Improving Sleep Quality

and Quantity in the ICU

Group D
Haleh Carrera
Leyla Eskenazi
Yael Eskenazi
Colleen Green
Isaac Hendricks
Marissa Jones
Sydney Navarez
Rebecca Paoli
John Santoro
 Why is Sleep Important In the ICU?
Extreme lack of sleep in patients can cause anxiety, confusion, memory
problems and decreased orientation or cognition (Ryu, Park & Park, 2012).

It can negatively affect physiological parameters including protein synthesis,

cell dissolution, and immunity. It can cause low arterial O2 saturation and
hypertension. Sleep speeds up the process of healing in injured tissues
(Yazdannik, Zareie, Hasanpour & Kashefi, 2014).

It can also reduce respiratory muscular resistance, and interfere with

patients separation from mechanical ventilation (Yazdannik, Zareie, Hasanpour &
Kashefi, 2014).

These effects place ICU patients at greater risk for infection, complications,
systemic diseases, prolonged hospital stay and mortality (Li, Wang, Wu, Liang &
Tung, 2011).
 Sleep in the ICU
ICU patients were found to have poor sleep quality, which included severe
irregularity in circadian rhythm and sleep cycle as well as decreased total sleep
and sleep efficiency (Li, Wang, Wu, Liang & Tung, 2011).

ICU patients are awake about 50-60% of their sleep time, and at the most in
3-5% of the remaining time, reach the third and fourth stages of sleep, which
play the healing stages of sleep (Yazdannik, Zareie, Hasanpour & Kashefi, 2014).

ICU patients predominantly experienced a light, non rapid eye movement

stage, plus a high frequency of arousals and awakenings and extreme
reduction in REM sleep. (Su, Lai, Chang, Yiin, Perng, & Chen, 2013)

One study found that total sleep time in ICU patients could be as little as 17
hours per day (Su et al., 2013)
 Why Are They Not Sleeping?
Noise, light, treatment interventions, painful procedures, and
psychological and mental stress can all interfere with sleep

SOUND:

The guideline published by the World Health Organization says

the optimum standard noise levels during day are 35 dB and 30
dB at night. To have deep sleep, the noise level should be kept
below 40 dB (Li, Wang, Wu, Liang & Tung, 2011)
Research shows that mean noise in ICU is 53-65 dB and reaches
over 80 dB in a 24-h period (Yazdannik, Zareie, Hasanpour &
Kashefi, 2014)
 Why Are They Not Sleeping?
LIGHT:

Continuous light exposure in an ICU can alter patients circadian

rhythm by breaking the natural daynight rhythm. (Li, Wang, Wu, Liang &
Tung, 2011)

Nocturnal light intensity in an ICU can be >1000 lx, which can sway
melatonin secretion and cause deviations in a patients circadian
clock and nightly secretion of melatonin (Yazdannik, Zareie, Hasanpour & Kashefi,
2014)

Research regarding melatonin secretion, in ICU patients, shows that

they suffer from acute sleep deprivation as a result of low nocturnal
secretion of melatonin (Yazdannik, Zareie, Hasanpour & Kashefi, 2014)
 PICOT

Will reducing sleep disturbances through staff and patient

interventions, during the 12-hour night shift in the adult intensive care
setting, help to increase quality of sleep compared to no intervention?

P: Adult intensive care setting

I: Reducing sleep disturbances
C: Compared to no intervention.
O: Increase quality of sleep
T: During the 12-hour night
Summary of Current Practice
Local
Banner University Medical provides quiet time signs within units
Tucson Medical Center implements quiet hours and offers ear plugs
(Tucson Medical Center, 2016).
State
Mercy Gilbert Medical Center has carpeted hallways and decreased
noise (Eberst, 2008).
National
Valley Hospital in New York implements quiet time in the afternoon and
early morning (Feldman & Sobrino-Bonilla, 2014).
Select Connecticut hospitals use a bundle of quiet time and sleep tool
kits (Rege, 2016)
Despite current protocols, noise levels have consistently been rising above
Synopsis of Current Literature
The current literature on improving the sleep quality and quantity of adult ICU
patients evaluates the effectiveness of both environmental and patient-based
interventions

The patient-based interventions studied include the use of earplugs and

eye masks during sleep and listening to calming music before sleep

The environmental interventions studied include quiet time and reducing

the noise-level in the ICU at night
Synopsis of Current Literature
Contd
The use of earplugs and eye masks, listening to relaxing music before/during
sleep, quiet time, and reducing noise-levels were all found to improve sleep
quality. Most studies assessed these interventions independently; however, one
study assessed a bundle including earplugs, eye masks, and music.
Listening to calming music, eye masks, and earplugs were also found to
positively affect sleep quantity (Ryu, Park, & Park, 2012; Jones & Dawson, 2012).
Interventions to improve the sleep of adult ICU patients were found to
decrease length of stay (Flannery, Oyler, & Weinhouse, 2016 ).
None of the reviewed studies compared the efficacy of different sleep
improvement interventions.
Only two studies assessed sleep quality and quantity utilizing objective
physiological measures such as polysomnography and skin conductance
(Czaplik et al., 2016; Su et al., 2013).
 Summary of Strengths
Five articles are Randomized-Controlled Trials, decreasing selection bias
Ensures that every participant has an equal chance of being in the intervention or control
group (Pannuchi & Wilkins, 2011)
Two articles utilized objective measures of sleep to determine quality of sleep: One article
used skin conductance the other Polysomnography:; both of these studies also measured
physiologic parameters ( HR, BP)
Objective measures decrease bias and increase reliability of the results (Su et al., 2013)
Eight of the studies had both a control and an experimental group allowing for a comparison
between the two groups
Multiple studies had a pre-post design
All but one study met the Power: the sample size was large enough to conclude significance
(University of Ottawa, 2016)
The studies were all conducted in a different hospital
Allowed for the analysis of the effectiveness of the interventions included in the proposed
Bundle in several different patient populations throughout the nation and internationally
Summary of Limitations
Multiple articles utilized subjective measures of sleep (e.g., questionnaires)
Decreases the reliability of the results: harder to interpret and allows for bias
(Pannuchi & Wilkins, 2011)

Multiple studies utilized a small sample size and were conducted in one hospital
Limits generalizability
Many of the studies analyzed patients sleep quality and duration over one or two
days
Time term bias (Pannuchi & Wilkins, 2011)
Is the intervention effective over a longer period of time?
To increase reliability and validity, testing at different points is needed (Ryu,
Park, & Park, 2012)
Evidence Based Nursing
Recommendations Supporting Best
Practice
I. Patient Use of Earplugs During Sleep
. Offering patients earplugs for use during sleep
I. Patient Use of Eye Masks During Sleep
. Offering patients eye masks for use during sleep
I. Implementing a scheduled quiet time from 11:00 pm to 5:00
am
. Reducing volume of alarms, lowering staff voice level, minimizing
external sounds, dimming hallway lights
I. Playing of relaxing music before/during sleep
. Offering a variety of relaxing music to play before/during sleep in
patients room
Evidence Based Nursing
Recommendations Supporting Best
Practice Contd
I. Patient Use of Earplugs During Sleep
The use of earplugs has a positive impact on quantity and quality of
sleep

Positive impact on stress levels with lower heart rates and lower blood
pressures (Czaplik et al., 2016)

More patients reported longer sleep using earplugs (Jones & Dawson, 2012)

Skin conductance in patients who used earplugs was significantly reduced

(Czaplik et al., 2016)

Measured patient sleep disturbances were reduced (Yazdannik, Zareie, Hasanpour&

Kashefi, 2014)
Evidence Based Nursing
Recommendations Supporting Best
Practice Contd
II. Patient Use of Eye Masks During Sleep

The use of eye masks has a positive impact on quantity and

quality of sleep
Positive impact on stress levels with lower heart rates and blood pressures
(Czaplik et al., 2016)

More patients reported longer sleep using eye masks (Jones & Dawson, 2012)

Measured patient sleep disturbances were reduced (Yazdannik, Zareie, Hasanpour &
Kashefi, 2014)
Evidence Based Nursing
Recommendations Supporting Best
Practice Contd
III. Implementing a scheduled quiet time from 11:00 pm to 5:00
am

Quiet time interventions can affect noise level and the patient's
sleep wake cycle
Scheduled quiet time would be a positively perceived intervention with a
therapeutic benefit (Gardner, Collins, Osborne, Henderson & Eastwood , 2009)

Reducing external environmental stimuli can promote sleep among patients in a

SICU (Li, Wang, Wu, Liang & Tung, 2011)

Perceived sleep disruption from the heart monitor alarm, talking, ventilator
alarm, cellular phones and landline phones were significantly lower (Li, Wang, Wu,
Liang & Tung, 2011)

Patients in the intervention group were 1.6 times more likely to fall asleep (Li,
 Evidence Based Nursing
Recommendations Supporting Best
Practice
IV. Contd
Playing of relaxing music before/during sleep
Several studies found that patients who listened to sleep-
inducing music showed significantly improved quantity and
quality of sleep
sedating music decreased total sleep time spent in N2 sleep & increased total
sleep time spent in N3 sleep* during first 2 hours of sleep (Su et al., 2013).
Mean quantity of sleep was significantly higher in those who were exposed to
music before/during sleep (Ryu, Park & Park, 2012)
Participants who listened to music experienced a statistically significant
decrease in heart rate (Li, Wang, Wu, Liang & Tung, 2011)
Music had sedating effects on ICU participants (reductions in heart rate, mean
arterial pressure, and respiratory rate) (Su et al., 2013)
Overall Application of Nursing
Practice
Education for staff

Purchasing necessary equipment

Implementing specific therapies into practice

Time frame goal of 3 months for training and implementation of

therapies
Timeline
DAY 1-30
Supplies will be ordered through the finance department.

Training staff will create online training module explaining the

implementation process of quiet time, earplugs, eye masks, and music
therapy.

Information within the module will contain current research of enhancing

sleep and how these therapies will be applied to the hospital.

Quiz after the training module will be available to staff after the module
is complete. Staff must achieve a grade of 90% to pass the entire
module.
Day 30
Announcement to staff will be implemented by

Email
Flyers on news board in unit
Charge nurse will announce during change of shift report
Details will consist of the upcoming training modules being available online
and staff has 30 days to complete module along with quiz.
Day 31-61
This allotted time frame is for the staff to take the online module and quiz.

During this time, training staff will be available through email and phone if
there are any problems with the program and any questions about the
change in practice.

Charge nurse will verbalize reminders to staff to complete modules within

this allotted time to ensure compliance of hospital staff.
Day 62-90
This timeframe is for the implementation of the specific therapies for
improving sleep.
Charge nurse will remind staff during the change of shift about implementing
new protocols for enhancing patients sleep.
Questions during this phase can be communicated to supervisor and training
staff.
50% of the patients will complete a survey regarding the use of the
interventions randomly during their ICU stay to determine effectiveness of
interventions.
Quality improvement meeting will be held at the end of the 90 day period for
therapy evaluation.
Detailed Cost Analysis
Obvious Costs:

Materials [Eye masks, Ear plugs]

Training [In-service for nurses, managers, other staff, materials]
Hidden Costs:

Time [Will this impact the nurses workload?]

Use of hospital facilities [e.g., electricity]
Evaluation of the bundle = Time and Cost
Direct Costs of the ICU Sleep Bundle
Eye Masks & Earplugs per patient cost

Richardson, Allsop, Coghill, & Turnock (2007) found the cost to be 2.5 per
patient
2.5 = $3.06 in US currency
Accounting for 16.4% inflation between 2007 and 2016:
0.164 X $3.06 = $0.50
$3.06 + $0.50 = $3.56 in 2016 (US Department of Labor, 2016)
Training ($1,420)

Labor cost for education staff to create a training module ($20/hr X 24 hours
= $480)
Labor for computer programming into the website ($35/hr X 24 hours =
$840)
Labor cost for nurses and other staff members to complete the course
Indirect Costs of the ICU Sleep
Bundle
Hidden costs always exist and need to be evaluated / anticipated
Time [Will this impact the nurses workload?]
Need to survey the nurses to determine the cost of this
Use of hospital facilities [e.g., electricity]
How much electricity is being used playing music? Running more fans?? Evaluate
this...
Evaluation of the bundle = Time and Cost
Having a team to evaluate this also costs money
Mini-research study has costs to implement
Quality team costs the hospital money
Importance of nurses pitching in
So What is the Cost Benefit?
Health insurance will not pay for these expenses
How will the hospital benefit from the implementation of this
bundle?????
Average Daily Hospital day cost in Arizona: $2,035 - $2,474
Example:
80 bed ICU
$3.56 (per pt cost) X 80 (# of beds) X 7 day stay = $1,994 (Materials)
$1420 (training costs)
= $3,414 + Unknown ($3414??) = $6,828
If 50% of the patients reduce their length of stay by one day
$2255 (avg) X 40 = Save $90,000 - $6828 (cost) = NET ~$83,000
Savings
If 25% of the patients reduce their length of stay by one day
Risk vs. Benefit to Patient, Nurse, and Hospital
Risk Benefit
Patient: Patient:
Discomfort(falling off, hot, sweating) Earplugs and eye masks further
(Richardson, Allsop, Coghill, & Turnock, 2007) decrease perception of external noises
Risk for Infection (Guen, Nicolas-Robin, Lebard, Arnulf, &
Difficulty hearing fire alarms Langeron 2013)
Increased patient-satisfaction (Jones &
Nurse: Dawson,
2012)
May interfere with assessments
Impeded staff visual acuity Nurse:
Increased sleepiness of staff Allow more time for other
responsibilities
Hospital: Potentially improved nurse-patient
Increased risk for occupational injuries relationship
Costs associated with the program are
not covered by insurance. All upfront Hospital:
costs Non-pharm interventions cost-
effective
Increased patient satisfaction surveys/
Evaluation- SMART Outcomes
1. Patient will sleep for at least two consecutive hours upon implementation of
the sleep-bundle by the end of the nurses night shift.

Rationale: A full cycle through the different stages of sleep normally requires 90110
minutes. A minimum of 2 hours of uninterrupted sleep time for ICU patients is suggested for
night-time sleep periods (Su et al., 2013).

2. The ICU will implement quiet time by dimming lights and reducing noise from
2300 to 0500 during the night shift.

Rationale: Environmental changes can help promote the quantity and quality of sleep in the
patient because they are not woken up or startled as frequently (Li, Wang, Vivenne Wu,
Liang, & Tung, 2011).

3. Patient will report an increase in quality of sleep using the survey after
implementing the bundle by the end of the nurses shift.

Rationale: Using a sleep survey will provide a way to measure sleep quality, allowing for
objective analysis of data.
Evaluation
Survey- Based on Richardson-Campbell Sleep Questionnaire
1. Sleep depth: My sleep last night was: light sleep (0) ... deep sleep (100)
2. Sleep latency: Last night, the first time I got to sleep, I: just never could fall
asleep (0) ... fell asleep almost immediately (100)
3. Awakenings: Last night, I was: awake all night long (0) ... awake very little
(100)
4. Returning to sleep: Last night, when I woke up or was awakened, I: couldn't
get back to sleep (0) ... got back to sleep immediately (100)
5. Sleep quality: I would describe my sleep last night as: a bad night's sleep
(0) ... a good night's sleep (100)
6. Noise: I would describe the noise level last night as: very noisy (0) ... very quiet
(100)
(Kamdar et al., 2012; Hu, Jiang, Hegadoren, & Zhang, 2015)
Summary
Many factors within the ICU affect the ability of patients to
get adequate sleep.

Increasing the patients quality of sleep within the ICU can

benefit patients by promoting healing and decreasing their
length of stay.

Current research shows that relaxing music, ear plugs, eye

masks, and quiet time are among the interventions to
promote sleep within the ICU.
Summary Contd
Implementation including training can be effectively
managed within a 90 day timeline.

Incorporating these interventions will benefit hospitals by

decreasing costs from prolonged hospital stays.

These interventions are shown to be more feasible than

pharmacological interventions and can increase patient
satisfaction rates among hospitals.
References
Czaplik, M., Rossaint, R., Kaliciak, J., Follmann, A., Kirfel, S., Scharrer, R., Guski, M., Vorlnder, M., Marx, G., & Coburn, M. (2016).

Psychoacoustic analysis of noise and the application of earplugs in an ICU: A randomised controlled clinical trial. European

Journal of Anaesthesiology (EJA), 33(1), 14-21. doi: 10.1097/EJA.0000000000000313

Eberst, L. (2008). Innovation at work: Arizona Medical Center shows how to be a healing hospital. Catholic Health Association of

the United States. Retrieved from https://www.chausa.org/publications/health-progress/article/march-april-2008/innovation-

at-work---arizona-medical-center-shows-how-to-be-a-'healing-hospital'

Feldman, V. & Sobrino-Bonilla, Y. (2014). Dim down the lights: implementing quiet time in the coronary care unit. American

Association of Critical-Care Nurses. Retrieved from http://ccn.aacnjournals.org/content/34/6/74.full

Flannery, A. H., Oyler, D. R., & Weinhouse, G. L. (2016). The impact of interventions to improve sleep on delirium in the ICU: A

systematic review andresearch framework. Critical Care Medicine, 1. doi:10.1097/CCM.0000000000001952

Gardner, G., Collins, C., Osborne, S., Henderson, A., & Eastwood, M. (2009). Creating a therapeutic environment: A non-randomised

controlled trial of a quiet time intervention for patients in acute care. International Journal of Nursing Studies, 46(6), 778-

786. doi:10.1016/j.ijnurstu.2008.12.009
References (Contd)
Guen, M. L., Nicolas-Robin, A., Lebard, C., Arnulf, I., & Langeron, O. (2013). Earplugs and eye masks vs routine care prevent sleep

impairment in post-anaesthesia care unit: A randomized study. British Journal of Anaesthesia, 112(1), 89-95.

doi:10.1093/bja/aet304

Hu, R. F., Jiang, X. Y., Hegadoren, K. M., & Zhang, Y. H. (2015). Effects of earplugs and eye masks combined with relaxing music on

sleep, melatonin and cortisol levels in ICU patients: A randomized controlled trial. Critical Care (London, England), 19, 115-

015-0855-3. doi: 10.1186/s13054-015-0855-3

Jones, C., & Dawson, D. (2012). Eye masks and earplugs improve patient's perception of sleep. Nursing in Critical Care, 17(5), 247-

254. doi:10.1111/j.1478-5153.2012.00501.x

Kamdar, B. B., Shah, P. A., King, L. M., Kho, M. E., Zhou, X., Colantuoni, E., ... & Needham, D. M. (2012). Patient-nurse interrater

reliability and agreement of the Richards-Campbell sleep questionnaire. American Journal of Critical Care, 21(4), 261-269.

Kamdar, B. B., King, L. M., Collop, N. A., Sakamuri, S., Colantuoni, E., Neufeld, Bienvenu, O., Rowden, A., Touradji, P., Brower, R., &

Needham, D. M. (2013). The effect of a quality improvement intervention on perceived sleep quality and cognition in a

medical ICU. Critical Care Medicine, 41(3), 800. doi: 10.1097/CCM.0b013e3182746442

Li, S. Y., Wang, T. J., Wu, S. F. V., Liang, S. Y., & Tung, H. H. (2011). Efficacy of controlling night-time noise and activities to improve
 References (Contd)
Pannucci, C. J., & Wilkins, E. G. (2011). Identifying and avoiding bias in research. Plastic and Reconstructive Surgery, 126(2), 619.

Rege, A. (2016). Three ways Connecticut hospitals are helping patients sleep better. Beckers infection control & clinical quality.

Retrieved from http://www.beckershospitalreview.com/quality/3-ways-connecticut-hospitals-are-helping-patients-sleep-

better.html

Richardson A, Allsop M, Coghill E, Turnock C. (2007). Earplugs and eye masks: Do they improve critical care patients sleep.

Nursing in Critical Care, 12, 27886.

Ryu, M.-J., Park, J. S. and Park, H. (2012). Effect of sleep-inducing music on sleep in persons with percutaneous transluminal

coronary angiography in the cardiac care unit. Journal of Clinical Nursing, 21(5-6), 728735. doi:10.1111/j.1365-

2702.2011.03876.x

Su, C., Lai, H., Chang, E., Yiin, L., Perng, S., & Chen, P. (2013). A randomized controlled trial of the effects of listening to non

commercial music on quality of nocturnal sleep and relaxation indices in patients in medical intensive care unit. Journal of

Advanced Nursing,69(6), 1377-1389. doi:10.1111/j.1365-2648.2012.06130.x

The University of Ottowa. (2016). Statistical power of study. Retrieved from

https://www.med.uottawa.ca/sim/data/Study_Design_Power_e.htm
References (Contd)
Xie, H., Kang, J., & Mills, G. H. (2009). Clinical review: The impact of noise on patients sleep and the effectiveness of noise

reduction strategies in intensive care units. Critical Care 13(2), 1-8. doi: 10.1186/cc7154

Yazdannik, A. R., Zareie, A., Hasanpour, M., & Kashefi, P. (2014). The effect of earplugs and eye mask on patients perceived sleep

quality in intensive care unit. Iranian journal of nursing and midwifery research, 19(6), 673-678.