Impact of a Pharmacist-Led Intensive Care Unit Sleep Improvement Protocol on Sleep Duration and Quality

Andrews, Jessica L.; Louzon, Patricia; Torres, X.; Pyles, Eric; Ali, Mahmood; Du, Yi; Devlin, John W.

doi:10.1177/1060028020973198

Cited by 16 publications

(45 citation statements)

References 26 publications

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“…9-11,13 Delirium, evaluated in 5 studies, 8 -10,13,14 was significantly lower with bundle use. Pharmacists were identified as participating in bundle design or being part of the care team in 4 of the studies 9,11-13 and led implementation, performed bundle elements, administered sleep assessments, and analyzed results in Andrews et al 12…”

Section: Resultsmentioning

confidence: 99%

“…Leaders can apply techniques and components from the 9 sleep bundle studies to optimize bundle development, implementation, and evaluation strategies (Table 1). 6-14 The 2018 PADIS guidelines, more recent articles focused on ICU risk factors for poor sleep, and RCTs evaluating nonpharmacological sleep improvement interventions and medication sleep improvement strategies also serve as valuable frameworks for sleep bundle component development. 2,4,23-33…”

Section: Resultsmentioning

confidence: 99%

“…Prior to starting bundle development, consider a literature review, engage with clinicians in your ICU who work at night, obtain input from ICU survivors and their families regarding their experiences with sleep, and reach out to critical care colleagues at other centers to learn what they are doing to improve sleep. 9,10,12,34…”

Section: Resultsmentioning

confidence: 99%

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Sleep-Promotion Bundle Development, Implementation, and Evaluation in Critically Ill Adults: Roles for Pharmacists

et al. 2021

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Objective: To review evidence for intensive care unit (ICU) sleep improvement bundle use, identify preferred sleep bundle components and implementation strategies, and highlight the role for pharmacists in developing and evaluating bundle efforts. Data Sources: Multiple databases were searched from January 1, 1990, to September 1, 2021, using the MeSH terms sleep, intensive care or critical care, protocol or bundle to identify comparative studies evaluating ICU sleep bundle implementation. Study Selection and Data Extraction: Study screening, data extraction, and risk-of-bias evaluation were conducted in tandem. The ICU quality improvement literature and Institute for Healthcare Improvement bundle improvement guidance were also reviewed to identify recommended strategies for successful sleep bundle use. Data Synthesis: Nine studies (3 randomized, 1 quasi-experimental, 5 before-and-after) were identified. Bundle elements varied and were primarily focused on nonpharmacological interventions designed to be performed during either the day or night; only 2 studies included a medication-based strategy. Five studies were associated with reduced delirium; 2 studies were associated with improved total sleep time and 2 with improved patient-perceived sleep. Pharmacists were involved directly in 4 studies. Relevance to Patient Care and Clinical Practice: Sleep improvement bundles are recommended for use in all critically ill adults; specific bundle elements and ICU team member roles should be individualized at the institution/ICU level. Pharmacists can help lead bundle development efforts and routinely deliver key elements. Conclusions: Pharmacists can play an important role in the development and implementation of ICU sleep bundles. Further research regarding the relative benefit of individual bundle elements on relevant patient outcomes is needed.

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Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

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Sleep-Promotion Bundle Development, Implementation, and Evaluation in Critically Ill Adults: Roles for Pharmacists

et al. 2021

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“…Certain baseline conditions including psychiatric comorbidities that could have influenced NNM use were not collected. The use and success of nonpharmacologic sleep improvement/delirium reduction strategies may have influenced NNM use, but a sleep improvement protocol was not in use in any ICU at the time of the study and data on the use of other delirium-reducing efforts was not able to be collected ( 1 , 12 ). Although we only included scheduled NNMs administered between 6:00 pm and 2:00 am period, it is possible that some of these orders were not prescribed with an intent to improve sleep.…”

Section: Discussionmentioning

confidence: 99%

“…The study was approved by the MGB Institutional Review Board (Number 2017P002269/PHS). At the time of the study, each ICU had implemented the ICU Liberation bundle ( 11 ); none had implemented a formal sleep improvement protocol ( 12 ). Twice daily delirium screening by bedside nurses using the Confusion Assessment Method for the ICU was well-established ( 13 ).…”

Section: Methodsmentioning

confidence: 99%

Characterization of Nocturnal Neuroactive Medication Use and Related Sleep Documentation in Critically Ill Adults

Hamidi

Roberts

Weinhouse

et al. 2021

Critical Care Explorations

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We retrospectively characterized scheduled, newly initiated, nocturnal neuroactive medication use, and related clinician documentation, in a cohort of consecutive adults admitted greater than or equal to 24 hours to seven different medical/surgical ICUs at two academic centers who had not received a scheduled nocturnal neuroactive medication prior to admission, over a 5-month period (April 1, 2017, to August 31, 2017). A total of 207 different newly initiated, scheduled nocturnal neuroactive medication orders were written (melatonin agonist 101 [48.8%], antipsychotic 80 [38.6%], antidepressant 17 [8.2%], benzodiazepine 9 [4.3%]) in 189 (9.7%) of the 1,955 patients. Among the 1,553 nights, the 189 patients spent in the ICU, a scheduled nocturnal neuroactive medication was administered on 1,103 (71%), an “as needed” nocturnal neuroactive medication was solely administered on 183 (11.8%), delirium occurred on 736 (47.4%), and nurses were twice as likely as physicians (28.8% vs 11.4%; p < 0.0001) to document a note about sleep quality. Among the 69.8% of patients discharged to the floor, and the 64.5% from the hospital, the scheduled nocturnal neuroactive medication was continued in 85.6% and 87.3%, respectively. Scheduled nocturnal neuroactive medication initiation is common, often continued beyond hospital discharge, and poorly documented.

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Nighttime medication administration and patient perception of sleep in the intensive care unit

Howell

Seung

et al. 2023

J Am Coll Clin Pharm

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Introduction Environmental, patient, disease, and care‐related factors can lead to sleep disruption in the intensive care unit (ICU). Medication administration is a potentially modifiable factor in this setting that has not been well described as a target for sleep improvement. Objectives To determine characteristics of nighttime medication administration practices in the ICU, evaluate the effect on patient perceived sleep, and assess the opportunity for pharmacist‐led nighttime medication administration stewardship. Methods This was a multicenter, retrospective, observational cohort study. Patients included for chart review had perceived sleep measured using the Richards‐Campbell Sleep Questionnaire (RCSQ). Data were collected on patient characteristics, ICU exposures, and nighttime medications administered. Four RCSQ groups defined for comparison were RCSQ 0–25 indicating “very poor” sleep, 26–50 “poor” sleep, 51–75 “good” sleep, and 76–100 “very good” sleep. Results Overall, 115 patients with RCSQ assessments and 435 nighttime medication administrations were included. Nighttime medications were most commonly cardiovascular (28.9%) and central nervous system (21.4%) agents, administered via intravenous (54.5%) and oral (22.7%) routes. Patient characteristics were comparable between the four groups except for history of head trauma. Patients reporting very poor sleep had a significantly higher median number of nighttime medications administered as compared to patients reporting very good sleep (4.0 [interquartile range (IQR) (2, 6)] vs. 2.5 [IQR 1, 4], adjusted p = 0.048). Approximately three‐quarters of nighttime medications occurred between the hours of 22:00–0:59 and 5:00–5:59. Nearly 40% of nighttime medications could have been retimed for daytime administration. Conclusions Unnecessary nighttime medication administration is common and associated with poor patient perceived sleep in the ICU. Pharmacists are well‐positioned to evaluate timing of medication administration and cluster medication‐related care for daytime hours, when appropriate. Nighttime medication stewardship optimization by pharmacists is an opportunity to improve patient perceived sleep in the ICU.

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Impact of a Pharmacist-Led Intensive Care Unit Sleep Improvement Protocol on Sleep Duration and Quality

Cited by 16 publications

References 26 publications

Sleep-Promotion Bundle Development, Implementation, and Evaluation in Critically Ill Adults: Roles for Pharmacists

Sleep-Promotion Bundle Development, Implementation, and Evaluation in Critically Ill Adults: Roles for Pharmacists

Characterization of Nocturnal Neuroactive Medication Use and Related Sleep Documentation in Critically Ill Adults

Nighttime medication administration and patient perception of sleep in the intensive care unit

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