A Sleep/Wake Protocol to Reduce Delirium in the CVICU and SICU

POSTER

A Sleep/Wake Protocol to Reduce Delirium in the CVICU and SICU Anna T. Dalton, BSN, RN, DNP Student Nancy A. Allen, PhD, ANP-BC, Joseph E. Tonna, MD Key Findings: Implementation of the Sleep/Wake Protocol was feasible, there was acceptable overall compliance with intervention components, and high nursing protocol satisfaction. Patient delirium scores decreased from 30% to 24%, although this was not statistically significant over the two-three month trial. Background Sleep • Critically ill and hemodynamically unstable patients are at an increased risk for experiencing a decrease in their quality of sleep. • Sleep deprivation in critically ill patients can lead to changes in patient cognition, increased hospital and ICU length of stay, and physiologic consequences. • 50% of patient sleep hours occur in fragmented, short bouts throughout the day. • Sleep deprivation has been associated with an increase in delirium. Delirium • ICU delirium is an acute brain dysfunction that causes a change in a patient’s cognition, attention, and consciousness. • 45-87% of critically ill patients will experience at least one episode of delirium during their ICU stay. • It has been suggested that improving sleep by reducing noise, nursing activities, and light can reduce the incidence of delirium. Methods • Pretest/Posttest study design (N=501) 12-bed SICU; 20-bed CVICU at a large academic facility in the Intermountain West • CVICU: Pre-data x 2 months; Post-data x 3 months • SICU: Pre-data x 3 months; Post-data x 2 months • Inclusion criteria: all adult (age >18) post-operative, trauma, and critically ill patients admitted to ICU’s during QI period • Exclusion criteria: Comatose, on paralytics, and/or no brain reflexes • Sleep/Wake Protocol • Day: mobility, limit caffeine, prevent naps, visual and auditory aids • Night: offer ear plugs, eye masks, optimize environment for sleep, minimize interruptions • Outcomes • Confusion Assessment Method-ICU: delirium measure • Richards-Campbell Sleep Questionnaire: perceived quality of sleep measure • Nurse Satisfaction Survey: usability/satisfaction of protocol Figure 1. Perceived Sleep Quality Table 2. ICU Delirium and Perceived Sleep Pre/Post Intervention ICU Outcome Any delirium, n(%) RCSQ Sleep Depth, Mean(SD) Sleep Latency, Mean (SD) # of Awakenings, Mean (SD) Ability to Return to Sleep, Mean (SD) Sleep Quality, Mean (SD) Noise Level, Mean (SD) PostPreIntervention Intervention (n=229) (n=272) 55 (24) 82 (30) Post-Pre (95% CI) PValue -6(-14 ~ 2) 0.13 51(26) 56 (24) 52(24) 49(24) 57(24) 53 (23) -2.36(-6.87~2.15) 0.59(-3.71~4.90) 0.69(-3.58~4.95) 0.30 0.79 0.75 58(25) 59(23) 1.17(-3.16~5.51) 0.59 50(26) 65(22) 49(25) 68(20) -0.60(-5.12~3.92) 2.67(-1.05~6.39) 0.79 0.16 Results • Pre- and post-intervention there were 272 and 229 patients who were screened for delirium and who participated in the RCSQ Table 1. Sleep/Wake Protocol Compliance • Incidence of delirium decreased 82/272 (30%) pre- vs 55/229 Compliance (24%) (p=0.13) post-intervention Intervention (n=229, n(%)) • Compliance with the Sleep/Wake Protocol ranged from 20Day Shift Actions 98%, respectively No caffeine After 3pm 118 (64) • Perceived sleep quality showed similar mean (SD) between % of day shift spent Napping 123 (70) Lights on, Blinds open, Doors open 194 (93) both groups with the greatest difference made in noise level Reasonable effort for noise in room 194 (94) (pre- 65(22%) vs post-intervention 68(20%) (p=0.16)) Eye glasses, hearing aids applied 113 (73) Chair position/mobility at least 2x30 minutes daily 84 (42) • Nurse satisfaction of the protocol was 88% Night Shift Actions Appropriate Pain Control Optimize Room Temperature Warm Bath before 2200 TV off by 2200 Prevent unnecessary alarms after 2200 Close curtains by 2200 Dim room light by 2200 Family out of room by 2200 Door partially or fully closed by 2200 Minimized RN Interruptions after 2200 # of Interruptions after 2200, mean(SD) Eye Masks Offered and Used Ear Plugs Offered and Used ICU Wide-Interventions Dim Hallway lights by 2200 Nurses station quiet Stop sign placed on Patient’s Door 201 (91) 224 (98) 80 (35) 145 (64) 208 (91) 191 (83) 184 (80) 179 (78) 197 (86) 164 (73) 7.1 (4.6) 42 (20) 43 (21) 220 (97) 209 (92) 183 (81) Conclusions • Sleep/Wake Protocol is feasible within a CVICU and SICU • Decreased incidence of delirium, although not statistically significant • Sleep quality was neither improved nor reduced • Staff were satisfied with the protocol • Further analysis is needed to examine the influence of preexisting sleep habits, medical conditions, and mechanical devices to determine if these variables affected the quality of sleep COLLEGE OF NURSING