhance outcomes after SCI.

Effects of dim light at night in C57BL/6J mice on recovery after spinal cord injury

Spinal cord injury (SCI) can cause long-lasting locomotor deficits, pain, and mood disorders. Anatomical and functional outcomes are exacerbated by inflammation after SCI, which causes secondary damage. One promising target after SCI is manipulating the circadian system, which optimizes biology and behavior for time of day - including neuroimmune responses and mood-related behaviors. Circadian disruption after SCI is likely worsened by a disruptive hospital environment, which typically includes dim light-at-night (dLAN). Here, we hypothesized that mice subjected to SCI, then placed in dLAN, would exhibit worsened locomotor deficits, pain-like behavior, and anxiety-depressive-like symptoms compared to mice maintained in light days with dark nights (LD). C57BL/6J mice received sham surgery or moderate T9 contusion SCI, then were placed permanently in LD or dLAN. dLAN after SCI did not worsen locomotor deficits; rather, SCI-dLAN mice showed slight improvement in open-field locomotion at the final timepoint. Although dLAN did not alter SCI-induced heat hyperalgesia, SCI-dLAN mice exhibited an increase in mechanical allodynia at 13 days post-SCI compared to SCI-LD mice. SCI-LD and SCI-dLAN mice had similar outcomes using sucrose preference (depressive-like) and open-field (anxiety-like) tests. At 21 dpo, SCI-dLAN mice had reduced preference for a novel juvenile compared to SCI-LD, implying that dLAN combined with SCI may worsen this mood-related behavior. Finally, lesion size was similar between SCI-LD and SCI-dLAN mice. Therefore, newly placing C57BL/6J mice in dLAN after SCI had modest effects on locomotor, pain-like, and mood-related behaviors. Future studies should consider whether clinically-relevant circadian disruptors, alone or in combination, could be ameliorated to enhance outcomes after SCI.

Evaluation of the sensory environment in a large tertiary ICU

BACKGROUND

ICU survival is improving. However, many patients leave ICU with ongoing cognitive, physical, and/or psychological impairments and reduced quality of life. Many of the reasons for these ongoing problems are unmodifiable; however, some are linked with the ICU environment. Suboptimal lighting and excessive noise contribute to a loss of circadian rhythms and sleep disruptions, leading to increased mortality and morbidity. Despite long-standing awareness of these problems, meaningful ICU redesign is yet to be realised, and the 'ideal' ICU design is likely to be unique to local context and patient cohorts. To inform the co-design of an improved ICU environment, this study completed a detailed evaluation of the ICU environment, focussing on acoustics, sound, and light.

METHODS

This was an observational study of the lighting and acoustic environment using sensors and formal evaluations. Selected bedspaces, chosen to represent different types of bedspaces in the ICU, were monitored during prolonged study periods. Data were analysed descriptively using Microsoft Excel.

RESULTS

Two of the three monitored bedspaces showed a limited difference in lighting levels across the day, with average daytime light intensity not exceeding 300 Lux. In bedspaces with a window, the spectral power distribution (but not intensity) of the light was similar to natural light when all ceiling lights were off. However, when the ceiling lights were on, the spectral power distribution was similar between bedspaces with and without windows. Average sound levels in the study bedspaces were 63.75, 56.80, and 59.71 dBA, with the single room being noisier than the two open-plan bedspaces. There were multiple occasions of peak sound levels > 80 dBA recorded, with the maximum sound level recorded being > 105 dBA. We recorded one new monitor or ventilator alarm commencing every 69 s in each bedspace, with only 5% of alarms actioned. Acoustic testing showed poor sound absorption and blocking.

CONCLUSIONS

This study corroborates other studies confirming that the lighting and acoustic environments in the study ICU were suboptimal, potentially contributing to adverse patient outcomes. This manuscript discusses potential solutions to identified problems. Future studies are required to evaluate whether an optimised ICU environment positively impacts patient outcomes.

Sleep during and following critical illness: A narrative review

Sleep is a complex process influenced by biological and environmental factors. Disturbances of sleep quantity and quality occur frequently in the critically ill and remain prevalent in survivors for at least 12 mo. Sleep disturbances are associated with adverse outcomes across multiple organ systems but are most strongly linked to delirium and cognitive impairment. This review will outline the predisposing and precipitating factors for sleep disturbance, categorised into patient, environmental and treatment-related factors. The objective and subjective methodologies used to quantify sleep during critical illness will be reviewed. While polysomnography remains the gold-standard, its use in the critical care setting still presents many barriers. Other methodologies are needed to better understand the pathophysiology, epidemiology and treatment of sleep disturbance in this population. Subjective outcome measures, including the Richards-Campbell Sleep Questionnaire, are still required for trials involving a greater number of patients and provide valuable insight into patients’ experiences of disturbed sleep. Finally, sleep optimisation strategies are reviewed, including intervention bundles, ambient noise and light reduction, quiet time, and the use of ear plugs and eye masks. While drugs to improve sleep are frequently prescribed to patients in the ICU, evidence supporting their effectiveness is lacking.

Sound and light levels in intensive care units in a large urban hospital in the United States

Intensive care units (ICUs) may disrupt sleep. Quantitative ICU studies of concurrent and continuous sound and light levels and timings remain sparse in part due to the lack of ICU equipment that monitors sound and light. Here, we describe sound and light levels across three adult ICUs in a large urban United States tertiary care hospital using a novel sensor. The novel sound and light sensor is composed of a Gravity Sound Level Meter for sound level measurements and an Adafruit TSL2561 digital luminosity sensor for light levels. Sound and light levels were continuously monitored in the room of 136 patients (mean age = 67.0 (8.7) years, 44.9% female) enrolled in the Investigation of Sleep in the Intensive Care Unit study (ICU-SLEEP; Clinicaltrials.gov: #NCT03355053), at the Massachusetts General Hospital. The hours of available sound and light data ranged from 24.0 to 72.2 hours. Average sound and light levels oscillated throughout the day and night. On average, the loudest hour was 17:00 and the quietest hour was 02:00. Average light levels were brightest at 09:00 and dimmest at 04:00. For all participants, average nightly sound levels exceeded the WHO guideline of < 35 decibels. Similarly, mean nightly light levels varied across participants (minimum: 1.00 lux, maximum: 577.05 lux). Sound and light events were more frequent between 08:00 and 20:00 than between 20:00 and 08:00 and were largely similar on weekdays and weekend days. Peaks in distinct alarm frequencies (Alarm 1) occurred at 01:00, 06:00, and at 20:00. Alarms at other frequencies (Alarm 2) were relatively consistent throughout the day and night, with a small peak at 20:00. In conclusion, we present a sound and light data collection method and results from a cohort of critically ill patients, demonstrating excess sound and light levels across multiple ICUs in a large tertiary care hospital in the United States. ClinicalTrials.gov, #NCT03355053. Registered 28 November 2017, https://clinicaltrials.gov/ct2/show/NCT03355053.

Improve sleep in critically ill patients: Study protocol for a randomized controlled trial for a multi-component intervention of environment control in the ICU

INTRODUCTION

In critically ill patients, sleep and circadian rhythms are greatly altered. These disturbances have been associated with adverse consequences, including increased mortality. Factors associated with the ICU environment, such as exposure to inadequate light and noise levels during the day and night or inflexible schedules of daily care activities, have been described as playing an essential role in sleep disturbances. The main objective of this study is to evaluate the impact of the use of a multifaceted environmental control intervention in the ICU on the quantity and quality of sleep, delirium, and post-intensive care neuropsychological impairment in critically ill patients.

METHODS

This is a prospective, parallel-group, randomized trial in 56 critically ill patients once they are starting to recover from their acute illness. Patients will be randomized to receive a multifaceted intervention of environmental control in the ICU (dynamic light therapy, auditory masking, and rationalization of ICU nocturnal patient care activities) or standard care. The protocol will be applied from enrollment until ICU discharge. Baseline parameters, light and noise levels, polysomnography and actigraphy, daily oscillation of plasma concentrations of Melatonin and Cortisol, and questionnaires for the qualitative evaluation of sleep, will be assessed during the study. In addition, all patients will undergo standardized follow-up before hospital discharge and at 6 months to evaluate neuropsychological impairment.

DISCUSSION

This study is the first randomized clinical trial in critically ill patients to evaluate the effect of a multicomponent, non-pharmacological environmental control intervention on sleep improvement in ICU patients. The results will provide data about the potential synergistic effects of a combined multi-component environmental intervention in ICU on outcomes in the ICU and long term, and the mechanism of action.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT. Registered on January 10, 2023. Last updated on 24 Jan 2023.

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

Background: Sleep and circadian disruption (SCD) is common and severe in the ICU. On the basis of rigorous evidence in non-ICU populations and emerging evidence in ICU populations, SCD is likely to have a profound negative impact on patient outcomes. Thus, it is urgent that we establish research priorities to advance understanding of ICU SCD. Methods: We convened a multidisciplinary group with relevant expertise to participate in an American Thoracic Society Workshop. Workshop objectives included identifying ICU SCD subtopics of interest, key knowledge gaps, and research priorities. Members attended remote sessions from March to November 2021. Recorded presentations were prepared and viewed by members before Workshop sessions. Workshop discussion focused on key gaps and related research priorities. The priorities listed herein were selected on the basis of rank as established by a series of anonymous surveys. Results: We identified the following research priorities: establish an ICU SCD definition, further develop rigorous and feasible ICU SCD measures, test associations between ICU SCD domains and outcomes, promote the inclusion of mechanistic and patient-centered outcomes within large clinical studies, leverage implementation science strategies to maximize intervention fidelity and sustainability, and collaborate among investigators to harmonize methods and promote multisite investigation. Conclusions: ICU SCD is a complex and compelling potential target for improving ICU outcomes. Given the influence on all other research priorities, further development of rigorous, feasible ICU SCD measurement is a key next step in advancing the field.

Evaluation of Medications Used for Hospitalized Patients With Sleep Disturbances: A Frequency Analysis and Literature Review

PURPOSE

Poor sleep during hospitalization is common and implicated in worse patient outcomes. Despite implementation of non-pharmacologic techniques, medications are still frequently required. The study objective is to assess the frequency of new medications administered for sleep in hospitalized patients and to review literature evaluating these drug therapies in the inpatient setting.

METHODS

This retrospective study included adult inpatients if they received a new medication for sleep during a 5-day period. Patients were excluded if the medication was continued from home or if sleep was not the documented indication. For the literature review, a MEDLINE search was conducted to identify studies pertaining to pharmacotherapy for sleep in hospitalized patients.

RESULTS

Of 1,968 patient-days reviewed, a medication for sleep was given for 166 patient-days (8.4%) in 78 patients. Melatonin was most commonly received (70.5%), followed by benzodiazepines (9.6%). A review of antihistamines, benzodiazepines, melatonin, quetiapine, trazodone, and Z-drugs (non-benzodiazepine hypnotics) was conducted and 23 studies were included.

CONCLUSIONS

Despite widespread use of pharmacotherapy for sleep, there is a paucity of data evaluating use in the inpatient setting. Although there is significant heterogeneity among studies, melatonin has the strongest evidence for use and is an attractive option given its lack of adverse reactions and drug interactions. Benzodiazepines and Z-drugs were also frequently utilized; however, their reduced clearance in the elderly and potential for compounded sedative effects should be weighed heavily against potential sleep benefits. Antipsychotic agents cannot be recommended for routine use due to limited data and the potential for significant adverse effects.

Optimizing Sleep and Circadian Health in the NeuroICU

Purpose of Review

This article introduces fundamental concepts in circadian biology and the neuroscience of sleep, reviews recent studies characterizing circadian rhythm and sleep disruption among critically ill patients and potentially links to functional outcomes, and draws upon existing literature to propose therapeutic strategies to mitigate those harms. Particular attention is given to patients with critical neurologic conditions and the unique environment of the neuro-intensive care unit.

Recent Findings

Circadian rhythm disruption is widespread among critically ill patients and sleep time is reduced and abnormally fragmented. There is a strong association between the degree of arousal suppression observed at the bedside and the extent of circadian disruption at the system (e.g., melatonin concentration rhythms) and cellular levels (e.g., core clock gene transcription rhythms). There is a paucity of electrographically normal sleep, and rest-activity rhythms are severely disturbed. Common care interventions such as neurochecks introduce unique disruptions in neurologic patients. There are no pharmacologic interventions proven to normalize circadian rhythms or restore physiologically normal sleep. Instead, interventions are focused on reducing pharmacologic and environmental factors that perpetuate disruption.

Summary

The intensive care environment introduces numerous potent disruptors to sleep and circadian rhythms. Direct neurologic injury and neuro-monitoring practices likely compound those factors to further derange circadian and sleep functions. In the absence of direct interventions to induce normalized rhythms and sleep, current therapy depends upon normalizing external stimuli.

Adding Insult to Injury: Sleep Deficiency in Hospitalized Patients

Sleep deficiency is a common problem in the hospital setting. Contributing factors include preexisting medical conditions, illness severity, the hospital environment, and treatment-related effects. Hospitalized patients are particularly vulnerable to the negative health effects of sleep deficiency that impact multiple organ systems. Objective sleep measurement is difficult to achieve in the hospital setting, posing a barrier to linking improvements in hospital outcomes with sleep promotion protocols. Key next steps in hospital sleep promotion include improvement in sleep measurement techniques and harmonization of study protocols and outcomes to strengthen existing evidence and facilitate data interpretation across studies.

Respective Impact of Day and Night Bed Baths on Critical Care Patients

BACKGROUND

Despite data supporting the reduction of interactions with patients during nighttime, bed bathing is sometimes performed within this period in sedated patients unable to manage their own hygiene care.

OBJECTIVES

To compare patient physiologic variables and adverse effect incidence between night and day bed baths.

METHODS

This was a single-center prospective observational study in a 12-bed intensive care unit during 2 months. Night period was defined to run from 10 pm to 6 am. Night bed baths were provided to sedated ventilated patients whatever their sedation, if their Richmond Agitation Sedation Scale score was -2 or deeper. Bed bath-induced changes in physiological variables, treatments, and related unscheduled events were registered during both night and day bed baths.

RESULTS

Twenty-one patients (aged 62.9 [52.5-73.2] years, 14 male patients) were included. We registered 97 night bed baths and 95 day bed baths. Heart rate increased only after day bed baths (85 beats/min [bpm] [69-97 bpm] vs 88 bpm [73-98 bpm], P = .02). Increase in Richmond Agitation Sedation Scale score occurred, respectively, during 13 (13.4%) and 8 (8.4%) night and day bed baths, without significant differences. Body temperature significantly decreased during both night and day bed baths (respectively, 37°C [36.6°C-37.4°C] vs 36.6°C [36.2°C-37.2°C], P < .0001; and 36.9°C [36.5°C-37.2°C] vs 36.7°C [36.2°C-37.2°C], P = .0006). Overall, unscheduled events, whether physiologic changes, pain, or calling a physician in rescue occurred in 97 procedures (50.5%), irrespective of their timing (night vs day, respectively 53% [54.6%] vs 44% [46.3%], P = .31).

DISCUSSION

Although unscheduled events occurred in half of bed baths, differences evidenced between nighttime and daytime bed baths were scarce. The appropriateness of nighttime bed bathing remains questionable.

Updated Perspectives on the Management of Sleep Disorders in the Intensive Care Unit

Sleep disorders and circadian dysrhythmias are extremely prevalent in critically ill patients. Impaired sleep has a variety of etiologies, exhibits a wide range of negative effects and, moreover, might deteriorate the patient's prognosis. Despite a number of scientific findings and increased awareness, the importance of sleep optimization is still lower on the list of priories in the intensive care unit (ICU). The techniques of measuring and the evaluation of sleep quantity and quality are a great challenge in the ICU setting. The subjective and objective tools of sleep validation continue to suffer from deficiencies. Treatment approaches to improve the critically ill patient's sleep have focused on non-pharmacologic and pharmacologic strategies with some promising results. But pharmacological interventions alone could not provide sufficient patient benefit. Being aware and knowing of sleep problems and the beneficial effect of the necessary therapies in ICU patients requires greater acceptance. The application of available methods and the development of new methods to prevent sleep disorders in the ICU offer the potential to improve the critically ill patient's outcome.

The Impact of Earplugs and Eye Masks on Sleep Quality in Surgical ICU Patients at Risk for Frequent Awakenings

OBJECTIVES

Sleep disturbances may contribute to the development of delirium, prolonged ICU stay, and increased mortality. There is conflicting data on the effectiveness of earplugs and eye masks for sleep promotion in the ICU. This study evaluates the impact of earplugs and eye masks on sleep quality in postoperative surgical ICU patients at risk for frequent awakenings.

DESIGN

Prospective randomized controlled trial.

SETTING

Surgical ICU within the University of Texas Southwestern Medical Center.

PATIENTS

Adult, female patients admitted to the surgical ICU requiring hourly postoperative assessments following breast free flap surgery between February 2018 and October 2019.

INTERVENTIONS

Patients were randomized into an intervention group or a control group. The intervention group received earplugs and eye masks in addition to standard postoperative care, whereas the control group received standard postoperative care.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was overall sleep quality assessed via the Richards-Campbell Sleep Questionnaire. Secondary outcomes of patient satisfaction and rates of ICU delirium were assessed with a modified version of the Family Satisfaction in the ICU survey and the Confusion Assessment Method for the ICU. After a planned interim analysis, the study was stopped early because prespecified criteria for significance were attained. Compared with the control group's average Richards-Campbell Sleep Questionnaire total score of 47.3 (95% CI, 40.8-53.8), the intervention group's average Richards-Campbell Sleep Questionnaire total score was significantly higher at 64.5 (95% CI, 58.3-70.7; p = 0.0007). There were no significant between-group differences for Confusion Assessment Method for the ICU scores or modified Family Satisfaction in the ICU survey scores.

CONCLUSIONS

These results suggest that earplugs and eye masks are effective in improving sleep quality in ICU patients undergoing frequent assessments. The results strengthen the evidence for nonpharmacologic sleep-promoting adjuncts in the ICU.

Impact of Sleep Deprivation in the Neurological Intensive Care Unit: A Narrative Review

Sleep is fundamental for everyday functioning, yet it is often negatively impacted in critically ill patients by the intensive care setting. With a focus on the neurological intensive care unit (NeuroICU), this narrative review summarizes methods of measuring sleep and addresses common causes of sleep disturbance in the hospital including environmental, pharmacological, and patient-related factors. The effects of sleep deprivation on the cardiovascular, pulmonary, immune, endocrine, and neuropsychological systems are discussed, with a focus on short-term deprivation in critically ill populations. Where evidence is lacking in the literature, long-term sleep deprivation studies and the effects of sleep deprivation in healthy individuals are also referenced. Lastly, strategies for the promotion of sleep in the NeuroICU are presented.

Sleep Deprivation in the Intensive Care Patient

TOPIC

Sleep deprivation in the intensive care unit setting.

CLINICAL RELEVANCE

The Society of Critical Care Medicine has identified sleep deprivation as a significant contributor to the development of delirium in adult patients in the intensive care unit. Thus, preventing and managing sleep deprivation is important in reducing the incidence of delirium in this patient population. A multifaceted and multidisciplinary approach to promoting sleep in the intensive care unit setting that includes sleep hygiene routines, nursing care plans, and appropriate medication regimens may improve patient outcomes, including reducing delirium.

PURPOSE OF ARTICLE

To review the current literature on sleep deprivation in the intensive care unit setting and present care guidelines in a concise format. This information may be helpful in the development of clinical tools and may guide future quality improvement projects aimed at reducing delirium through sleep promotion in critical care patients.

CONTENT COVERED

A review of current literature and national organization recommendations revealed consistent themes in addressing the problem of sleep deprivation in the intensive care unit. Modifiable and nonmodifiable risk factors included frequent care interactions, light, noise, medication effects, and preexisting sleep problems.

Circadian Hygiene in the ICU Environment (CHIE) study

Objective: To investigate the environment and care in the intensive care unit (ICU) and its relationship to patient circadian temperature disruption. Design: 30-day, prospective period prevalence study. Setting: 27-bed tertiary ICU. Participants: Patients expected to remain in the ICU for at least 24 hours. Main outcome measures: Temperature, relative humidity, light and sound intensity in the ICU; nursing interventions (using the Therapeutic Intervention Scoring System-28); and core body temperature of ICU patients. Results: Of 28 patients surveyed, 20 (71%) were mechanically ventilated. Median (interquartile range [IQR]) light intensity peaked at 07:00 at 165 (12-1218) lux with a trough at 23:00 of 15 (12-51) lux and was consistently < 100 lux between 21:00 and 06:00. Peak median (IQR) sound intensity was at 07:00 (62.55 [57.87-68.03] dB) while 58.84 (54.81-64.71) dB at 02:00. Ambient temperature and humidity varied with median (IQR) peaks of 23.11°C (22.74-23.31°C) at 16:00 and 44.07% (32.76-51.08%) at 11:00 and median troughs of 22.37°C (21.79-22.88°C) at 05:00 and 39.95% (31.53-47.95%) at 14:00, respectively. Disturbances to sleep during the night occurred due to care activities including linen changes (15 patients, 54%) and bathing (13, 46%). On the day before and the day of the study, 13 patients (47%) and 10 patients (36%), respectively, had a circadian rhythm on core body temperature without an association with illness severity, nursing intervention or environmental measures. Conclusions: The ICU has low light intensity with relative humidity and ambient temperature not aligned to normal human circadian timing. Noise levels are commonly equivalent to conversational speech while patient care procedures interrupt overnight sleep. The contribution of these factors to disrupted CBT rhythmicity is unclear.

Let Sleeping Patients Lie, avoiding unnecessary overnight vitals monitoring using a clinically based deep-learning model

Impaired sleep for hospital patients is an all too common reality. Sleep disruptions due to unnecessary overnight vital sign monitoring are associated with delirium, cognitive impairment, weakened immunity, hypertension, increased stress, and mortality. It is also one of the most common complaints of hospital patients while imposing additional burdens on healthcare providers. Previous efforts to forgo overnight vital sign measurements and improve patient sleep used providers’ subjective stability assessment or utilized an expanded, thus harder to retrieve, set of vitals and laboratory results to predict overnight clinical risk. Here, we present a model that incorporates past values of a small set of vital signs and predicts overnight stability for any given patient-night. Using data obtained from a multi-hospital health system between 2012 and 2019, a recurrent deep neural network was trained and evaluated using ~2.3 million admissions and 26 million vital sign assessments. The algorithm is agnostic to patient location, condition, and demographics, and relies only on sequences of five vital sign measurements, a calculated Modified Early Warning Score, and patient age. We achieved an area under the receiver operating characteristic curve of 0.966 (95% confidence interval [CI] 0.956–0.967) on the retrospective testing set, and 0.971 (95% CI 0.965–0.974) on the prospective set to predict overnight patient stability. The model enables safe avoidance of overnight monitoring for ~50% of patient-nights, while only misclassifying 2 out of 10,000 patient-nights as stable. Our approach is straightforward to deploy, only requires regularly obtained vital signs, and delivers easily actionable clinical predictions for a peaceful sleep in hospitals.

Sleep-disrupting effects of nocturnal nursing interventions in intensive care unit patients: A systematic review

Patients staying in the intensive care unit (ICU) require constant monitoring and numerous nursing interventions performed as needed, irrespective of daytime or night-time. The disturbing effect of nocturnal nursing interventions and their contribution to sleep disruptions are unclear. The review analysed nocturnal nursing interventions, and their character, frequency and effects on sleep quality. The databases CINAHL, PubMed and Scopus were searched to identify and subsequently evaluate 19 studies (1,531 patients) meeting the algorithm used. Although nocturnal nursing interventions provided to ICU patients were frequent and varied, they were responsible for only a minority of observed sleep disruptions. The most frequent nocturnal intervention was Vital signs monitoring (Nursing Interventions Classification, 6,680). Implementation of sleep protocols, of which an integral part is clustering and planning of nocturnal interventions, appears to be effective. The review suggests that nursing interventions are not the main cause of sleep disruptions in the ICU. In an effort to improve the quality of sleep in ICU patients, other factors causing disturbance need to be addressed as well. The current trend is more careful planning of nursing care, clustering of interventions and minimizing nocturnal disruptions to allow patients at least one uninterrupted sleep cycle (90 min).

Impact of a Sleep Enhancement Protocol on Nighttime Room Entries in an Inpatient Rehabilitation Facility

PURPOSE

This study examined whether a sleep enhancement protocol (SEP) could reduce nighttime room entries (NREs) for patients with orthopedic injury (OI) or acquired brain injury (ABI) in an inpatient rehabilitation facility.

DESIGN

A two-wave prospective study assessing standard of care (SOC) versus SEP.

METHODS

Sixty-five participants completed baseline and follow-up questionnaires and wore an actigraph for approximately 7 days. In the SEP, nighttime care was "bundled."

FINDINGS

In SOC, NREs were associated with less efficient sleep and greater daytime fatigue. Nighttime room entries were approximately 50% lower in the SEP than SOC. Participants in the OI SOC had more room entries than any other group. There were no significant changes in room entries in the ABI SEP group.

CONCLUSIONS

There was a relationship between NREs and sleep. The SEP was effective at reducing NREs for patients with OI, but not ABI.

CLINICAL RELEVANCE

Sleep enhancement protocols in inpatient rehabilitation facilities may be effective at improving sleep. Future research may focus on developing individualized protocols to improve sleep across patients with a variety of presenting diagnoses.

Circadian Disruption in Critical Illness

Circadian rhythms play a vital role in metabolic, hormonal, and immunologic function and are often disrupted in patients in the ICU. Circadian rhythms modulate the molecular machinery that responds to injury and illness which can impact recovery. Potential factors contributing to the alteration in circadian rhythmicity in intensive care unit (ICU) patients include abnormal lighting, noise, altered feeding schedules, extensive patient care interactions and medications. These alterations in circadian rhythms in ICU patients may affect outcomes and therefore, normalization of circadian rhythmicity in critically ill patients may be an important part of ICU care.

The effects of noise levels on pain, anxiety, and sleep in patients

BACKGROUND

Intensive care is a noisy environment for patients and one that affects pain, anxiety levels, and sleep quality.

AIMS AND OBJECTIVES

To determine the relationship between noise levels and pain, anxiety, and sleep levels in patients in intensive care units.

DESIGN

A descriptive and observational study design was used.

METHODS

This study was conducted between June and December 2018 in a public hospital and included 111 patients admitted to surgical critical care for at least 24 hours. Three Benetech Gm1351 manual sound level metres were used to measure noise. A Patient Information Form, a pain Visual Analog Scale (VAS), the Spielberger State-Trait Anxiety Inventory, and the Richards Campbell Sleep Questionnaire (RCSQ) were used for data collection.

RESULTS

The mean age of the patients was 57.29 years. The mean noise level detected in the intensive care unit was 66.52 dB (dB). Patients' mean pain VAS score was 3.79 ± 1.72, the mean State Anxiety Inventory score was 39.74 ± 2.98, and the mean total RCSQ score was 25.10 ± 13.17. Our findings show that patients in the intensive care unit are exposed to high noise levels and that, while this has no effect on pain, it significantly impacts anxiety and quality of sleep.

CONCLUSIONS

Noise levels in intensive care units significantly exceed recommended thresholds, and this adversely affects patients' anxiety levels and sleep quality. It is important for suitably restful conditions to be provided for patients, to be aware of the potential for anxiety, and for these factors to be borne in mind when planning nursing interventions.

RELEVANCE TO CLINICAL PRACTICE

Further studies on the effects of noise levels on pain, anxiety, and sleep levels in patients admitted to intensive care units are needed.

[Sleep in the intensive care unit]

Zahlreiche Patienten werden täglich auf Intensivstationen behandelt, häufig über einen längeren Zeitraum. Der Schlaf spielt eine nicht zu unterschätzende Rolle für diese Patienten. Schlafstörungen sind ein relevantes Problem für Intensivpatienten. Sie führen zu einer höheren Prävalenz eines Delirs bei diesen Patienten und somit zu einer längeren Verweildauer auf der Intensivstation und zu einer höheren Mortalität. Dieser Artikel versucht die Ursachen von Schlafstörungen in der Intensivmedizin und mögliche Strategien zur Vermeidung von Schlafstörungen aufzuzeigen.

Sleep and Delirium in Adults Who Are Critically Ill: A Contemporary Review

Sleep is important to health and well-being, and studies in healthy adults have demonstrated that sleep deprivation impacts respiratory, immune, and cognitive function. Historically, because of the nature of critical illness, sleep has not been considered a priority for patient care in the ICU. More recently, research has demonstrated that sleep is markedly abnormal in patients who are critically ill. In addition, there is often disruption of circadian rhythms. Delirium is a syndrome of acute alteration in mental status that occurs in the setting of contributing factors such as serious illness, medication, and drug or alcohol intoxication or withdrawal. Delirium is a frequent occurrence in critical illness, and research has demonstrated several adverse outcomes associated with delirium including persistent cognitive impairment and increased mortality. Sleep deprivation and delirium share many common symptoms. The similarity in symptoms between sleep disruption and delirium have prompted experts to draw links between the two and question both the relationship and its direction. In addition, the inclusion of sleep disturbance to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition in its constellation of symptoms used in diagnosing delirium has increased awareness of the link between sleep and delirium. This paper will review the literature on sleep in critical illness and the potential mechanisms and pathways that may connect sleep and delirium.

Pilot study: an intensive care unit sleep promotion protocol

Purpose

Disturbances, such as in-room activity and sound, are significant sources of sleep disruption among critically ill patients. These factors are potentially modifiable. We tested the impact of an intensive care unit (ICU) sleep promotion protocol on overnight in-room disturbance.

Methods

Our protocol restricted non-urgent bedside care from 00:00 to 03:59. Patients were assigned to usual care (n=30) or the sleep protocol (n=26). The primary outcomes were measures of in-room activity, sound and light. These three types of disturbance were compared between arms during a baseline time block (20:00–23:59) and a rest time block (00:00–03:59). We assessed the sleep protocol effect with generalised linear models.

Results

Usual care and sleep protocol patients had equivalent levels of in-room activity, sound and light during the baseline time block (20:00–23:59). In contrast, during the rest time block (00:00–03:59), the sleep protocol arm had 32% fewer room entries (rate ratio (RR) 0.68, p=0.001) and 9.1 fewer minutes of in-room activity (p=0.0002). Also, the length of time between room entrances increased from 26.4 to 45.8 min (p=0.0004). The sleep protocol arm also had lower sound during the rest time block. Mean A-weighted sound was 2.5 decibels lower (p=0.02), and there were 36% fewer peaks (RR 0.64, p=0.02). Light levels were highly variable and not changed by the sleep protocol.

Conclusions

Sleep promotion protocols can improve in-room activity and sound. This provides a better sleep opportunity and may, therefore, improve ICU sleep.

Trial registration number

1112009428

Analysis of patients' sleep disorder after total knee arthroplasty-A retrospective study

BACKGROUND

Sleep disorder after total knee arthroplasty (TKA) is complex as it greatly differs from patient to patient. Thus, it can be seen that we should further know the detail in sleep disorders following TKA to find well solutions to achieve satisfactory sleep and better recovery.

METHODS

Between October 2011 and January 2016, 965 patients accepted primary TKA. We reviewed each patient's data. Sleep disorder was evaluated via subjective instruments. The Sleep Questionnaire in the present study is a 12-item instrument that evaluates sleep in terms of three dimensions: sleep quality; disruptive factors; and specific forms. Patients were identified and confirmed as at least 1 kind of sleep disorders according to the Second Edition of the International Classification of Sleep Disorders (ICSD-2). And we compare the clinical characteristics and difference in postoperative recovery of different types of sleep disorders.

RESULTS

Sleep disturbances persisted approximately 2 months postoperatively. 75.9% patients was classified into primary insomnias, while 24.1% was secondary insomnias. There was the largest number of those who were adjustment sleep disorder. Pains, mental elements, and factors intrinsic to the patients were the most significant causes of insomnia of patients. There were significant differences in VAS pain score (P < 0.001*), active ROM (P < 0.001*) and LOS in hospital (P < 0.001*) among varied forms of insomnias.

CONCLUSIONS

Our data revealed that adjustment insomnia ranked first. Specifically, the factors affecting sleep quality postoperatively included pains, mental elements, and factors intrinsic to the patients etc. In addition, we found that patients with difficulty in staying asleep and non-restorative sleep has increased pain scores and LOS in hospital with decreased active ROM in comparison to difficulty in falling asleep and too early awakening. Our data may be of a certain benefit to rational use of medication to improve diverse insomnias and to make patients recover better.

Evaluating Sleep in a Surgical Trauma Burn Intensive Care Unit: An Elusive Dilemma

BACKGROUND

Evidence points to the adverse effects of sleep deprivation on a person's health. Despite decades of attention to the issue, patients, particularly those in the intensive care unit (ICU), continue to suffer.

OBJECTIVE

The purpose of this pilot study was to examine patients' perceptions of their sleep experience in the surgical trauma burn ICU and identify contributing factors.

METHODOLOGY

Patients were administered the 6-question Richards-Campbell Sleep Questionnaire (RCSQ) consisting of a 0- to 100-mm scale, with a low score indicating poor sleep quality. They were also asked an additional open-ended question.

RESULTS

Sixty patients participated. Data revealed a low overall RCSQ score of 43.6 of 100. Of the 5 validated questions on the RCSQ, the question with the lowest mean (35.6) targeted depth of sleep. The question pertaining to falling asleep immediately scored the highest at 52.2. The open-ended question revealed that 37% reported "interruptions" as the reason for not sleeping. Pain was also cited as a factor by 30%, with 11.7% citing discomfort from the bed as an irritant. An additional 21.6% reported noise as the central reason, with "pumps/monitor" noise as the most frequent culprit at 62%.

DISCUSSION

The pilot study results demonstrate that most participants perceived their sleep as poor in quality. These results direct targeted interventions that can be incorporated to reduce sleep deprivation in ICUs.

Sleep Deprivation in Intensive Care Unit - Systematic Review

Background

Sleep disturbances in intensive care unit (ICU) patients have been studied worldwide for over 30 years. Factors contributing to sleep disturbances are still being identified, and therapeutic procedures aimed at the mitigation of such ailments are consequently being developed.

Objectives

The aim of this study was to review the literature on sleep disturbances in intensive care unit patients.

Material and Methods

MEDLINE PubMed, OVID, Web of Science, and EBSCO databases have been searched using adequate keywords.

Results

Sleep disorders in ICUs were common among all of the analysed articles. Noise plays a significant role in sleep interruption (11.5 - 17% of awakenings). It was noted that the introduction of "white noise" into the ICU environment proved unsuccessful in reducing the magnitude of changing noise levels. Nursing care activities significantly disturb nocturnal rest, and 42.7 such procedures per every 12-hour night shift were registered. Aggregating nursing care interventions was suggested in order to reduce the number of stimuli experienced by the patient.

Conclusion

Changes in sleep structure developing during an ICU stay may significantly contribute to sleep disorders once the hospitalisation is over.

Non-circadian signals in the intensive care unit: Point prevalence morning, noon and night

BACKGROUND

Intensive care unit (ICU) sleep disturbance is severe and potentially related to abnormal light and sound exposure.

OBJECTIVES

To assess the prevalence of measures of light and sound disturbance in ICU patient rooms, and whether these could be modified by a sleep-promotion intervention.

METHODS

This observational study with a before and after design for a quality improvement initiative surveyed environmental factors in ICU rooms at 01:00 08:00, and 12:00. Surveys assessed light usage, television usage, window shade position, and room door/curtain position. Factors were compared before and after an ICU sleep-promotion intervention.

RESULTS

990 (pre-intervention) and 819 (post-intervention) occupied rooms were surveyed. Pre-intervention, the prevalence of night-time factors included: bright lights on (21%), television on (46%), and room door open (94%). Post-intervention, more rooms had all lights off at night (41% v 50%, p = 0.04), and fewer rooms had open door curtains (57% v 42%, p = 0.001) and window shades (78% v 62%, p = 0.002).

CONCLUSIONS

Disruptive environmental factors are common in the ICU. Some factors improve with sleep-promotion interventions.

"They can rest at home": an observational study of patients' quality of sleep in an Australian hospital

Background

Poor sleep is known to adversely affect hospital patients’ recovery and rehabilitation. The aim of the study was to investigate the perceived duration and quality of patient sleep and identify any environmental factors associated with patient-reported poor sleep in hospital.

Method

A cross-sectional study was conducted involving 15 clinical units within a 672-bed tertiary-referral hospital in Australia. Semi-structured interviews to determine perceptions of sleep quantity and quality and factors that disturb nocturnal sleep were conducted with patients and nursing staff. Environmental noise, light and temperature were monitored overnight, with concurrent logging of noise sources by observers.

Results

Patients reported a mean reduction in hospital sleep duration, compared to home, of 1.8 h (5.3 vs. 7.1 h; p < 0.001). The proportions of patients reporting their sleep quality to be poor/very poor, fair and of good quality were 41.6, 34.2 and 24.2% respectively. Patients reported poorer sleep quality than nurses (p < 0.05). Patients, nurses and observers all reported the main factors associated with poor sleep as clinical care interventions (34.3%) and environmental noise (32.1%). Noise levels in all 15 clinical areas exceeded WHO recommended levels of < 30 dB [A] by 36.7 to 82.6%, with peak noise levels of 51.3 to 103.3 dB (A).

Conclusion

Hospital in-patients are exposed to factors which reduce the duration and quality of their sleep. These extrinsic factors are potentially modifiable through behaviour change and reconfiguration of the clinical environment. The findings from this study provided the foundation for a quality improvement project currently underway to improve patients’ sleep.

Quality of Sleep Among Intensive Care Unit Patients: A Literature Review

Investigating sleep disturbances among intensive care unit (ICU) patients and its serious consequences is considered a crucial issue for nurses. The need of sleep increases during hospitalization time to preserve energy for the healing process. Previous studies have demonstrated that sleep disturbance is one of the most common complaints of patients in the ICUs, with a prevalence of more than 50%. Although the total sleep time might be normal, the patients' sleep is fragmented and light in the intensive care settings. The main purpose of this review is to generate a clear view of what is known about sleep disturbances among ICU patients as well as to identify the gap in knowledge regarding this issue. This was done by describing, summarizing, clarifying, and evaluating well-selected previous studies about this topic. In addition, this concise review has focused on the prevalence of sleep disturbances in the ICU, factors contributing to poor quality of sleep among ICU patients, and the physiological effects of poor sleep on the patients' prognosis.

Sleep in the Intensive Care Unit in a Model of Family-Centered Care

The desire for families to be physically present to support their loved ones in the intensive care unit, and guidelines in favor of this open visitation approach, require that clinicians consider both patient and family sleep. This article reviews the causes of poor sleep for patients and their family members in the intensive care unit as well as the expected changes in cognition and emotion that can result from sleep deprivation. Measures are proposed to improve the intensive care unit environment to promote family sleep. A framework to educate family members and engage them in preservation of their and their loved one's circadian rhythm is also presented. Although further research is needed, the proposed framework has the potential to improve outcomes for patients and their families in the intensive care unit.

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.

Night-time care routine interaction and sleep disruption in adult cardiac surgery

AIMS AND OBJECTIVES

To explore the context and the influence of night-time care routine interactions (NCRIs) on night-time sleep effectiveness (NSE) and daytime sleepiness (DSS) of patients in the cardiac surgery critical-care and progressive-care units of a hospital.

BACKGROUND

There exists a paucity of empirical data regarding the influence of NCRIs on sleep and associated outcomes in hospitalised adult cardiac surgery patients.

METHODS

An exploratory repeated-measures research design was employed on the data provided by 38 elective cardiac surgery patients (mean age 60.0 ± 15.9 years). NCRI forms were completed by the bedside nurses and patients completed a 9-item Visual Analogue Sleep Scale (100-mm horizontal lines measuring NSE and DSS variables). All data were collected during postoperative nights/days (PON/POD) 1 through 5 and analysed with IBM SPSS software.

RESULTS

Patient assessment, medication administration and laboratory/diagnostic procedures were the top three NCRIs reported between midnight and 6:00 a.m. During PON/POD 1 through 5, the respective mean NSE and DSS scores ranged from 52.9 ± 17.2 to 57.8 ± 13.5 and from 27.0 ± 22.6 to 45.6 ± 16.5. Repeated-measures ANOVA showed significant changes in DSS scores (p < .05). NSE and DSS were negatively correlated (r = -.44, p < .05), but changes in NSE scores were not significant (p > .05). Finally, of 8 NCRIs, only 1 (postoperative exercises) was significantly related to sleep variables (r > .40, p < .05).

CONCLUSION AND RELEVANCE TO CLINICAL PRACTICE

Frequent NCRIs are a common occurrence in cardiac surgery units of a hospital. Further research is needed to make a definitive conclusion about the impact of NCRIs on sleep/sleep disruptions and daytime sleepiness in adult cardiac surgery. Worldwide, acute and critical-care nurses are well positioned to lead initiatives aimed at improving sleep and clinical outcomes in cardiac surgery.

Creating Naptime: An Overnight, Nonpharmacologic Intensive Care Unit Sleep Promotion Protocol

Introduction:

Patients in the intensive care unit (ICU) have significantly disrupted sleep. Sleep disruption is believed to contribute to ICU delirium, and ICU delirium is associated with increased mortality. Experts recommend sleep promotion as a means of preventing or shortening the duration of delirium. ICU Sleep promotion protocols are highly complex and difficult to implement. Our objective is to describe the development, pilot implementation, and revision of a medical ICU sleep promotion protocol.

Methods:

Naptime is a clustered-care intervention that provides a rest period between 00:00 and 04:00. We used literature review, medical chart review, and stakeholder interviews to identify sources of overnight patient disturbance. With stakeholder input, we developed an initial protocol that we piloted on a small scale. Then, using protocol monitoring and stakeholder feedback, we revised Naptime and adapted it for unitwide implementation.

Results:

We identified sound, patient care, and patient anxiety as important sources of overnight disturbance. The pilot protocol altered the timing of routine care with a focus on medications and laboratory draws. During the pilot, there were frequent protocol violations for laboratory draws and for urgent care. Stakeholder feedback supported revision of the protocol with a focus on providing 60- to 120-minute rest periods interrupted by brief clusters of care between 00:00 and 04:00.

Discussion:

Four-hour blocks of rest may not be possible for all medical ICU patients, but interruptions can be minimized to a significant degree. Involvement of all stakeholders and frequent protocol reevaluation are needed for successful adoption of an overnight rest period.

Perceptions and Practices Regarding Sleep in the Intensive Care Unit. A Survey of 1,223 Critical Care Providers

RATIONALE

Poor sleep affects a majority of critically ill patients and is believed to be associated with adverse intensive care unit (ICU) outcomes such as delirium. While recent guidelines recommend sleep promotion efforts to improve delirium and other ICU outcomes, little is known about critical care providers' beliefs regarding sleep in the ICU.

OBJECTIVES

To evaluate providers' perceptions and practices regarding sleep in the ICU.

METHODS

From April to July 2014, the Sleep in the ICU Survey was disseminated to ICU providers via institutional e-mail lists and four international critical care society distribution lists.

MEASUREMENTS AND MAIN RESULTS

A total of 1,223 surveys were completed by providers from 24 countries. Respondents were primarily nurses (59%) or physicians (39%). Most respondents indicated that ICU patients experienced "poor" or "very poor" sleep (75%) and that poor sleep could affect the ICU recovery process (88%). Respondents also felt that poor sleep was associated with negative ICU outcomes such as the development of delirium (97%), longer length of stay (88%), poor participation in physical therapy (87%), and delayed liberation from mechanical ventilation (83%). The minority (32%) of providers had sleep-promoting protocols; these providers tended to believe their patients slept longer and experienced better sleep quality.

CONCLUSIONS

Though most clinicians believe that sleep in the ICU is poor and adversely affects patient outcomes, a minority of the ICUs represented by our respondents have sleep promotion protocols. These findings highlight discordant provider perceptions and practices surrounding sleep in the ICU, as well as a possible lack of available evidence-based guidelines for promoting sleep in the ICU.

Reducing sound and light exposure to improve sleep on the adult intensive care unit: An inclusive narrative review

Purpose

Sleep disturbance is common in intensive care units. It is associated with detrimental psychological impacts and has potential to worsen outcome. Irregular exposure to sound and light may disrupt circadian rhythm and cause frequent arousals from sleep. We sought to review the efficacy of environmental interventions to reduce sound and light exposure with the aim of improving patient sleep on adult intensive care units.

Methods

We searched both PubMed (1966-30 May 2017) and Embase (1974-30 May 2017) for all relevant human (adult) studies and meta-analyses published in English using search terms ((intensive care OR critical care), AND (sleep OR sleep disorders), AND (light OR noise OR sound)). Bibliographies were explored. Articles were included if reporting change in patient sleep in response to an intervention to reduce disruptive intensive care unit sound /light exposure.

Results

Fifteen studies were identified. Nine assessed mechanical interventions, four of which used polysomnography to assess sleep. Five studies looked at environmental measures to facilitate sleep and a further two (one already included as assessing a mechanical intervention) studied the use of sound to promote sleep. Most studies found a positive impact of the intervention on sleep. However, few studies used objective sleep assessments, sample sizes were small, methodologies sometimes imperfect and analysis limited. Data are substantially derived from specialist (neurosurgical, post-operative, cardiothoracic and cardiological) centres. Patients were often at the 'less sick' end of the spectrum in a variety of settings (open ward beds or side rooms).

Conclusions

Simple measures to reduce intensive care unit patient sound/light exposure appear effective. However, larger and more inclusive high-quality studies are required in order to identify the measures most effective in different patient groups and any impacts on outcome.

Sleep in Hospitalized Older Adults

Hospitalization is a period of acute sleep deprivation for older adults owing to environmental, medical, and patient factors. Although hospitalized patients are in need of adequate rest and recovery during acute illness, older patients face unique risks owing to acute sleep loss during hospitalization. Sleep loss in the hospital is associated with worse health outcomes, including cardiometabolic derangements and an increased risk of delirium. Because older patients are at risk of polypharmacy and medication side effects, a variety of nonpharmacologic interventions are recommended first to improve sleep loss for hospitalized older adults.

Enhancing Hospital Well-being and Minimizing Intensive Care Unit Trauma: Cushioning Effects of Psychosocial Care

CONTEXT

Hospitalization has the potential to induce hospital anxiety, while admission in the Intensive Care Unit (ICU) is found to surpass the anxiety and result in what is termed as "ICU Trauma."

AIMS

This study aimed to determine the impact of psychosocial care and quality of ICU on ICU trauma and hospital well-being in patients who underwent coronary artery bypass grafting (CABG).

SETTINGS AND DESIGN

This correlational study involved 250 CABG patients, who were recruited from five major corporate hospitals.

PARTICIPANTS AND METHODS

The ICU Psychosocial Care Scale, Hospital Wellbeing Scale, and ICU Trauma Scale were used. Each of the participants was assessed individually. The ICU Practices Checklist was used to assess the environment of the ICU in the hospital.

STATISTICAL ANALYSIS USED

Descriptive statistics, correlation, and simple and multiple linear regression analyses were done.

RESULTS

The results revealed the significant contribution of psychosocial care in ICU in enhancing hospital well-being as well as minimizing ICU trauma of patients who underwent CABG. The results of multiple regressions clearly indicated that psychosocial care was a powerful predictor of hospital well-being and ICU trauma.

CONCLUSIONS

Although psychosocial care was not a component of hospital well-being and had a negative correlation with ICU trauma, it contributed significantly with a cushioning effect to minimize trauma and helped enhance the feelings and experiences of well-being among patients in ICU.

The influence of care interventions on the continuity of sleep of intensive care unit patients

Objective:

to identify care interventions, performed by the health team, and their influence on the continuity of sleep of patients hospitalized in the Intensive Care Unit.

Method:

descriptive study with a sample of 12 patients. A filming technique was used for the data collection. The awakenings from sleep were measured using the actigraphy method. The analysis of the data was descriptive, processed using the Statistical Package for the Social Sciences software.

Results:

529 care interventions were identified, grouped into 28 different types, of which 12 (42.8%) caused awakening from sleep for the patients. A mean of 44.1 interventions/patient/day was observed, with 1.8 interventions/patient/hour. The administration of oral medicine and food were the interventions that caused higher frequencies of awakenings in the patients.

Conclusion:

it was identified that the health care interventions can harm the sleep of ICU patients. It is recommended that health professionals rethink the planning of interventions according to the individual demand of the patients, with the diversification of schedules and introduction of new practices to improve the quality of sleep of Intensive Care Unit patients.

Factors Influencing Patients' Sleep in the Intensive Care Unit: Perceptions of Patients and Clinical Staff

BACKGROUND

Multiple factors are believed to contribute to disruption of patients' sleep and negatively affect clinical outcomes in the intensive care unit. Achieving restorative sleep for critically ill patients remains a challenge.

OBJECTIVES

To explore the perceptions and beliefs of staff, patients, and surrogates regarding the environmental and nonenvironmental factors in the medical intensive care unit that affect patients' sleep.

METHODS

This qualitative study included 24 medical intensive care unit staff (7 physicians, 5 respiratory therapists, 10 nurses, and 2 patient-care assistants), 8 patients, and 6 patient surrogates. Semistructured interviews were conducted, and qualitative analysis of content was used to code, categorize, and identify interview themes.

RESULTS

Interview responses revealed 4 themes with related subthemes: (1) The overnight medical intensive care unit environment does affect sleep, (2) nonenvironmental factors such as difficult emotions and anxiety also affect sleep, (3) respondents' perceptions about sleep quality in the medical intensive care unit were highly variable, and (4) suggestions for sleep improvement included reassuring patients and care-clustering strategies.

CONCLUSIONS

Results of this study suggest that environment is not the only factor influencing patients' sleep. Decreases in environmental sources of disturbance are necessary but not sufficient for sleep improvement. Guideline-recommended clustered care is needed to provide adequate sleep opportunity, but patients' emotions and anxiety also must be addressed.

Nursing Interactions With Intensive Care Unit Patients Affected by Sleep Deprivation: An Observational Study

BACKGROUND

Patients in intensive care units (ICUs) often experience sleep deprivation due to different factors. Its consequences are damaging both physiologically and psychologically. This study focuses particularly on nursing interactions as the main factor involved in sleep deprivation issues.

OBJECTIVES

The aims of this study were to examine the frequency, pattern, and types of nocturnal care interactions with patients in the respiratory and cardiology ICUs; analyze the relationship between these interactions and patients' variables (age, sex, recovery diagnosis, and acuity of care); and analyze the differences in patterns of nocturnal care interactions among the units.

METHODS

This is an observational retrospective study that analyzes the frequency, pattern, and types of nocturnal care interactions with patients between 7 PM and 6 AM recording data in the activity data sheets.

RESULTS

Data consisted of 93 data assessment sheets. The mean number of care interactions per night was 18.65 (SD, 3.71). In both ICUs, interactions were most frequent at 7 PM, 10 PM, and 6 AM. Only 8 uninterrupted sleep periods occurred. Frequency of interactions correlated significantly with patients' acuity scores and the number of nurse interventions in both ICUs.

CONCLUSIONS

Patients in ICUs have fragmented sleep patterns. This study underlines the need to develop new management approaches to promote and maintain sleep.

Effect of White Noise on Sleep in Patients Admitted to a Coronary Care

Introduction: Sleep disorders are a common problem in patients in the critical care unit. The objective of the present study was to determine the effect of white noise on the quality of sleep in patients admitted to the CCU.

Methods: The present study was single-blind, quasi-experimental study. A total of 60 patients were selected using the purposive sampling method. Quality of sleep was measured with PSQI on the first day in admission, then after three nights of admission without any intervention for control group and for the experimental group quality of sleep measured by white noise with intensity of 50-60 dB then Quality of sleep was measured with PSQI. Data were analyzed by SPSS 13 software.

Results: The average total sleep time in the control group before the study reached from 7.08 (0.8) to 4.75 (0.66) hours after three nights of hospitalization, while in the experimental group, no significant changes were seen in the average sleep hours (6.69 ± 0.84 vs. 6.92 ± 0.89, P = 0.15).The average minutes of sleep in the control group before the study reached from 12.66 (7.51) to 25.83 (11.75) minutes after a three- night stay, while in the experimental group, no significant changes were observed in the average sleep duration (12.16 ± 7.50 vs. 11 ±6. 07, P = 0.16).

Conclusion: The use of white noise is recommended as a method for masking environmental noises, improving sleep, and maintaining sleep in the coronary care unit.

The effect of nocturnal patient care interventions on patient sleep and satisfaction with nursing care in neurosurgery intensive care unit

BACKGROUND

Sleep disturbance in an intensive care unit is a common problem. One of the main factors causing sleep disturbances in an intensive care unit is nocturnal patient care interventions.

AIMS AND OBJECTIVES

This study aims to determine the impact of patient care interventions performed at night in a neurosurgical intensive care unit on patients' sleep and their nursing care satisfaction.

METHODS

The descriptive study was conducted on 82 patients in a neurosurgical intensive care unit between January 2009 and March 2010. The data were collected by data collection instruments and Newcastle Satisfaction with Nursing Scales. The data were statistically analyzed by frequency, mean, standard deviation, chi-square, and Mann-Whitney U test.

RESULTS

The study showed that 53.7% of the patients experienced sleep disturbances in the neurosurgical intensive care unit. Because of nursing interventions at night, 39.1% of these patients had their sleep affected, but this problem did not cause any negative impact on the patients' satisfaction (Newcastle Satisfaction with Nursing Scales score = 88.21 ± 9.83). The patients received, on average, 42.21 ± 7.45 times patient care interventions at night; however, the frequency of patient care interventions at night showed no effect on sleep disturbances in this study (p > .05). The most frequently given patient care interventions were, respectively, vital signs monitoring, neurological assessment, and repositioning in bed. These interventions were performed commonly at 6 a.m., 12 a.m., and 7 p.m.

CONCLUSION

In this study, despite the patients reporting sleep disturbances in the neurosurgical intensive care unit because of nocturnal patient care interventions that prevented them from sleeping, the patients' satisfaction on the given nursing care was not negatively impacted. To reduce sleep disturbances because of nursing care initiatives and promote uninterrupted sleep in the intensive care unit, it can be useful to develop new protocols regulating night care activities.