A team of doctors, nurses, psychologists, and pharmacists in the medical intensive care unit (MICU) at The Johns Hopkins Hospital implemented a project to see if by taking simple steps to reduce nighttime noise, light, and staff interruptions, as well as stopping certain medications for insomnia, they could reduce delirium and improve patient perceptions about the quality of their sleep. Their findings are described in an article posted online by Critical Care Medicine.
“With our interventions, we were able to improve a patient’s odds of being free of delirium in the ICU by 54 percent, even after taking into account the diagnosis, need for mechanical ventilation, age, and other factors,” says Biren Kamdar, MD, MBA, MHS, a Johns Hopkins pulmonary and critical care fellow who led the initiative. “In addition, many patients said that the ICU was quiet and comfortable enough for them to get a good night’s sleep,” he says.
Three sets of interventions were introduced in stages. The first was a 10-item environmental checklist that included turning off televisions, room and hallway lights, safely consolidating the number of staff visits to patient rooms overnight for drawing blood and giving medications to reduce interruptions, reducing overhead pages, and minimizing unnecessary equipment alarms.
In the second stage, patients also were offered eye masks, ear plugs, and tranquil music. In the final stage, a new medication guideline was introduced that discouraged giving patients certain commonly prescribed drugs for sleep, such as benzodiazepines, that are known to cause delirium.
Before all of the interventions had been instituted, the researchers did a baseline assessment of 122 patients in the intensive care unit over an 8-week period. After all of the measures were in place, another 178 patients were evaluated.
“Each patient was evaluated twice a day for delirium using the Confusion Assessment Method for the ICU (CAM-ICU), a widely used delirium screening tool. After 13 weeks, during which all of the interventions had been in place, we saw a substantial reduction in patient delirium compared to the baseline group,” Kamdar says.