S.H.H.H. 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. Discuss Article and do critique form Heather Brand March 2013

And now……… S.H.H.H. Insert video clip of fireworks Heather Brand March 2013

S.H.H.H. (Sleep Hygiene in Hospitals for patient Healing) Introducing: S.H.H.H (Sleep Hygiene in Hospitals for patient Healing) Discuss why I am so passionate about this subject. Being a ICU pt myself, working night for many years and being guilty of being loud Heather Brand, RN, BSN, CCRN University of Colorado Hospital Medical ICU March 2013 Heather Brand March 2013

S.H.H.H. 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 Heather Brand March 2013

S.H.H.H. 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 Circadian rhythms and sleep cycles normally occur every 90min during hours of sleep¹ This gives the patient, ultimately, 3 sleep cycles or 5hours hours to assist in restorative sleep Heather Brand March 2013

Physiological Effects of Sleep Deprivation³ 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 Mention the JC literature we just discussed and read the first paragraph: “sleep deprivation caused impared gluc tolerance and reduced insulin sensitvity. Cortisol and GH was altered.” In less than a week, these changes were seen in patient’s in an ICU. Heather Brand March 2013

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. 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. It can be deduced that by doing this, it will decrease the potential for further complications (e.g, delirium, increase hospital stay etcc) That’s me after spending many a late nights after kiddos are in bed working on my project Heather Brand March 2013

DATA COLLECTION REVIEW S.H.H.H MICU DATA COLLECTION REVIEW

Predata was a two-step data collection: S.H.H.H. S.H.H.H Predata was a two-step data collection: Interruptions in the patient’s rooms Recording of noise levels on the unit Go into how the data was collected, use the final tally sheet to go over Heather Brand March 2013

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 Go over what I found on predata collection for interruptions: Date: 30DAYS   Room#: 47 PATIENTS FOR 235 HOURS Vented Not Vented (circle one) = 27 Pressors No Pressors (circle one) = 7 Pt Stable Unstable (circle one) = 45 Acuity score: Any other pertinent info about pt acquity: Number of times the following disciplines enter a patient's room: TOP 3 ACTIVITIES PERFORMED (FOR TOTALS) DISCIPLINE: ACTIVITY PERFORMED: MD: 14 H&P. RE ASSESSMENT, F/U Registered Nurse: 329 MEDS, UOP, ASESSMENTS Respiratory Therapy: 55 RETAPE, VENT CHG, VENT CK CNA: 91 STOCKING, TURNING, BATHS Environmental Services: 32 TRASH EMPTY Radiology: 12 CXR ECG/Health Tech: 6 12LEAD EKG Any other discipline indicate below: 4 EEG LEAD CKS Go over the methodology of collecting this data for my research in noise levels: Selected certain rooms for their hypothesized noise levels, randomly chosen order over 12hour shift (7p-7a) for three shifts Nurses’s stations over 2 12 hour shifts Tube system Doors shutting Heather Brand March 2013

S.H.H.H In a study published in the

S.H.H.H. S.H.H.H This is how our unit compared to a study done by: ____________________________ Titled:___________________________________________ Heather Brand March 2013

S.H.H.H. 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 Heather Brand March 2013

S.H.H.H. 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 Heather Brand March 2013

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

What was the highest levels of noise you ask? S.H.H.H. S.H.H.H What was the highest levels of noise you ask? Who can guess? Heather Brand March 2013

S.H.H.H. 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) Patient’s room (during a code) Nurses’s station shift change on Monday night at 7pm Heather Brand March 2013

S.H.H.H Something to think about: Sound of jackhammer 110db Sound of heavy traffic 88db Sound of a Motorcycle driving by 95db So…A jackhammer has the same noise level as shift change in our unit. WOW Our doors shutting is compared to the sound of heavy traffic and the tube system dropping is compared to a Harley motorcycle driving by you at 2 feet Heather Brand March 2013

What does all this data mean? S.H.H.H What does all this data mean?

S.H.H.H. Joke! Heather Brand March 2013

S.H.H.H What can we do?

S.H.H.H RECOMMENDATIONS FOR STAFF INDIRECT PATIENT CARE AREA 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) My sleep hygiene project is not meant to add to our already full workflow. No forms to fill out, documentation to chart in EPIC. Just simple, effective ways to decrease the stimulus in the patient’s room and care areas. Heather Brand March 2013

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...) -Discretion of nursing standards of practice -dimmer switch in new tower! Heather Brand March 2013

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 All these recommendations will be posted at nurses’ station Will be a floor sign when entering units that will announce that S.H.H.H is in effect along with a info sheet for families that will be posted in our bedside red folders Heather Brand March 2013

S.H.H.H What will the future hold? Incorporate a “nap time” during the day Sleep masks Ear plugs Sound machines Once the culture change has been established, would like to introduce other areas of sleep promoting activities: Heather Brand March 2013

S.H.H.H. S.H.H.H Tada! Optimistically, what this could mean for our patients: create an environment condusive to sleep will assist patients in getting a more restful restorative sleep. This will decrease the incidence of ICU delirium, along with decrease secondary physiological complications (immune response etcc)….therefore decreasing hospital stay and cost for the patient and the hospital.  Heather Brand March 2013

Questions???

References National Sleep Foundation Cmiel, C., et al. (2004) Noise Control: A Nursing Team’s Approach to Sleep Promotion. American Journal of Nursing. 104(2): 40-48. Ganze, FD. (2012) Sleep and immune function. Critical Care Nurse, 32(2): 19-25. Matthews EE. (2011) Sleep disturbances and fatigue in critically ill patients. AACN Advanced Critical Care.22(3): 204-224. Kamdar, BB. (2012) Sleep deprivation in critical illness: it's role in physical and psychological recovery. Journal of Intensive Care Medicine. 1, 110-123. Kamdar, B. B. (2012) Patient-nurse interrater reliability and agreement of the Richards-Campbell sleep questionnaire American Journal of Critical Care, 21, 261-269. 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. 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. Cureton-Lane RA, Fontaine D. (1997) Sleep in the pediatric ICU: an empirical investigation. American Journal of Critical Care. 6(1): 56-63