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The Effect of a Quality Improvement Intervention on Perceived Sleep Quality and Cognition in a Medical ICU*

Kamdar, Biren B. MD, MBA, MHS1,2; King, Lauren M. RN, MSN1,3; Collop, Nancy A. MD4; Sakamuri, Sruthi BS5; Colantuoni, Elizabeth PhD1,6; Neufeld, Karin J. MD, MPH1,7; Bienvenu, O. Joseph MD, PhD1,7; Rowden, Annette M. PharmD8; Touradji, Pegah PhD1,9,10; Brower, Roy G. MD2; Needham, Dale M. MD, PhD1,2,10

doi: 10.1097/CCM.0b013e3182746442
Clinical Investigations

Objectives: To determine if a quality improvement intervention improves sleep and delirium/cognition.

Design: Observational, pre–post design.

Setting: A tertiary academic hospital in the United States.

Patients: 300 medical ICU patients.

Interventions: This medical ICU-wide project involved a “usual care” baseline stage, followed by a quality improvement stage incorporating multifaceted sleep-promoting interventions implemented with the aid of daily reminder checklists for ICU staff.

Measurements and Main Results: Primary ICU outcomes were perceived sleep quality and noise ratings (measured on a 0–100 scale using the valid and reliable Richards–Campbell Sleep Questionnaire) and delirium/coma-free days. Secondary outcomes included ICU and hospital length of stay and mortality. Post-ICU measures of cognition and perceived sleep quality were evaluated in an ICU patient subset. During the baseline and sleep quality improvement stages, there were 122 and 178 patients, respectively, with more than one night in the ICU, accounting for 634 and 826 patient-days. Within the groups, 78 (63.9%) and 83 (46.6%) patients received mechanical ventilation. Over the 826 patient-day quality improvement period, checklist item completion rates ranged from 86% to 94%. In multivariable regression analysis of the quality improvement vs. baseline stages, improvements in overall Richards-Campbell Sleep Questionnaire sleep quality ratings did not reach statistical significance, but there were significant improvements in daily noise ratings (mean ± SD: 65.9±26.6 vs. 60.5±26.3, p = 0.001), incidence of delirium/coma (odds ratio: 0.46; 95% confidence interval, 0.23–0.89; p = 0.02), and daily delirium/coma-free status (odds ratio: 1.64; 95% confidence interval, 1.04–2.58; p = 0.03). Improvements in secondary ICU outcomes and post-ICU outcomes did not reach statistical significance.

Conclusions: An ICU-wide quality improvement intervention to improve sleep and delirium is feasible and associated with significant improvements in perceived nighttime noise, incidence of delirium/coma, and daily delirium/coma-free status. Improvement in perceived sleep quality did not reach statistical significance.

1 Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, MD.

2 Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD.

3 Medical Intensive Care Unit, Johns Hopkins Hospital, Baltimore, MD.

4 Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Emory University, Atlanta, GA.

5 Department of Biology, Johns Hopkins University, Baltimore, MD.

6 Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.

7 Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, MD.

8 Department of Pharmacy, Johns Hopkins Hospital, Baltimore, MD.

9 Division of Rehabilitation Psychology and Neuropsychology, Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, MD.

10 Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, MD.

* See also p. 922.

Supported, in part, by a grant from the National Institutes of Health to Dr. Kamdar (F32 HL104901), who is a recipient of a Ruth L. Kirschstein NRSA award.

This study was performed at Johns Hopkins University, Baltimore, MD.

The authors have not disclosed any potential conflicts of interest.

For information regarding this article, E-mail: dale.needham@jhmi.edu

© 2013 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins