Improving inpatient environments to support patient sleep

To determine if a quality improvement intervention improves sleep and delirium/cognition.

Sleep deprivation is common among intensive care patients and may be associated with delirium. We investigated whether the implementation of a bundle of non-pharmacological interventions, consisting of environmental noise and light reduction designed to reduce disturbing patients during the night, was associated with improved sleep and a reduced incidence of delirium. The study was divided into two parts, before and after changing our practice. One hundred and sixty-seven and 171 patients were screened for delirium pre- and post-intervention, respectively. Compliance with the interventions was > 90%. The bundle of interventions led to an increased mean (SD) sleep efficiency index (60.8 (3.5) before vs 75.9 (2.2) after, p = 0.031); reduced mean sound (68.8 (4.2) dB before vs 61.8 (9.1) dB after, p = 0.002) and light levels (594 (88.2) lux before vs 301 (53.5) lux after, p = 0.003); and reduced number of awakenings caused by care activities overnight (11.0 (1.1) before vs 9.0 (1.2) after, p = 0.003). In addition, the introduction of the care bundle led to a reduced incidence of delirium (55/167 (33%) before vs 24/171 (14%) after, p < 0.001), and less time spent in delirium (3.4 (1.4) days before vs 1.2 (0.9) days after, p = 0.021). Increases in sleep efficiency index were associated with a lower odds ratio of developing delirium (OR 0.90, 95% CI 0.84-0.97). The introduction of an environmental noise and light reduction programme as a bundle of non-pharmacological interventions in the intensive care unit was effective in reducing sleep deprivation and delirium, and we propose a similar programme should be implemented more widely.

Delirium occurs frequently in critically ill patients and has been associated with both short-term and long-term consequences. Efforts to decrease delirium prevalence have been directed at identifying and modifying its risk factors. One potentially modifiable risk factor is sleep deprivation. Critically ill patients are known to experience poor sleep quality with severe sleep fragmentation and disruption of sleep architecture. Poor sleep while in the intensive care unit is one of the most common complaints of patients who survive critical illness. The relationship between delirium and sleep deprivation remains controversial. However, studies have demonstrated many similarities between the clinical and physiologic profiles of patients with delirium and sleep deprivation. This article aims to review the literature, the clinical and neurobiologic consequences of sleep deprivation, and the potential relationship between sleep deprivation and delirium in intensive care unit patients. Sleep deprivation may prove to be a modifiable risk factor for the development of delirium with important implications for the acute and long-term outcome of critically ill patients.