Sleep like a baby?

The effect of a multicomponent multidisciplinary bundle of interventions on sleep and delirium in medical and surgical intensive care patients.
Patel J, Baldwin J, Bunting P, Laha S
Anaesthesia. 2014 Jun;69(6):540-9

STUDY APPRAISER: Dr Paul James

Link to abstract: http://www.ncbi.nlm.nih.gov/pubmed/24813132

Background

  • ICU patients are observed to have a poor quality of sleep, with a predominance of Phase I sleep (light, high Theta wave activity) and a lack of slow wave or REM sleep
  • Sleep deprivation is common among intensive care patients, high levels of noise and light are commonly cited causes
  • After pain and anxiety, poor sleep has been identified as one of the top complaints of patients who survive ICU stays
  • Sleep deprivation and delirium are intrinsically linked
  • The investigated hypothesised that a multi-component, multi-disciplinary non pharmacological approach to sleep promotion may reduce incidence of delirium as has been seen in studies outside of ICU

Study design

  • Patients :
    • Adult intensive care patients on a mixed medical and surgical ICU(Royal Preston Hospital) who had not received sedation in the preceding 24 hours. Patients with pre-existing sleep disorders, neurosurgical patients, and patients with delirium were excluded from the cohort
  • Intervention
    • Sleep promotion through non-pharmacological methods of noise reduction and light reduction
  • Outcomes
    • Incidence of delirium
    • Sleep efficiency
  • Single Centred, Cohort study, 24 bedded teaching hospital ICU

Methods

  • Ethical approval obtained
  • Informed consent obtained prior to admission if planned, or when clinically stable in emergency admissions
  • Cohort-based study, before and after implementation of sleep promoting means
  • Initial data on sleep, environmental noise and light, and the incidence of delirium
  • Followed by a 21 day period of staff training and implementation of sleep bundles
  • Data collection was then performed to evaluate the impact of the interventions
  • Patients included were asked to undertake the Richards Campbell Sleep Questionnaire each morning during their ICU stay and the mean score from this was used to calculate the sleep efficiency index
  • Post ICU sleep questionnaires also informed of overall sleep quality
  • All Patients with a RASS of less than -4 also had 4 daily CAM-ICU delirium assessments

 

Population

  • Patients on ICU 24 hours after stopping sedation, Patient > 18 years of age, Patient spending one or more nights on the ICU.
  • Neuro patients, patients with delirium or pre-existing sleep problems and history of cognitive dysfunction were excluded

Intervention

  • Introduction of sleep bundles, including modification of environment ( Lights and noise levels), ear plugs and eye masks for all patrients

Outcome

  • Delerium
  • Sleep efficiency

Results

  • Application of the interventions produced a reduction in mean (SD) night-time noise from (68.8 (4.2) dB before to 61.8 (9.1) dB after (p = 0.002)
  • Light levels were reduced from 594 (88.2) lux before to 301 (53.5) lux after (p = 0.003)
  • Staff interactions and patient waking’s on intervention were also reduced
  • Increase in the mean (SD) sleep efficiency index following the multi-component intervention, 60.8 (3.5) vs 75.9 (2.24), p < 0.001
  • Increase in sleep quality and reduction in daytime sleepiness
  • Post ICU questionnaire data revealed a significant reduction in reported barriers to sleep ( Noise, Light and disturbance)
  • Patients spent more time asleep at night (6.6 h (55%) before vs 8.6 h (72%), p < 0.001, and more patient nights contained a 3-h window of uninterrupted sleep (32% before vs 39% after, p = 0.029)
  • Reduction in the incidence of delirium (55/167 (33%) before vs 24/171 (14%) after, p < 0.001), OR 0.33 (95% CI 0.19–0.57)
  • Reduced total time delirious

Conclusions

  • “The introduction of an environmental noise and light reduction programme as a bundle of non-pharmacological interventions in the intensive care unit was effective in reducing sleep deprivation and delirium”

Discussion

  • Suggested that bias may be observed as the interventions fell in a research setting, therefore further data collection is planned to ensure this is not the case
  • Sleep bundles would seem appropriate interventions which are relatively easy and low cost. May become subject to institutional drift…

Study Limitations

  • Single centre
  • Sleep questionnaires are not validated in the Critical care population
  • Not unique, but adds to a growing body of evidence
  • Other interventions – Music, light boxes, early exercise, outside visits during the day… not included but could have been
  • Drug withdrawal – abrupt withdrawal of BZDP`s may cause worsening sleep fragmentation and rebound insomnia (24 hours, ? Long enough)

 

Link to abstract: http://www.ncbi.nlm.nih.gov/pubmed/24813132

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