Bundling sleep promotion with delirium prevention: ready for prime time?

Transcription

1 Bundling sleep promotion with delirium prevention: ready for prime time? A night in a typical intensive care unit (ICU) is punctuated by a chorus of alarms, voices, and telephone rings, direct and indirect light pollution, and interruptions from unfamiliar care providers. Poor-quality sleep often results, characterised by frequent disruptions, fragmentation, perturbed circadian rhythms, and a loss of restorative deep stages of sleep [1]. As a consequence, critically ill patients report poor sleep as an important source of ICUrelated anxiety and stress [2] and list sleep disturbance among the worst memories of their ICU experience [3]. Despite this knowledge about poor sleep in the ICU, a large gap exists in our understanding of its effects on patient outcomes. It is widely hypothesised that poor quality of sleep is associated with delirium in the ICU and therefore with the negative consequences of delirium, including prolonged length of stay and long-term physical, cognitive, and psychological sequelae [4]. However, previous investigations on this topic were limited in size, enrolled heterogeneous patient populations, and/or were limited by non-validated measures of sleep or delirium [5 9]. Recently, promotion of sleep in the ICU has gained increased attention due, in part, to new efforts to minimise the use of sedative medications [10, 11], prevent delirium [12], promote early mobilisation [13] and improve post-icu neuropsychological outcomes [14]. As such, in its recently published Pain, Agitation, and Delirium guidelines, the American College of Critical Care Medicine recommended promoting sleep in adult ICU patients by optimizing patients environments, using strategies to control light and noise, clustering patient care activities, and decreasing stimuli at night to protect patient s sleep cycles, but acknowledged the low quality of evidence supporting this recommendation [15]. In this issue of Anaesthesia, Patel and colleagues contribute to the growing literature in this field by evaluating a sleep-promotion and delirium-prevention intervention in a 24-bed mixed medical/surgical ICU in the UK [16]. This multidisciplinary, multi-faceted effort involved both ICU-wide and patient-specific interventions to promote sleep, including minimisation of environmental night-time noise and light, provision of eye masks and earplugs, and clustering of patient care activities, and a delirium-prevention intervention involving daily medication review, pain control, minimisation of sedation, and early mobilisation. Compliance with interventions was optimised using daily prompts and frequent reminders. To implement this intervention, the authors employed a pre/post design, with a 24-day preintervention baseline period with data collection on noise, light, sleep and delirium, followed by a 21-day break period to allow for adoption of the intervention, and then a 26-day post-intervention period that replicated the baseline data collection. All patients underwent thricedaily evaluations for sedation and delirium using the Richmond Agitation Sedation Scale (RASS) [17] and Confusion Assessment Method for the ICU (CAM-ICU) [18], respectively. Additionally, a subset of patients without pre-existing sleep or cognitive disorders, neurosurgical admission diagnosis, sedation during the previous 24 hours or delirium during the ICU stay was enrolled consecutively for the sleep assessment, which included a daily Richards-Campbell Sleep Questionnaire (RCSQ) [19] and a one-time 2014 The Association of Anaesthetists of Great Britain and Ireland 527

2 Sleep in the ICU Questionnaire (SICUQ) [20]. The authors evaluated 167 and 171 patients for delirium assessment during the pre- and post-intervention periods, respectively, and 30 and 29 for the sleep assessment. Of the 338 patients who underwent delirium assessment, 288 (85%) were elective, postoperative admissions to the ICU. The authors reported statistically significant pre- versus post-intervention improvements in the incidence (33% versus 14%, respectively; p < 0.001) and mean duration (3.4 versus 1.2 days, respectively; p = 0.02) of delirium, in the quality of sleep (RCSQ mean score 60.8 versus 75.9, respectively; p < 0.001; SICUQ median ratings 4 versus 7, respectively, p < 0.001), and in the mean night-time noise and light levels, sleep duration, and number of nightly awakenings. Moreover, unadjusted statistical analyses demonstrated that improved sleep efficiency was associated with a reduction in the odds of developing delirium. While this low-cost, multifaceted intervention demonstrated important potential benefits, the authors appropriately noted several limitations, including a single-centre design, uncertainty of sustainability of the intervention or benefits beyond the 26-day intervention period, and potential bias due to unblinded data collection by staff members who were aware of the intervention. Additionally, the authors highlighted the limitation of using the RCSQ [19], SICUQ [20], and bedside observation to measure sleep, since these instruments have not been validated in heterogeneous ICU populations. Given that polysomnography, the gold standard for sleep measurement, is not feasible for widespread use in the ICU setting, subjective instruments pose a financially and logistically practical alternative for this study design. Further validation of these instruments is warranted, as research on sleep in the ICU continues to grow. In addition, other issues should be considered in reviewing Patel et al. s study s results. First, there was limited reporting of missing data and no adjustment for potential confounders that differed between the pre- and post-intervention groups. Second, patients were excluded from performing sleep quality assessments if they had known pre-icu sleep pathology, delirium in the ICU, or had received sedation 24 hours before enrolment. This exclusion helped to support more accurate assessment of patient- quality of sleep in the ICU, but also markedly reduced the sample size and generalisability of the findings. Third, in the statistical analysis, only a single randomly-selected sleep assessment was used for each patient, potentially limiting the study s findings. Patel et al. have made an important contribution in building upon previous studies of multi-component interventions to demonstrate further the feasibility and potential benefits of interventions, such as ICU-wide noise and light reduction protocols (e.g. quiet time interventions [9, 21 28]), earplugs and eye masks [28 31], and relaxation techniques including tranquil music, back massage, and guided imagery [9, 28, 32, 33] (Table 1). Notably, the effort by Patel et al. closely paralleled a recent publication by Kamdar et al. [28], which reported on a 145-day, multi-faceted sleep promotion intervention that enrolled 300 patients from a single medical ICU and involved sequential additive interventions involving environmental noise and light reduction, non-pharmacologic interventions (eye masks, earplugs and tranquil music), but also unlike Patel et al. included a pharmacologic sleep aid guideline. Both Patel et al. and Kamdar et al. demonstrated significant pre/post improvements in cognitive impairment and noise ratings, and provide evidence of the feasibility and safety of multi-faceted interventions to improve sleep and delirium in the ICU, adding to a growing research foundation to support the design of more rigorous future studies. In summary, Patel et al. should be commended for evaluating a novel multi-faceted intervention to improve sleep and delirium in the ICU, and adding to a growing body of literature on ICU-wide, multi-disciplinary sleep promotion and delirium prevention efforts. Additional studies are needed to advance our understanding of the relationship of ICU-related sleep disruption and delirium. Such efforts are important to evaluate new ideas for improving critically ill patients short- and long-term physical, cognitive, and mental health outcomes. Competing interests No external funding and no competing interests declared The Association of Anaesthetists of Great Britain and Ireland

3 Anaesthesia 2014, 69, Table 1 Studies of multi-component interventions to promote sleep in the intensive care unit. Outcomes Study Patel et al. [16] (UK, n = 338) Foster and Kelly [9] (USA, n = 32) Kamdar et al. [28] (USA, n = 300) Maidl et al. [27] (USA, n = 129) Faraklas et al. [26] (USA, n = 130) Jones and Dawson [29] (UK, n = 100) Li et al. [25] (Asia, n = 55) Hu et al. [30] (Asia, n = 14) Dennis et al. [24] (USA, n = 50) Richardson [31] (UK, n = 64) Monsen and Edell-Gustafsson [23] (Europe, n = 23) Richardson [32] (USA, n = 36) Study design Setting Quiet time protocol Eye masks Earplugs Back massage Relaxation / music Guided imagery Pharmacologic aids Delirium prevention Sleep Polysomnography RCSQ SICUQ Observation / other Noise levels Lights levels Delirium Primary outcomes P S U U U U U U U U U delirium, noise, light; improved sleep P M U U U U U U No improvement in delirium, sleep, or noise P M U U U U U U U U adjusted odds of daily and incident delirium/ coma; improved noise Q G U U No improvement in sleep ratings P B U U sleep latency and complaints of disruptions and noise P G U U U sleep quantity but not quality P S U U U U Improved sleep quality, interruptions and noise R L U U U REM sleep, arousals, improved sleep quality P N U U U U light and noise, odds of observed sleep Q C U U U Increased sleep quantity P N U U U minimum noise level (8 of 14 nights) and patient care interactions R G U U U No pre-post improvement in sleep; MICU sleep worse than SICU/CCU Main limitations Unadjusted analyses; one-time sleep measurement size, missing data RCSQ instead of PSG, no noise/light measurement No pre-intervention group, nurses not blinded stopped early (loss of study coordinator) size, frequent intervention refusal size, one-time sleep assessment Use of laboratory setting and healthy subjects size, same-day prepost assessment size, unvalidated measure of sleep Bias in reporting of patient care interactions Varied gender response to intimate intervention, short duration, small sample size 2014 The Association of Anaesthetists of Great Britain and Ireland 529

4 Table 1 (continued) Outcomes Sleep Study Olson et al. [22] (USA, n = 239) Walder et al. [21] (Europe, n = 17) Richards et al. [33] (USA, n = 69) Study design Setting Quiet time protocol Eye masks Earplugs Back massage Relaxation / music Guided imagery Pharmacologic aids Delirium prevention Polysomnography RCSQ SICUQ Observation / other Noise levels Lights levels Delirium Primary outcomes P N U U U U observed sleep; noise and light; noise/light and sleep association P S U U U U noise and light; no improvement in sleep R C U U U U Sleep efficiency, TST, REM and sleep latency with back-massage Main limitations Unblinded and non-continuous sleep assessments Subjective measure of sleep Inclusion of only males aged ICU, Intensive care unit; RCSQ, Richards-Campbell Sleep Questionnaire; PSG, polysomnography; SICUQ, Sleep in the ICU Questionnaire; REM, rapid-eye movement; TST, total sleep time; P, pre-post observational; Q, quasi-experimental; R, randomised; B, burn ICU; C, cardiac ICU; G, general/multiple ICUs; L, laboratory/simulated ICU; M, medical ICU; N, neurological ICU; S, surgical ICU B. B. Kamdar Clinical Instructor Division of Pulmonary and Critical Care Medicine David Geffen School of Medicine at UCLA Los Angeles CA, USA bkamdar@mednet.ucla.edu B. B. Kamdar Assistant in Anaesthesia Department of Anaesthesiology, Critical Care, and Pain Medicine Massachusetts General Hospital Harvard Medical School Boston MA, USA D. M. Needham Associate Professor Outcomes After Critical Illness and Surgery (OACIS) Group Division of Pulmonary and Critical Care Medicine and Department of Physical Medicine & Rehabilitation Johns Hopkins University Baltimore MD, USA References 1. Freedman NS, Gazendam J, Levan L, Pack AI, Schwab RJ. Abnormal sleep/ wake cycles and the effect of environmental noise on sleep disruption in the intensive care unit. American Journal of Respiratory and Critical Care Medicine 2001; 163: Novaes MA, Knobel E, Bork AM, Pavao OF, Nogueira-Martins LA, Ferraz MB. Stressors in ICU: perception of the patient, relatives and health care team. Intensive Care Medicine 1999; 25: Simini B. Patients perceptions of intensive care. Lancet 1999; 354: Weinhouse GL, Schwab RJ, Watson PL, et al. Bench-to-bedside review: delirium in ICU patients - importance of sleep deprivation. Critical Care 2009; 13: Gulevich G, Dement W, Johnson L. Psychiatric and EEG observations on a case of prolonged (264 hours) wakefulness. Archives of General Psychiatry 1966; 15: Helton MC, Gordon SH, Nunnery SL. The correlation between sleep deprivation and the intensive care unit syndrome. Heart and Lung 1980; 9: Yildizeli B, Ozyurtkan MO, Batirel HF, Kuscu K, Bekiroglu N, Yuksel M. Factors associated with postoperative delirium after thoracic surgery. Annals of Thoracic Surgery 2005; 79: Trompeo AC, Vidi Y, Locane MD, et al. Sleep disturbances in the critically ill patients: role of delirium and sedative agents. Minerva Anestesiologica 2011; 77: Foster J, Kelly M. A pilot study to test the feasibility of a nonpharmacologic intervention for the prevention of delirium in the medical intensive care unit. Clinical Nurse Specialist 2013; 27: Shehabi Y, Bellomo R, Reade MC, et al. Early intensive care sedation predicts long-term mortality in ventilated critically ill patients. American Journal of Respiratory and Critical Care Medicine 2012; 186: Strom T, Martinussen T, Toft P. A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomised trial. Lancet 2010; 375: Brummel NE, Girard TD. Preventing Delirium in the Intensive Care Unit. Critical Care Clinics 2013; 29: The Association of Anaesthetists of Great Britain and Ireland

5 Anaesthesia 2014, 69, Needham DM. Mobilizing patients in the intensive care unit: improving neuromuscular weakness and physical function. Journal of the American Medical Association 2008; 300: Pandharipande PP, Girard TD, Jackson JC, et al. Long-term cognitive impairment after critical illness. New England Journal of Medicine 2013; 369: Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Critical Care Medicine 2013; 41: Patel J, Baldwin J, Bunting P, Laha S. The effect of a multi-component multidisciplinary bundle of interventions on sleep and delirium in medical and surgical intensive care patients. Anaesthesia 2014; 69: Ely EW, Truman B, Shintani A, et al. Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS). Journal of the American Medical Association 2003; 289: Ely EW, Inouye SK, Bernard GR, et al. Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU). Journal of the American Medical Association 2001; 286: Richards KC, OSullivan PS, Phillips RL. Measurement of sleep in critically ill patients. Journal of Nursing Measurement 2000; 8: Freedman NS, Kotzer N, Schwab RJ. Patient perception of sleep quality and etiology of sleep disruption in the intensive care unit. American Journal of Respiratory and Critical Care Medicine 1999; 159: Walder B, Francioli D, Meyer JJ, Lancon M, Romand JA. Effects of guidelines implementation in a surgical intensive care unit to control nighttime light and noise levels. Critical Care Medicine 2000; 28: Olson DM, Borel CO, Laskowitz DT, Moore DT, McConnell ES. Quiet time: a nursing intervention to promote sleep in neurocritical care units. American Journal of Critical Care 2001; 10: Monsen MG, Edell-Gustafsson UM. Noise and sleep disturbance factors before and after implementation of a behavioural modification programme. Intensive Critical Care Nursing 2005; 21: Dennis CM, Lee R, Woodard EK, Szalaj JJ, Walker CA. Benefits of quiet time for neuro-intensive care patients. Journal of Neuroscience Nursing 2010; 42: Li SY, Wang TJ, Vivienne Wu SF, Liang SY, Tung HH. Efficacy of controlling night-time noise and activities to improve patients sleep quality in a surgical intensive care unit. Journal of Clinical Nursing 2011; 20: Faraklas I, Holt B, Tran S, Lin H, Saffle J, Cochran A. Impact of a nursing-driven sleep hygiene protocol on sleep quality. Journal of Burn Care Research 2013; 34: Maidl CA, Leske JS, Garcia AE. The Influence of quiet time for patients in critical care. Clinical Nursing Research 2013; doi: / Kamdar BB, King LM, Collop NA, et al. The effect of a quality improvement intervention on sleep quality and cognition in a medical ICU. Critical Care Medicine 2013; 41: Jones C, Dawson D. Eye masks and earplugs improve patients perception of sleep. Nursing in Critical Care 2012; 17: Hu RF, Jiang XY, Zeng YM, Chen XY, Zhang YH. Effects of earplugs and eye masks on nocturnal sleep, melatonin and cortisol in a simulated intensive care unit environment. Critical Care 2010; 14: R Richardson A, Allsop M, Coghill E, Turnock C. Earplugs and eye masks: do they improve critical care patients sleep? NursinginCriticalCare2007; 12: Richardson S. Effects of relaxation and imagery on the sleep of critically ill adults. Dimensions of Critical Care Nursing 2003; 22: Richards KC. Effect of a back massage and relaxation intervention on sleep in critically ill patients. American Journal of Critical Care 1998; 7: doi: /anae Quality and safety in healthcare revisted: a challenge to anaesthetists The Francis Report of the Mid Staffs Public Inquiry, published in February 2013, clearly documents appalling care at Mid Staffs NHS Foundation Trust between 2005 and 2009 [1]. Anaesthetists feature in both the Mid Staffs Inquiry and Bristol Inquiry of the previous decade. Although, in 2001, the Bristol Inquiry panel into excessive deaths following paediatric cardiac surgery were impressed by the extensive experience of anaesthetists in applying a systems approach to safety and commended the work of the Royal College of Anaesthetists and the Association of Anaesthetists of Great Britain and Ireland [2], the Francis Report noted that anaesthetists were mildly criticised in the children s service peer review in 2006 and stated that anaesthetists on the emergency rota did not have regular involvement in the care of children and might not be maintaining their skills in that area [3]. However, the 2003 children s service 2014 The Association of Anaesthetists of Great Britain and Ireland 531