Objective To determine if a quality improvement (QI) intervention improves sleep and delirium/cognition. Design Observational, pre-post design. Setting A tertiary academic hospital in the US. Patients 300 medical ICU (MICU) patients. Interventions This MICU-wide project involved a “usual care” baseline stage, followed by a QI stage incorporating multi-faceted sleep-promoting interventions implemented with the aid of daily reminder checklists for ICU staff. Measurements and Main Results Primary ICU outcomes were perceived sleep quality and noise ratings (measured on a 0-100 scale using the valid and reliable Richards-Campbell Sleep Questionnaire [RCSQ]) and delirium/coma-free days. Secondary outcomes included ICU and hospital length of stay and mortality. Post-ICU measures of cognition and perceived sleep quality were evaluated in an ICU patient subset. During the baseline and sleep QI stages there were 122 and 178 patients, respectively, with >1 night in the ICU, accounting for 634 and 826 patient-days. Within the groups, 78 (63.9%) and 83 (46.6%) patients received mechanical ventilation. Over the 826 patient-day QI period, checklist item completion rates ranged from 86-94%. In multivariable regression analysis of the QI vs. baseline stages, improvements in overall RCSQ sleep quality ratings did not reach statistical significance, but there were significant improvements in daily noise ratings (mean ± standard deviation: 65.9 ± 26.6 vs. 60.5 ± 26.3, P=0.001), incidence of delirium/coma (odds ratio: 0.46; 95% confidence interval, 0.23-0.89; P=0.02), and daily delirium/coma-free status (odds ratio: 1.64; 95% confidence interval, 1.04-2.58; P=0.03). Improvements in secondary ICU outcomes and post-ICU outcomes did not reach statistical significance. Conclusions An ICU-wide QI intervention to improve sleep and delirium is feasible and associated with significant improvements in perceived nighttime noise, incidence of delirium/coma, and daily delirium/coma-free status. Improvement in perceived sleep quality did not reach statistical significance.
Through a structured quality improvement process, use of sedative infusions can be substantially decreased and days awake without delirium significantly increased, even in severely ill, mechanically ventilated patients with acute lung injury.
Critically ill patients commonly experience poor sleep quality in the intensive care unit (ICU) because of various modifiable factors. To address this issue, an ICU-wide, multifaceted quality improvement (QI) project was undertaken to promote sleep in the Johns Hopkins Hospital Medical ICU (MICU). To supplement previously published results of this QI intervention, the present article describes the specific QI framework used to develop and implement this intervention, which consists of 4 steps: (a) summarizing the evidence to create a list of sleep-promoting interventions, (b) identifying and addressing local barriers to implementation, (c) selecting performance measures to assess intervention adherence and patient outcomes, and (d) ensuring that all patients receive the interventions through staff engagement and education and regular project evaluation. Measures of performance included daily completion rates of daytime and nighttime sleep improvement checklists and completion rates of individual interventions. Although long-term adherence and sustainability pose ongoing challenges, this model provides a foundation for future ICU sleep promotion initiatives.
Objective-Disrupted sleep is a common and potentially modifiable risk factor for delirium in the intensive care unit (ICU). As part of a quality improvement (QI) project to promote sleep in the ICU, we examined the association of perceived sleep quality ratings and other patient and ICU risk factors with daily transition to delirium.Design-Secondary analysis of prospective observational study. Setting-Medical ICU (MICU) over a 201-day period.Patients-223 patients with ≥1 night in the MICU in between two consecutive days of delirium assessment. Interventions-NoneMeasurements-Daily perceived sleep quality ratings were measured using the Richards Campbell Sleep Questionnaire (RCSQ). Delirium was measured twice-daily using the Confusion Assessment Method for the ICU (CAM-ICU Conclusions-We found no association between daily perceived sleep quality ratings and transition to delirium. Infusion of benzodiazepine and/or opioid medications was strongly associated with transition to delirium in the ICU in mechanically ventilated patients and is an important, modifiable risk factor for delirium in critically ill patients.
This protocol provides adequate BG control within the clinically acceptable range of 80-199 mg/dL but not within the narrower range of 140-180 mg/dL, with a low incidence of hypoglycemia. Risk factors for hypoglycemia and barriers to protocol adherence in the cardiac surgery population should be elucidated.
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