By the Blouin News Science & Health staff

Preventive measures reduce delirium risk for ICU patients

by in Medicine, Research.

Hospital beds in a file photo.

Hospital beds in a file photo. (REUTERS/Lee Celano)

The medical intensive care unit (ICU) is one of the most chaotic places for hospital patients to sleep in, and frequent disruptions, noise, light, and care interruptions disturb patients’ sleep, increasing the likelihood of confusion and delirium. Calming down the environment is an emerging and effective strategy for preventing delirium.

The risk of delirium was cut by more than half (54%) by adopting an environmental quality improvement program in a medical ICU, according to a program described in the March 2013 issue of the journal Critical Care Medicine. The program also showed significant improvements in perceived nighttime noise, incidence of delirium/coma, and daily delirium/coma-free status. Perceived sleep quality did not improve.

“We took a multifaceted approach to promoting sleep, minimizing noise and distractions, and normalizing circadian rhythms,” says Biren Kamdar, MD, adult pulmonary and critical care fellow at Johns Hopkins School of Medicine, who led the study. Poor sleep quality is a well-recognized risk factor for ICU delirium, which can also lead to longlasting cognitive dysfunction after leaving the ICU.

This observational study, conducted at Johns Hopkins Medical Institutions, involved putting an ICU-wide quality improvement program in place to improve restful sleep. The approach involved minimizing nighttime disruptions, facilitating nighttime sleep, discouraging excessive napping in the daytime, as well as promoting normal circadian rhythms by raising window blinds during the day, encouraging physical rehabilitation, and avoiding caffeine before bed. The nighttime ICU environment was changed, which involved limiting overhead pages, turning off patients’ televisions, dimming hallway lights, and grouping nursing tasks so that patients were interrupted less frequently. Earplugs, eye masks, and soothing music were offered to patients.

If patients were still unable to sleep with those measures in place, appropriate sleep medications (zolpidem/Ambien) or atypical antipsychotics, such as haloperidol were prescribed. Sedating medicines known to precipitate delirium (benzodiazepines, antihistamines, and trazodone) were avoided. Throughout the program, ICU staff used a daily checklist to enhance the changes they were adopting.

“The program proved feasible over a 201-day period,” says Kamdar. “Even though other studies have looked at altering the ICU environment, nothing has been done on this scale.” During the quality-improvement phase of the study, 178 patients were evaluated.

In a separate study by A Le and associates in the division of trauma at the University of Arizona, in Tucson, revealed high numbers of nocturnal nursing interactions in all ICUs, with surgical ICUs having the largest numbers. Nursing staff estimated that as many as one-fifth of the interruptions in the surgical ICU could have been safely omitted. The authors argued that protocols for nighttime sleep promotion should be adopted and standardized in ICUs.

A patient survey of 116 patients in the intensive care unit revealed poor/very poor sleep quality in the ICU by 59% of patients, according to a 2012 study in the Italian journal Minerva Anestesiologica by A Little and colleagues from Mount Sinai Hospital, Toronto, Canada.

A third study led by Nathan E. Brummel, MD, pulmonary and critical care medicine, Vanderbilt University, Nashville, TN, and published in the January 2013 journal Critical Care Clinics, echoes Kamdar’s findings, this time suggesting that by addressing modifiable risk factors, such as inappropriate sedation, eliminating medications that lead to delirium, immobility, and getting people up in the ICU can prevent adverse outcomes associated with delirium and critical illness.

Taken together, these studies suggest that ICU patients benefit from environmental changes that minimize interruptions during the nighttime, enhance nighttime sleep, and maintain daytime circadian rhythm. The changes in the ICU also are inexpensive and low risk.