JOURNAL CLUB

Promoting Sleep by Nursing Interventions in Health Care

Settings: A Systematic Review

Hellstrom A. et al. (2011). Promoting Sleep by Nursing Interventions in Health Care Settings: A Systematic Review. Worldview on

Evidenced-Based Nursing 8(3): 128-142.

AND NOW………

INTRODUCING:S.H.H.H

(Sleep Hygiene in Hospitals for patient Healing)

Heather Brand, RN, BSN, CCRNUniversity of Colorado HospitalMedical ICUMarch 2013

S.H.H.H

What is it?: A way to encourage sleep hygiene practices to

provide an optimal environment for sleep promotion

Aimed to minimize factors that can disturb and disrupt patient sleep, both environmental and personal¹

S.H.H.H

The aim of S.H.H.H To increase the awareness of noise

levels and interruptions in the patient’s room

S.H.H.H

Physiological Effects of Sleep Deprivation³

S.H.H.H

Physiological Effects of Sleep Deprivation7

Impaired glucose tolerance Reduced insulin sensitivity Lowered growth hormone Higher cortisol levels Metabolic disturbances Decrease cell proliferation Decrease in immune system mediators Higher risk of delirium

S.H.H.H

Limitations to evaluating patient sleep in the ICU Our patient population is often times

intubated and sedated and can not verbalize or recall the quality of sleep they received

Therefore……..

S.H.H.H

With all the research available on the physiologic effects of sleep deprivation, it is inferred that providing an environment conducive to sleep will help assist in patient healing.

S.H.H.H

MICUDATA COLLECTION REVIEW

S.H.H.H

Predata was a two-step data collection:

1. Interruptions in the patient’s rooms

2. Recording of noise levels on the unit

S.H.H.H

Interruptions in the patient’s room Logged the # of times staff went in

patient’s room and reason for interruption between hours of 11pm-4am

On average number of interruptions on a stable patient were: 13.4 interruptions

So, in 5 hours a stable patient’s sleep was potentially interrupted over 10 times!!!

Major culprits: Nursing, CNA, RT, EVS

S.H.H.H

In a study published in the

S.H.H.H

Nursing RT EVS MISC0

2

4

6

8

10

12

14

16

UCH MICUStudyColumn1

S.H.H.H

MICU Noise levels Recorded for 30 days in random patient rooms and

nurse’s stations for a total of 204 hours Average decibel (db) level in patient’s room

55db Average decibel (db) level at nurse’s station during

non peak hours 58db during peak hours (shift change)

88db Pneumatic tube dropping

102db ICU unit doors shutting

96db

S.H.H.H

In a study published in the American Journal of Nursing titled, Noise Control: A Nursing Team’s Approach to Sleep Promotion²

Average db level in patient’s room 53db Average db level at nurse’s station during

non peak 60db

during peak hours (shift change) 86db ICU doors shutting 72db

S.H.H.H

EPA recommended noise level for high acquit patient care areas8:

45db-55db during the day 35db during the night

NOISE LEVEL RESULTS

Nurse's Station non peak hours

Patient's Room

0

10

20

30

40

50

60

70

80

90

58

88

55

60

86

534555

35

UCH MICU Studied Hospital EPA reccomendations

S.H.H.H

What was the highest levels of noise you ask?

S.H.H.H

And the winner is…. Highest level recorded in a patient’s room

between 7p-7a : 98db (recorded at 3am)

Highest level recorded around the nurse’s

station between 7p-7a: 110db (recorded at 7:15pm)

S.H.H.H

Something to think about: Sound of jackhammer 110db Sound of heavy traffic 88db Sound of a Motorcycle driving by 95db

S.H.H.H

What does all this data mean?

S.H.H.H

What can we do?

S.H.H.H

RECOMMENDATIONS FOR STAFF HOURS: 2300-0400

INDIRECT PATIENT CARE AREA Overhead unit lights out no later than 2300 Soft voices around patient care areas Keep doors into unit open No transfer of patient calls into rooms after 2300 Decrease volume on audible alarm of central cardiac

monitor Educate personnel entering unit of Quiet Time hours

(signage will be posted)

S.H.H.H

DIRECT PATIENT CARE AREA Consider doing midnight assessment at 2200 or

get MD to write order to defer midnight assessment on stable patients

Change vital signs to Q2hours on hemodynamically stable patients

Lights out in room from 2300-0400 use flashlight if needed If patient/family able to communicate; assess pt

home bedtime rituals and try to facilitate some of the rituals (bath before bed, white noise, sleep mask, earplugs, music, TV on or TV off, bedtime etc...)

S.H.H.H

DIRECT PATIENT CARE AREA Turn down cardiac monitor volume Turn down IV pump alarm volume Check volumes on your pumps and make sure bags changed out

so they don't alarm during designated hours Shut door to room and pull curtain, if not a high fall risk Close blinds No non essential staff in room; recommend tasks to be done

before or after designated times RT re-taping tube, CNA restocking, EVS emptying trash in room,

etc Educate family members regarding MICU quiet time

recommendations Encourage family to limit number of times they enter and exit

patient room Encourage family to put cell phone on vibrate Adhere to patient visitation guidelines

S.H.H.H

What will the future hold? Incorporate a “nap time” during the day Sleep masks Ear plugs Sound machines

S.H.H.H

Tada!

QUESTIONS???

REFERENCES

1. National Sleep Foundation2. Cmiel, C., et al. (2004) Noise Control: A Nursing Team’s Approach to Sleep Promotion.

American Journal of Nursing. 104(2): 40-48.3. Ganze, FD. (2012) Sleep and immune function. Critical Care Nurse, 32(2): 19-25.4. Matthews EE. (2011) Sleep disturbances and fatigue in critically ill patients. AACN

Advanced Critical Care.22(3): 204-224. 5. Kamdar, BB. (2012) Sleep deprivation in critical illness: it's role in physical and

psychological recovery. Journal of Intensive Care Medicine. 1, 110-123. 6. Kamdar, B. B. (2012) Patient-nurse interrater reliability and agreement of the

Richards-Campbell sleep questionnaire American Journal of Critical Care, 21, 261-269.7. Hellstrom A, et al. (2011) Promoting sleep by nursing interventions in health care

settings: A systematic review. World Views on Evidence-Based Nursing. 3, 128-142.8. Xie, Hui. (2009) Clinical review: the impact of noise on patient's sleep and the

effectiveness of noise reduction strategies in intensive care units. Critical Care. 13, 208-216.

9. Cureton-Lane RA, Fontaine D. (1997) Sleep in the pediatric ICU: an empirical investigation. American Journal of Critical Care. 6(1): 56-63