The Effect of a Quality Improvement Intervention on Sleep and Delirium in Critically Ill Patients in a Surgical ICU.

BACKGROUND: Delirium is a deleterious condition affecting up to 60% of patients in the surgical ICU (SICU). Few SICU-focused delirium interventions have been implemented, including those addressing sleep-wake disruption, a modifiable delirium risk factor common in critically ill patients. RESEARCH QUESTION: What is the effect on delirium and sleep quality of a multicomponent nonpharmacologic intervention aimed at improving sleep-wake disruption in patients in the SICU setting? STUDY DESIGN AND METHODS: Using a staggered pre-post design, we implemented a quality improvement intervention in two SICUs (general surgery or trauma and cardiovascular) in an academic medical center. After a preintervention (baseline) period, a multicomponent unit-wide nighttime (ie, efforts to minimize unnecessary sound and light, provision of earplugs and eye masks) and daytime (ie, raising blinds, promotion of physical activity) intervention bundle was implemented. A daily checklist was used to prompt staff to complete intervention bundle elements. Delirium was evaluated twice daily using the Confusion Assessment Method for the Intensive Care Unit. Patient sleep quality ratings were evaluated daily using the Richards-Campbell Sleep Questionnaire (RCSQ). RESULTS: Six hundred forty-six SICU admissions (332 baseline, 314 intervention) were analyzed. Median age was 61 years (interquartile range, 49-70 years); 35% of the cohort were women and 83% were White. During the intervention period, patients experienced fewer days of delirium (proportion ± SD of ICU days, 15 ± 27%) as compared with the preintervention period (20 ± 31%; P = .022), with an adjusted pre-post decrease of 4.9% (95% CI, 0.5%-9.2%; P = .03). Overall RCSQ-perceived sleep quality ratings did not change, but the RCSQ noise subscore increased (9.5% [95% CI, 1.1%-17.5%; P = .02). INTERPRETATION: Our multicomponent intervention was associated with a significant reduction in the proportion of days patients experienced delirium, reinforcing the feasibility and effectiveness of a nonpharmacologic sleep-wake bundle to reduce delirium in critically ill patients in the SICU. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT03313115; URL: www.clinicaltrials.gov.

Evaluation of Sleep Quality and Daytime Sleepiness in Dentistry Students

Abstract Objective: To evaluate sleep quality and excessive daytime sleepiness in undergraduate dentistry students. Material and Methods: This research is characterized as an observational study of transversal type, having analysed undergraduate students in dentistry from a public university in the State of Pernambuco, Brazil. The sample consisted of 325 students enrolled between the 1st and 10th academic semester. Sleep quality was evaluated using the Pittsburgh Sleep Quality Index (PSQI), while excessive daytime sleepiness was analysed through the Epworth Sleepiness Scale (ESS). The t-Student and Mann-Whitney tests were used for the numerical values, with the F-test (ANOVA) or the Kruskal-Wallis test being used to compare more than two categories. Results: It was observed that 71.1% of students presented a poor sleep quality, with more than half of the students exhibiting excessive daytime sleepiness (58.1%). A relationship between sleep quality and the academic semester was verified. However, gender and age were not associated with sleep quality or with excessive daytime sleepiness. Conclusion: A high prevalence of poor sleep quality and excessive daytime sleepiness was observed among undergraduate students in dentistry. The data suggest that the undergraduate degree in Dentistry can influence the students' quality of sleep, regardless of age or gender.

Comparison of staff and family perceptions of causes of noise pollution in the Pediatric Intensive Care Unit and suggested intervention strategies.

Noise and excessive, unwanted sound in the Pediatric Intensive Care Unit (PICU) is common and has a major impact on patients' sleep and recovery. Previous research has focused mostly on absolute noise levels or included only staff as respondents to acknowledge the causes of noise and to plan for its reduction. Thus far, the suggested interventions have not ameliorated noise, and it continues to serve as a barrier to recovery. In addition to surveying PICU providers through internet-based software, patients' families were evaluated through in-person interviews utilizing a pretested instrument over 3 months. Families of patients admitted for more than 24 h were considered eligible for evaluation. Participants were asked to rank causes of noise from 1 to 8, with eight being highest, and identified potential interventions as effective or ineffective. In total, 50 families from 251 admissions and 65 staff completed the survey. Medical alarms were rated highest (mean ± standard deviation [SD], 4.9 ± 2.1 [2.8-7.0]), followed by noise from medical equipment (mean ± SD, 4.7 ± 2.1 [2.5-6.8]). This response was consistent among PICU providers and families. Suggested interventions to reduce noise included keeping a patient's room door closed, considered effective by 93% of respondents (98% of staff; 88% of families), and designated quiet times, considered effective by 82% (80% of staff; 84% of families). Keeping the patient's door closed was the most effective strategy among survey respondents. Most families and staff considered medical alarms an important contributor to noise level. Because decreasing the volume of alarms such that it cannot be heard is inappropriate, alternative strategies to alert staff of changes in vital signs should be explored.

Noise and sleep on board vessels in the Royal Norwegian Navy.

Previous research indicates that exposure to noise during sleep can cause sleep disturbance. Seamen on board vessels are frequently exposed to noise also during sleep periods, and studies have reported sleep disturbance in this occupational group. However, studies of noise and sleep in maritime settings are few. This study's aim was to examine the associations between noise exposure during sleep, and sleep variables derived from actigraphy among seamen on board vessels in the Royal Norwegian Navy (RNoN). Data were collected on board 21 RNoN vessels, where navy seamen participated by wearing an actiwatch (actigraph), and by completing a questionnaire comprising information on gender, age, coffee drinking, nicotine use, use of medication, and workload. Noise dose meters were used to assess noise exposure inside the seamen's cabin during sleep. Eighty-three sleep periods from 68 seamen were included in the statistical analysis. Linear mixed-effects models were used to examine the association between noise exposure and the sleep variables percentage mobility during sleep and sleep efficiency, respectively. Noise exposure variables, coffee drinking status, nicotine use status, and sleeping hours explained 24.9% of the total variance in percentage mobility during sleep, and noise exposure variables explained 12.0% of the total variance in sleep efficiency. Equivalent noise level and number of noise events per hour were both associated with increased percentage mobility during sleep, and the number of noise events was associated with decreased sleep efficiency.

The Efficacy of Earplugs as a Sleep Hygiene Strategy for Reducing Delirium in the ICU: A Systematic Review and Meta-Analysis.

OBJECTIVE: A systematic review and meta-analysis to assess the efficacy of earplugs as an ICU strategy for reducing delirium. DATA SOURCES: MEDLINE, EMBASE, and the Cochrane Central Register of controlled trials were searched using the terms "intensive care," "critical care," "earplugs," "sleep," "sleep disorders," and "delirium." STUDY SELECTION: Intervention studies (randomized or nonrandomized) assessing the efficacy of earplugs as a sleep hygiene strategy in patients admitted to a critical care environment were included. Studies were excluded if they included only healthy volunteers, did not report any outcomes of interest, did not contain an intervention group of interest, were crossover studies, or were only published in abstract form. DATA EXTRACTION: Nine studies published between 2009 and 2015, including 1,455 participants, fulfilled the eligibility criteria and were included in the systematic review. Studies included earplugs as an isolated intervention (n = 3), or as part of a bundle with eye shades (n = 2), or earplugs, eye shades, and additional sleep noise abatement strategies (n = 4). The risk of bias was high for all studies. DATA SYNTHESIS: Five studies comprising 832 participants reported incident delirium. Earplug placement was associated with a relative risk of delirium of 0.59 (95% CI, 0.44-0.78) and no significant heterogeneity between the studies (I, 39%; p = 0.16). Hospital mortality was reported in four studies (n = 481) and was associated with a relative risk of 0.77 (95% CI, 0.54-1.11; I, 0%; p < 0.001). Compliance with the placement of earplugs was reported in six studies (n = 681). The mean per-patient noncompliance was 13.1% (95% CI, 7.8-25.4) of those assigned to receive earplugs. CONCLUSIONS: Placement of earplugs in patients admitted to the ICU, either in isolation or as part of a bundle of sleep hygiene improvement, is associated with a significant reduction in risk of delirium. The potential effect of cointerventions and the optimal strategy for improving sleep hygiene and associated effect on patient-centered outcomes remains uncertain.

Positive and negative effects of mechanical ventilation on sleep in the ICU: a review with clinical recommendations.

PURPOSE: Sleep is an essential physiologic process that helps to restore normal body homeostasis. Sleep disturbances have been shown to be associated with poor clinical outcomes, such as a greater risk of cardiovascular disease and increasing mortality. Critically ill patients, particularly those receiving mechanical ventilation, may be more susceptible to sleep disruption. METHODS AND RESULTS: Mechanical ventilation is an important factor influencing sleep in critically ill patients as it may have positive or negative effects, depending on patient population, mode, and specific settings. Other causes of sleep disruption include the acute illness itself, the daily routine care, and the effects of medications. Improving sleep in patients admitted to an intensive care unit has the potential to improve both short- and long-term clinical outcomes. In this article we review the specific aspects of sleep in critically ill mechanically ventilated patients, including abnormal sleep patterns and loss of circadian rhythm, as well as the effects of mechanical ventilation and intravenous sedatives on sleep quality and quantity. CONCLUSIONS: We provide recommendations for clinicians regarding optimal ventilatory settings and discuss fields for future research.

The role of sleep hygiene in promoting public health: A review of empirical evidence.

The ineffectiveness of sleep hygiene as a treatment in clinical sleep medicine has raised some interesting questions. If it is known that, individually, each specific component of sleep hygiene is related to sleep, why wouldn't addressing multiple individual components (i.e., sleep hygiene education) improve sleep? Is there still a use for sleep hygiene? Global public health concern over sleep has increased demand for sleep promotion strategies accessible to the population. However, the extent to which sleep hygiene strategies apply outside clinical settings is not well known. The present review sought to evaluate the empirical evidence for sleep hygiene recommendations regarding exercise, stress management, noise, sleep timing, and avoidance of caffeine, nicotine, alcohol, and daytime napping, with a particular emphasis on their public health utility. Thus, our review is not intended to be exhaustive regarding the clinical application of these techniques, but rather to focus on broader applications. Overall, though epidemiologic and experimental research generally supported an association between individual sleep hygiene recommendations and nocturnal sleep, the direct effects of individual recommendations on sleep remains largely untested in the general population. Suggestions for clarification of sleep hygiene recommendations and considerations for the use of sleep hygiene in nonclinical populations are discussed.

Randomized, controlled trial of yoga in women with breast cancer undergoing radiotherapy.

PURPOSE: Previous research incorporating yoga (YG) into radiotherapy (XRT) for women with breast cancer finds improved quality of life (QOL). However, shortcomings in this research limit the findings. PATIENTS AND METHODS: Patients with stages 0 to III breast cancer were recruited before starting XRT and were randomly assigned to YG (n = 53) or stretching (ST; n = 56) three times a week for 6 weeks during XRT or waitlist (WL; n = 54) control. Self-report measures of QOL (Medical Outcomes Study 36-item short-form survey; primary outcomes), fatigue, depression, and sleep quality, and five saliva samples per day for 3 consecutive days were collected at baseline, end of treatment, and 1, 3, and 6 months later. RESULTS: The YG group had significantly greater increases in physical component scale scores compared with the WL group at 1 and 3 months after XRT (P = .01 and P = .01). At 1, 3, and 6 months, the YG group had greater increases in physical functioning compared with both ST and WL groups (P < .05), with ST and WL differences at only 3 months (P < .02). The group differences were similar for general health reports. By the end of XRT, the YG and ST groups also had a reduction in fatigue (P < .05). There were no group differences for mental health and sleep quality. Cortisol slope was steepest for the YG group compared with the ST and WL groups at the end (P = .023 and P = .008) and 1 month after XRT (P = .05 and P = .04). CONCLUSION: YG improved QOL and physiological changes associated with XRT beyond the benefits of simple ST exercises, and these benefits appear to have long-term durability.

The challenge of sleep management in military operations.

It has long been known that short-term (days) insufficient sleep causes decrements in mental effectiveness that put individuals at increased risk of committing errors and causing accidents. More recently, it has been discovered that chronic poor sleep (over years) is associated with a variety of negative health outcomes (metabolic syndrome, obesity, degraded behavioral health). Implementing an effective sleep health program is, therefore, in the best interests of active duty personnel and their families both in the short- and long-term. Like managing physical activity or nutrition, effectively managing sleep health comes with its unique set of challenges arising from the fact that individuals who routinely do not obtain sufficient sleep are generally desensitized to feeling sleepy and are poor at judging their own performance capabilities--and individuals cannot be compelled to sleep. For these reasons, an optimally effective sleep health program requires 3 components: (1) a rigorous, evidence-based sleep education component to impart actionable knowledge about optimal sleep amounts, healthy sleep behaviors, the known benefits of sleep, the short- and long-term consequences of insufficient sleep, and to dispel myths about sleep; (2) a nonintrusive device that objectively and accurately measures sleep to empower the individual to track his/her own sleep/wake habits; and (3) a meaningful, actionable metric reflecting sleep/wake impact on daily effectiveness so that the individual sees the consequences of his/her sleep behavior and, therefore, can make informed sleep health choices.

Sleep disturbance, chronic stress, and depression in hospice nurses: testing the feasibility of an intervention.

PURPOSE/OBJECTIVES: To test the feasibility of a cognitive-behavioral therapy for an insomnia (CBT-I) intervention in chronically bereaved hospice nurses. DESIGN: Five-week descriptive correlational. SETTING: Nonprofit hospice in central Texas. SAMPLE: 9 agency nurses providing direct patient and family care. METHODS: Direct care nurses were invited to participate. Two intervention group sessions occurred at the hospice agency and included identification of dysfunctional thoughts and beliefs about sleep, stimulus control, sleep hygiene, and relaxation techniques to promote sleep. Measurements were taken at baseline and three and five weeks postintervention. MAIN RESEARCH VARIABLES: Sleep quality, depressive symptoms, and narrative reflections on the impact of sleep quality on self-care. FINDINGS: Participants reported moderate-to-severe sleep disturbances and moderate depressive symptoms. The CBT-I intervention was well accepted by the participants, and on-site delivery increased participation. CONCLUSIONS: Additional longitudinal study is needed to investigate the effectiveness of CBT-I interventions to improve self-care among hospice nurses who are at high risk for compassion fatigue and, subsequently, leaving hospice care. IMPLICATIONS FOR NURSING: Hospice nurses are exposed to chronic bereavement that can result in sleep disturbances, which can negatively affect every aspect of hospice nurses' lives. Cognitive-behavioral sleep interventions show promise in teaching hospice nurses how to care for themselves by getting quality sleep. KNOWLEDGE TRANSLATION: Identifying the risks for sleep disturbances and depressive symptoms in hospice nurses will allow for effective, individualized interventions to help promote health and well-being. If hospice nurses achieve quality sleep, they may remain in the profession without suffering from chronic bereavement, which can result in compassion fatigue. A CBT-I intervention delivered at the agency and in a group format was feasible and acceptable by study participants.

Use and success of pharmacologic and nonpharmacologic strategies for sleep problems.

PURPOSE: The purpose of this web-based, quantitative, descriptive, correlational study was to identify frequency of use and success of strategies to alleviate sleep problems, to determine whether there is any relationship between use and success (perceived effectiveness) of strategies, on the one hand, and adults' gender, age, income, or education, on the other. DATA SOURCES: Data were collected from a web-based survey that examined strategy use and success to alleviate insomnia. CONCLUSIONS: The most frequently used strategies and those perceived as successful in alleviating sleep problems included medications and sleep hygiene strategies. Users of some strategies differed from nonusers on gender, age, income, and education. IMPLICATIONS FOR PRACTICE: Results from this study can be used to advise patients with sleep problems about choosing strategies to help alleviate those problems to reduce insomnia and to lower the risks of comorbid illness and healthcare costs. This study contributes to the current available findings that focus on determining which strategies are being used to alleviate sleep problems, those perceived as the most successful, and identifying strategy use and success based on demographics.

[Non-face-to-face sleep improvement program in a workplace: bibliotherapy with and without behavioral self-control procedure].

BACKGROUND: Sleep hygiene education has been important health issue in the health promotion and the prevention of lifestyle-related diseases. A feasible and effective method is necessary for population approach. OBJECTIVE: To evaluate the effects of a non-face-to-face brief behavioral program for a sleep improvement in workplaces. METHODS: Research design was a cluster control trial. Three hundred and thirty participants were allocated to the bibliotherapy group (BTG; n=130) or self-control group (SCG; n=200). Two groups were recruited from separated local sections of a Japanese company each other. There was no eligibility criteria and the intervention was open to every worker in the workplaces. All participants received a self-help booklet and information on recent topics of insomnia-related health problems. SCG participants set several behaviors for habit improvement and monitored those behaviors for 4 wk additionally. The replies to the questionnaire showed that almost all of them had any sleep disturbances. RESULTS: A total of 158 participants in SCG (79%) and a total of 106 participants in BTG (82%) responded to the post questionnaire. Sleep parameters of pre and post questionnaires were compared between SCG and BTG. Overall, sleep onset latency was reduced and sleep efficiency was improved. The significant changes were found in only SCG. Re-analysis of pre and post 3-days' sleep diaries showed that the subjects in both group improved significantly in the main variables (total sleep time, number of awakenings, time spent awake, sleep efficiency). Sleep onset latency, wake after sleep onset, and daytime sleepiness improved significantly in only SCG. CONCLUSION: These results suggest that an additional target setting and self-monitoring could promote the effectiveness for sleep improvement of a bibliotherapy.

Filtering out the noise: evaluating the impact of noise and sound reduction strategies on sleep quality for ICU patients.

The review article by Xie and colleagues examines the impact of noise and noise reduction strategies on sleep quality for critically ill patients. Evaluating the impact of noise on sleep quality is challenging, as it must be measured relative to other factors that may be more or less disruptive to patients' sleep. Such factors may be difficult for patients, observers, and polysomnogram interpreters to identify, due to our limited understanding of the causes of sleep disruption in the critically ill, as well as the challenges in recording and quantifying sleep stages and sleep fragmentation in the intensive care unit. Furthermore, most research in this field has focused on noise level, whereas acousticians typically evaluate additional parameters such as noise spectrum and reverberation time. The authors highlight the disparate results and limitations of existing studies, including the lack of attention to other acoustic parameters besides sound level, and the combined effects of different sleep disturbing factors.

Sleep quality in mechanically ventilated patients: comparison of three ventilatory modes.

OBJECTIVES: To compare the influence of three ventilatory modes on sleep. DESIGN: Prospective, comparative, crossover study. SETTING: Medical intensive care unit in a university hospital. PATIENTS: Fifteen conscious, nonsedated, mechanically ventilated patients. INTERVENTIONS: Patients were successively ventilated with assist-control ventilation, clinically adjusted pressure support ventilation (cPSV), and automatically adjusted pressure support ventilation (aPSV). Sleep polysomnography was performed during three consecutive 6-hr periods, one with each mode in random order. Airway pressure and thorax and abdomen plethysmography were used to diagnose central apneas and ineffective efforts. MEASUREMENTS AND MAIN RESULTS: The main abnormalities were a low percentage of rapid eye movement (REM) sleep counting, for a median (25th-75th percentiles) of 10% (3.5-12.5) of total sleep, and a highly fragmented sleep with 29 arousals and awakenings per hour of sleep. REM sleep duration was similar in the three ventilatory modes, 7% in assist-control, 4% in aPSV, and 1% during cPSV (p = .54), as well as in the fragmentation index, 31 arousals and awakenings per hour in assist-control, 32 in aPSV, and 34 during cPSV (p = .62). Ineffective efforts occurred similarly with the three modes (seven per hour of sleep in assist-control, 16 in aPSV, and 12 during cPSV) or central apneas during PSV (five in aPSV, seven during cPSV). Minute ventilation was similar with the three modes. CONCLUSIONS: In conscious, mechanically ventilated patients, sleep architecture was highly abnormal, with a short REM stage and a high degree of fragmentation. The ventilatory mode did not influence sleep pattern, arousals, awakenings, and ineffective efforts.

Improving sleep hygiene of medical interns: can the sleep, alertness, and fatigue education in residency program help?

BACKGROUND: Because of concerns regarding sleep deprivation, the Accreditation Council for Graduate Medical Education limits duty hours and endorses education regarding sleep loss for residents. We assessed the effectiveness of a 60- to 90-minute lecture, the Sleep, Alertness, and Fatigue Education in Residency (SAFER) program, on sleep loss and recovery sleep in residents adhering to Accreditation Council for Graduate Medical Education duty hours. METHODS: From July 1, 2003, through June 24, 2005, interns from the inpatient medicine service at the University of Chicago were asked to wear wristwatch activity monitors. In March 2005, interns received the SAFER program intervention. We used fixed-effects linear regression to estimate within-subject mean sleep per call day (on-call, precall, postcall, and second-day postcall sleep). These estimates were compared with recommended minimum levels of preventive (7 hours of precall) and recovery (16 hours during the 2 days after call) sleep in healthy populations using 2-tailed t tests. These analyses were repeated to test the effect of the SAFER program. RESULTS: Fifty-eight of 81 interns (72%) participated for 147 intern-months (63%). Interns on call slept an average of 2.84 hours (95% confidence interval, 2.75-2.93 hours). Interns obtained less than recommended amounts of recovery sleep (14.06 hours [95% confidence interval, 13.84-14.28 hours]; P < .001). Intern preventive sleep was also less than recommended (6.47 hours [95% confidence interval, 6.39-6.56 hours]; P < .001). Interns attempted to compensate for their acute sleep loss; for each hour of on-call sleep loss, they received 18 minutes (95% confidence interval, 7-30 minutes) more recovery sleep (P = .003). The SAFER program had no significant beneficial effect on intern sleep. CONCLUSIONS: Under the current duty-hour regulations of the Accreditation Council for Graduate Medical Education, residents continue to be sleep deprived. The SAFER program has no impact on resident precall or postcall sleep.