Development and Implementation of a Multicomponent Protocol to Promote Sleep and Reduce Delirium in a Medical Intensive Care Unit

Abstract

Background: Evidence suggests that poor sleep increases risk of delirium. Because delirium is associated with poor outcomes, institutions have developed protocols to improve sleep in critically ill patients. Objective: To assess the impact of implementing a multicomponent sleep protocol. Methods: In this prospective, preimplementation and postimplementation evaluation, adult patients admitted to the medical intensive care unit (ICU) over 42 days were included. Outcomes evaluated included median delirium-free days, median Richards-Campbell Sleep Questionnaire (RCSQ) score, median optimal sleep nights, duration of mechanical ventilation (MV), ICU and hospital length of stay (LOS), and in-hospital mortality. Results: The preimplementation group included 78 patients and postimplementation group, 84 patients. There was no difference in median delirium-free days (1 day [interquartile range, IQR, = 0-2.5] vs 1 day [IQR = 0-2]; P = 0.48), median RCSQ score (59.4 [IQR = 43.2-71.6] vs 61.2 [IQR = 49.9-75.5]; P = 0.20), median optimal sleep nights (1 night [IQR = 0-2] vs 1 night [IQR = 0-2]; P = 0.95), and in-hospital mortality (16.7% vs 17.9%, P = 1.00). Duration of MV (8 days [IQR = 4-10] vs 4 days [IQR = 2-7]; P = 0.03) and hospital LOS (13 days [IQR = 7-22.3] vs 8 days [IQR = 6-17]; P = 0.05) were shorter in the postimplementation group, but both were similar between groups after adjusting for age and severity of illness. Conclusions and Relevance: This report demonstrates that implementation of a multicomponent sleep protocol in everyday ICU care is feasible, but limitations exist when evaluating impact on measurable outcomes. Additional evaluations are needed to identify the most meaningful interventions and best practices for quantifying impact on patient outcomes.

Sleep in the intensive care unit

“…This difference, however, was not statistically significant. Contrary to this, a study by Darby et al [38 ▪▪ ] incorporating a similar sleep bundle into the existing ABCDEF bundle for delirium prevention did not show any improvement in sleep quality or rates of delirium. Definitive conclusions are challenged however by missing data within studies, particularly as it relates to compliance with assessments of delirium and sleep quality.…”

Does improving sleep for the critically ill reduce the incidence and duration of delirium? An evidence‐based review

“…Cut-off scores for healthy sleep (population norms) have not yet been established, but there is beginning evidence that a score of 63 mm is a reliable cut-off score for good-quality sleep. 16 Darby et al 9 reported a prospective quality improvement study in which data were collected for delirium-free days After the implementation of a not dissimilar study by Patel et al 10 patients reported an increase in sleep quality (pre: 60.8 ± 3.5 vs. post: 75.9 ± 2.24 mm) and the incidence of delirium was lower (pre: 33 % [n = 55/167] vs. post: 14 % [n = 24/171]). In this study the difference between nocturnal mean light and sound levels and compliance measured before and after the implementation of the intervention indicated that clinicians adopted many components (sound pre: 68.8 ± 4.2 dB vs. post: 61.8 ± 9.1 dB; light levels per: 594 ± 88.2 lux vs. post: 301 ± 53.5 lux).…”

“…Darby et al 9 reported a prospective quality improvement study in which data were collected for delirium‐free days (1 [IQR 0–2.5] vs. 1 [0–2]) and RCSQ (59.4 [IQR 43.2–71.6] vs. 61.2 [49.9–75.5] mm) before and after the implementation of a multicomponent staged sleep protocol revealed no change in delirium and sleep outcomes. In this study, confounding factors were not controlled for in the analysis; the intervention was incremental (only patients who continued to experience poor sleep received interventions included in the additional stages, such as eye masks and melatonin) and stage 3 interventions included the administration of antipsychotics.…”

“…Delirium assessment is a challenging task. Delirium is identified from behavioural signs which may fluctuate presenting problems quantifying it, thus “delirium free days” (e.g., Darby et al 9 ) is probably a better metric than others such as the number of positive assessments (e.g., Tonna et al 12 ). In addition, many, often similar, factors impact on both sleep and delirium such as the environmental conditions (sound and light levels), model of care including family/person centredness and diagnosis (case mix).…”

A Rapid Systematic Review of Pharmacologic Sleep Promotion Modalities in the Intensive Care Unit

“…5 Although not recommended by PADIS, and despite questions regarding their benefit, medications with the potential to initiate or maintain sleep, or improve circadian entrainment, are often added to ICU sleep protocols. 5–7…”