Biren Kamdar, MD, MBA, MHS & Dale Needham, MD, PhD

birenk@gmail.com
8/2013

ICU Sleep Checklist Individual Patient Interventions

MRN: __ __ __ __ __ __ __ __

Patient initials: __ __

BED #: _____

Date when shift started: ___/___/ 20__

1. Day Shift Environmental Actions

a. No caffeine after 3pm:
3NPO 1yes 0no 2unknown

b. Encourage activities to prevent napping. % of day shift spent napping:

6N/A:RASS -4/-5 0<5% 15-25% 226-50% 351-75% 476-100% 5unknown

2. Night Shift Environmental Actions

a.
b.
c.
d.

Appropriate pain control:

Optimize room temp:
Warm bath before 10pm:
TV off by 10pm:

1yes
0no
2unknown
1yes
0no
2unknown
1yes
0no
2unknown
1yes
0no
2unknown
3patient wants TV left on

e.
f.
g.
h.

Prevent unnecessary alarms after 10pm: 1yes

0no
Close curtains to room by 10pm:
1yes
0no
Dim room lights by 10pm:
1yes
0no
Minimize RN interruptions after 10pm
# of interruptions after 10pm (Enter 0 if none): __

2unknown
2unknown
2unknown
2unknown

3. Night Shift Actions (*Select N/A only if patient is unable to respond to you when offering the intervention, eg, sedated)
a. Offer soft music:
b. Offer eye mask:
c. Offer ear plugs:

4N/A*
4N/A*
4N/A*

0not offered
0not offered
0not offered

1offered & used

1offered & used
1offered & used

2offered & refused

2offered & refused
2offered & refused

3unknown
3unknown
3unknown

4. Night Shift: Patient recd any of the medications below? 0no 2unknown 1yes-check all that apply
Check box S if medication given specifically for Sleep.
Check box N if medication given, but Not for sleep (i.e. for sedation, anxiety, etc).
Zolpidem (Ambien):
Lorazepam (Ativan):
Midazolam (Versed):

1S 2N
1S 2N
1S 2N

Haldol:
1S 2N
Morphine: 1S 2N
Fentanyl: 1S 2N

Quetiapine (Seroquel):
Clonazepam (Klonopin):
Olanzapine (Zyprexa):

1S 2 N
1S 2 N
1S 2 N

Trazodone (Desyrel):
1S 2N
Diphenhydramine (Benadryl): 1S 2N
Other:______________ 1S 2N

Name of Nurse collecting this information:

Reference: Kamdar BB, King LM, Collop NA, Sakamuri S, Colantuoni E, Neufeld KJ, Bienvenu OJ, Rowden AM, Touradji P, Brower RG, Needham DM.
The effect of a quality improvement intervention on perceived sleep quality and cognition in a medical ICU. Critical Care Medicine. 2013:800-9.

Biren Kamdar, MD, MBA, MHS & Dale Needham, MD, PhD
birenk@gmail.com
8/2013

ICU Sleep Checklist ICU-wide interventions

1. Dim hallways lights at 10pm:
0Not done 1Done. Time ACTUALLY performed: ___:___
2. Avoid overhead pages AFTER 10pm.
Estimated # of pages after 10pm (goal is 0 pages):
0 no pages
1 1-3
2 4-7
Reason for frequent pages (multiple
3 8-14 admissions, code blue, etc.): ________________________
4 15+

Name of Clerk collecting this information:

Reference: Kamdar BB, King LM, Collop NA, Sakamuri S, Colantuoni E, Neufeld KJ, Bienvenu OJ, Rowden AM, Touradji P, Brower RG, Needham DM.
The effect of a quality improvement intervention on perceived sleep quality and cognition in a medical ICU. Critical Care Medicine. 2013:800-9.