Sleep Promotion in the ICU: Implementation of Evidence Mindy Stites MSN, APRN, ACNS-BC, ACCNS-AG, CCNS, CCRN Critical Care Clinical Nurse Specialist

Steps in the EBP process 1. Cultivate a spirit of inquiry. 2. Ask a burning clinical question. 3. Collect the most relevant and best evidence. 4. Critically appraise the evidence. 5. Integrate evidence with clinical expertise, patient preferences, and values in making a practice decision or change. 6. Evaluate the practice decision or change. 7. Disseminate EBP results.

Step 1: Cultivate a Spirit of Inquiry

Step 2: Ask a Burning Clinical Question Does the implementation of a sleep promotion protocol in critically ill patients reduce rates of delirium and increase hours slept?

Step 3: Collect the Best Evidence Studies suggest that ICU patients get only 1-5 hours of sleep per night, with a mean of 4.5 hours (Elliott, 2011) Sleep architecture is also affected – Marked deficits in slow wave sleep (restorative sleep) – Abolished or reduced REM sleep (Drouot et al, 2008) – Sleep is associated with promotion of healing, hormone regulation, delirium, and participation in care

Literature Review

Step 4: Critically Appraise the Evidence Findings: – Limited literature – Minimal risk – “Right thing to do”

Study Outline Implement a protocolized sleep promotion bundle in 2/3 medical ICU units Evaluate: – Safety – Compliance – Effect on delirium rates, overall sleep quality Spread change

Step 5: Integrate evidence with clinical expertise, patient preferences, and values in making a practice decision or change

Exclusion Criteria 1.Frequent interventions required 2.Receiving mechanical ventilation on continuous sedation drip (Versed, Propofol, Precedex) 3.Undergoing resuscitation for shock 4. Frequent titration of medications that require extensive monitoring 5. Presence of stage II or greater pressure ulcer (relative contraindication) 6. Spinal cord injuries with limited or no ability to alter position independently 7. Safety concerns identified by the RN

Step 6: Evaluate the practice decision or change

Pre-Data Post-Data

Pre-Data Post-Data

Pre-Data Post-Data

Delirium Impact

Lessons Learned Frontline, multidisciplinary staff are CRITICAL participants in an EBP project Data collection is much more difficult than you think, but extremely important Evidence to back practice is limited, especially in nursing Ok to test and retest

Conclusion

References Elliott R, McKinley S, & Cistulli P. (2011). The quality and duration of sleep in the intensive care setting: An integrative review. International Journal of Nursing Studies 48: Drouot X, Cabello B, dOrtho M, Brochard L. (2008). Sleep in the intensive care unit. Sleep Medicine Reviews 12: Huang H et al. (2015). Effect of oral melatonin and wearing earplugs and eyemasks on nocturnal sleep in healthy subjects in a simulated intensive care unit environment: which might be a more promising strategy for ICU sleep deprivation? Critical Care 19:124 Bourne R, Mills G, Minelli C. (2008). Melatonin therapy to improve nocturnal sleep in critically ill patients: encouraging results from a small randomized controlled trial. Critical Care 12(2):R52