Sleep deprivation is frequently a direct result of the need for intensive care, constant surveillance and monitoring that combine to limit the opportunities for uninterrupted sleep in the intensive care unit (ICU). The problem is multifactorial, with patients' chronic underlying illness, pain, pharmacological interventions used for the treatment of the primary illness, as well as the ICU environment itself have all been shown to be contributing factors to the process of sleep deprivation. In response to a marked decline in patient satisfaction with the quietness of their ICU rooms, this study implemented and administered a series of effective noise-abatement steps. Consistent with the findings from other similar studies, the results of this study found that ICU patients rated survey showed that monitor alarms were rated as the most bothersome noise by the most patients, followed by IV pump alarms, staff talking, and bed alarms. Although not all sources of noise are tractable to easy resolution, many of these sources of ICU noise are fairly straightforward to remedy and ICU clinicians should be encouraged to take aggressive steps to promote improved sleep on the ICU. Table of Contents

Chapter 1: Introduction

Statement of Purpose/Rationale

Research Questions

Importance of the Study

Organization of the Study

Chapter 2: Synthesis of Review of Literature

Chapter 3: Data-Gathering Method/Procedures

Data-Gathering Method

Procedures

Chapter 4: Data Analysis

Chapter 5: Discussion/Application to Practice

Chapter One: Introduction

To sleep: perchance to dream: ay, there's the rub. -- Shakespeare's Hamlet, 1602

Introduction

Purpose/Rationale:

The epigram above is reflective of the experience of many intensive care patients who struggle to get to sleep, and once asleep, to stay asleep. The purpose of this study was to investigate the sources of noise and times of day that patients feel it is least quiet on an intensive care unit. The rationale in support of this initiative is based on the ability of this information to provide staff with the ability to effectively formulate a plan of action to implement and administer steps to ensure a quieter environment for our ICU patients. For this purpose, Press Ganey sends questionnaires to discharged patients to measure their perspectives on hospital care. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores are derived from answers given on these surveys, including scores concerning the quietness of their hospital room.

Like a number of other tertiary healthcare facilities, we recently had a large drop in satisfaction to an all-time low of 29% to the question: "During this hospital stay, how often was the area around your room quiet at night?" The possible responses were "Never, Sometimes, Usually or Always. As concerned staff members, we formed the CICU Quiet Initiative Committee in response and formulated the following overarching research questions to help guide this study:

Research Questions:

1. What specific times of day do you notice is noisier than others?

2. During your stay in the CICU what noise sources hindered your ability to rest?

3. If the noise was in your room, did staff respond without you using your call light?

Importance of the Study

Florence Nightingale stated that unnecessary noise is the cruelest abuse of care which can be inflicted on either the sick or the well. This was stated in 1859. Now, a century and a half later, this is still true despite innovations in medical technology. The constant binging of an alarm, the intermittent buzz of an IV pump, the startling alarm of a ventilator, the opening and closing of a patient's door and voices in conversation are all environmental noises that are only heightened by the often frightened patient in a busy ICU. There are many articles citing noise as hindering health and encouraging sleep promotion, which is the very outcome that we are trying to achieve for our patients. While it is clear that more research is needed to support evidence-based practices in any healthcare area, it is also clear that some things are fairly intuitive and straightforward and do not require an enormous investment in organizational resources to achieve significant results.

There are many studies which detail the detriment of the noisy environment in which a patient endures. So why can we not provide the quiet and healing environment that we so desire for our patients? More often than not it is the human factor. Studies have shown that ICU sound levels have a negative impact on sleep (Fontana & Pittiglio, 2010). Although sleep remains better described than understood in the scientific literature, a great deal has been learned about the normal sleep architecture and the adverse effects of disrupting...

For instance, according to Hultman, Coakley, Bulette et al. (2012), "Sleep is a complex physiologic process that is not fully understood. However, the effects of sleep disturbance in the hospitalized population are well documented" (p. 135). Because the most seriously ill patients in hospitals are located in the ICUs, the potential for harm due to sleep disturbance is particularly acute (Stanzak, 2006). In this regard, Stanzak emphasizes that, "Sleep deprivation is often a direct result of the need for intensive care, continuous surveillance and monitoring which affords very little opportunity for uninterrupted sleep" (p. 94). The implications of these results are severe for patients and providers alike. According to Neergaard (2012), "Patient satisfaction surveys are packed with complaints that the clamor makes it hard to sleep. Yet remarkably little is known about exactly how that affects patients' bodies -- and which types of noises are the most disruptive to shut-eye" (p. 3).
Despite the need for more research in this area, the etiologies of sleep disturbances in the ICU are increasingly recognized to be multifactorial, but there is a gap in the body of knowledge concerning the precise mechanisms that are responsible for disturbances in the sleep -- wake cycle in ICU settings (Freedman, Gazendam & Levan, 2001). Some researchers cite the enormous array of environmental factors as contributing to diminished quality and quantity of sleep in ICUs, but question whether noise can be singled out as the most bothersome. In this regard, Gabor, Cooper, Crombach et al. (2003) report that, "Recent studies have challenged the traditional hypothesis that excessive environmental noise is central to the etiology of sleep disruption in the intensive care unit (ICU)" (p. 708). Nevertheless, Freedman and his associates report that, "Environmental stimuli are proposed to be the most disruptive factors to achieving sleep in the ICU. The environmental stimulus most often cited in the literature to disturb sleep is noise" (p. 451). For the purposes of this study, noise is defined as "any unwanted or undesirable sound which is subjectively annoying or disrupts performance and is physiologically and psychologically stressful" (Wenham & Pittard, 2009, p. 178).

These assertions are supported by other researchers who have determined that ICU noise levels are significantly higher than the Environmental Protection Agency (EPA) recommendations for hospital room noise level maximum at night as well as during the day (Freedman et al., 2001). Polysomnographic studies that have analyzed the impact of nighttime noises in the ICU noise on sleep in normal individuals have shown decreased total sleep time, total REM time, and sleep efficiency, as well as increased REM latency and the number of arousals per hour of sleep (Freedman et al., 2001).

Despite the need for more research in this area, a number of contributing factors are known to further exacerbate the problem in the ICU. For example, the patient's underlying chronic illness, acute pain, the pharmacological preparations used in treatment of the primary illness, as well as the ICU environment have all been shown to contribute to the process of sleep deprivation (Stanzak, 2006). For example, drugs such as benzodiazepines, opioids, inhalation agents, anticholinergics, antibiotics, and muscle relaxants can interact and result in agitation and restlessness in ICU patients (Ozdemir & Karabulut, 2009). According to Ozdemir and Karabulut, "In addition to drug-drug interactions, some agents alone, including lorazepam and anticholinergics, have been associated with the development of agitation" (p. 120).

Indeed, even the level of communication skills used by the ICU nursing staff can have a positive or negative effect on patient agitation levels. The research to date indicates that it is important to use effective communication strategies to help ICU patients cope with agitation, and these include: (a) maximizing communications with intensive care unit patients, (b) providing ICU patients with communication aids, (c) providing ICU patients with reality links and reorientation cues, (d) involving patient and family in care planning and (d) using anxiety reduction techniques for ICU patients (Ozdemir & Karabulut, 2009).

Studies have correlated sleep disturbance in patients with decreased immune function, changes in mental status and increased stress levels. These effects may interfere with the healing process in adults who require acute care in a hospital setting (Patel, Chipman, Carlin, & Shade, 2008). In this regard, Patel et al. (2008) report that, "All body systems require an adequate amount of sleep to maintain proper function and any disruption in the sleep cycle can dramatically impair any or all of the body systems" (p. 309). Indeed, laboratory rats that were deprived of sleep for 3 weeks died as a result of their sleep deprivation (Patel et al.., 2008). Likewise, clinicians at…