Check Up: Unbroken ICU sleep lessens delirium

Intensive care patients who were allowed to have uninterrupted periods of sleep at Mercy Fitzgerald Hospital had less delirium and shorter hospitalizations, a new study found.

Delirium is a state of severe confusion and disorientation that poses a conundrum in intensive care units. Mechanical ventilation, sedating drugs, and intravenous opioid painkillers often contribute to delirium - and that contributes to the need for longer intensive care.

Longer stays also increase a patient's risk of a hospital- acquired infection.

Dominic Valentino, medical director of Mercy Fitzgerald's critical care units, proposed the sleep study, drawing on his background in sleep medicine.

"I thought this would be a logical process to evaluate ICU patients, allow them more structured sleep at night, and see if their incidence and duration of delirium is impacted," he said.

He and a team that included a nurse, a pharmacist, a dietitian, and a respiratory therapist developed the protocol, which protected patients' sleep from midnight until 4:30 a.m. During that time, room lights were turned off and loud talking was prohibited. Nurses monitored patients remotely, but suspended routine bloodwork, medications, and exams.

The do-not-disturb order could be interrupted only if a patient's medical condition required immediate intervention.

While 41/2 hours of sleep may not sound like much, it had a big effect.

In January and February 2013, 125 patients with heart failure, respiratory failure, or sepsis (a life-threatening infection) were put on the protocol at the hospital in Darby. Those who got uninterrupted nightly sleep for more than half their stay in intensive care shortened it by an average of 4.4 days. They also averaged about 2 days of delirium, compared with 3.5 days for patients who got uninterrupted nightly sleep for less than half their stay. (Delirium was evaluated using a standard verbal test, the Confusion Assessment Method.)

"Compared to 30 minutes of sleep, or an hour nap here and there, 41/2 hours is significant," Valentino said.

One of the biggest challenges of the study was convincing nurses that it would not hamper care or endanger patients.

"It's kind of anathema to the nurses, so we had to get their buy-in to get it off the ground," Valentino said.

He noted that the field of critical care is recognizing the importance of finding ways to reduce delirium because it can have long-term effects, including cognitive impairment and dementia.

At least one other recent study, at Johns Hopkins University Hospital, found that quieting nighttime noise and allowing continuous sleep reduced delirium among critically ill patients.

Because of its success, the Mercy Fitzgerald sleep protocol has been adopted at other Mercy Health System hospitals in West Philadelphia, East Norriton, and Northeast Philadelphia. It also earned a Delaware Valley Patient Safety Award from the Health Care Improvement Foundation, which promotes quality efforts in the Philadelphia area.

"Our peers think, 'Wow, this is a great idea,' " Valentino said. "There's little downside to it. It doesn't cost anything. It's not a new therapy. There are no side effects."

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