1. 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):
Discuss Article and do critique form
Heather Brand March 2013

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

3. 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

4. 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

5. 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

6. Physiological Effects of Sleep Deprivation³
S.H.H.H
Physiological Effects of Sleep Deprivation³

7. 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

8. 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……..

9. 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

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

11. 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

12. 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:
H&P. RE ASSESSMENT, F/U
Registered Nurse:
MEDS, UOP, ASESSMENTS
Respiratory Therapy:
RETAPE, VENT CHG, VENT CK
CNA:
STOCKING, TURNING, BATHS
Environmental Services:
TRASH EMPTY
Radiology:
CXR
ECG/Health Tech:
12LEAD EKG
Any other discipline indicate below:
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

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

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

15. 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

16. 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

17. S.H.H.H
EPA recommended noise level for high acquit patient care areas8:
45db-55db during the day
35db during the night

18. Noise Level Results

19. 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

20. S.H.H.H.
S.H.H.H
And the winner is….
Highest level recorded in a patient’s room between 7p-7a : db (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

21. 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

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

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

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

25. S.H.H.H RECOMMENDATIONS FOR STAFF INDIRECT PATIENT CARE AREA
HOURS:
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

26. 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
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

27. 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

28. 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

29. 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

30. Questions???

31. 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):
Ganze, FD. (2012) Sleep and immune function. Critical Care Nurse, 32(2):
Matthews EE. (2011) Sleep disturbances and fatigue in critically ill patients. AACN Advanced Critical Care.22(3):
Kamdar, BB. (2012) Sleep deprivation in critical illness: it's role in physical and psychological recovery. Journal of Intensive Care Medicine. 1,
Kamdar, B. B. (2012) Patient-nurse interrater reliability and agreement of the Richards-Campbell sleep questionnaire American Journal of Critical Care, 21,
Hellstrom A, et al. (2011) Promoting sleep by nursing interventions in health care settings: A systematic review. World Views on Evidence-Based Nursing. 3,
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,
Cureton-Lane RA, Fontaine D. (1997) Sleep in the pediatric ICU: an empirical investigation. American Journal of Critical Care. 6(1): 56-63