NursingLink

Good Night, Sleep Tight, Nurses Turn Off Hospital Light

To sleep, perchance to heal?

Not if you’re a patient in a typical ICU, with its beeping monitors, bright lights and frequent interruptions.

Spurred by a growing body of evidence about the health benefits of a good night’s sleep, however, critical-care doctors and nurses have begun paying more attention to the problem. Sleep deprivation can result in a decreased production of growth hormone needed for healing, impaired resistance to infection and increased oxygen use.

In the ICU, perhaps the hospital’s main bastion of technology, low-tech approaches, such as eye masks, back rubs and dimmed lights, might make the difference between life and death.

“The ICU patients, they’re sort of on the brink. They could live or they could die,” says nursing researcher Kathy Richards. “So one has to consider all things that could influence that. It’s not only the medicines we give.”

Doctors, nurses keep coming and going

Anyone who has stepped foot in an ICU knows it’s not exactly conducive to slumber.

For one, ICU patients often require high doses of morphine for pain and other medications that can interfere with sleep. But the most obvious obstacle to sound sleep is the environment. True, most ICUs now have individual patient rooms instead of cubicles separated by curtains, but the rooms were designed with infection control in mind, not peace and quiet.

“The ICU is a hostile place,” says Randall Friese, an assistant professor of burn, trauma and critical care at the University of Texas Southwestern Medical Center in Dallas. On top of lights blazing all night, Friese says, “noise is always a factor. Alarms are always a factor.” And, of course, frequent evaluations by a nurse or doctor are always a factor.

Family members often worry when a patient sleeps practically all night and all day after moving from the ICU to a regular patient room, says Judith Reishtein, an assistant professor of nursing at Philadelphia’s Drexel University. “Don’t worry about it,” Reishtein assures them. “He didn’t get enough sleep in the intensive care unit.”

A few years ago, a study in one New Jersey hospital found that critical-care patients were rarely left alone for even two hours at night. Researchers at Robert Wood Johnson University Hospital in New Brunswick reviewed 50 patients’ medical records to tally the number of times they received care from 7 p.m. to 7 a.m.

Out of 147 nights, the researchers reported in 2004 in the American Journal of Critical Care, they found only nine uninterrupted periods of two to three hours. Not all of the interruptions were for medical evaluations or care — for some reason, about two-thirds of routine daily baths were provided between 9 p.m. and 6 a.m.

Lead author Linda Tamburri, a clinical nurse specialist for critical-care medicine, and her co-authors shared their findings with their nurse and physician colleagues.

ICU doctors and nurses at her hospital now try to schedule multiple types of care — say, respiratory therapy and a blood draw — for a single visit to minimize night-time interruptions, Tamburri says.

And when patients are admitted to the ICU, she says, nurses ask them or a family member about their normal sleep routine. Do they like to watch television or drink a warm beverage to help them relax? Do they work the night shift and sleep during the day?

Snoozing on the surface

Clearly, the most critically ill patients cannot be left alone for more than a couple of hours, says Friese, lead author of a study of sleep patterns in ICU patients published last month in The Journal of Trauma: Injury, Infection and Critical Care. But, he says, “the bottom line is there are people in the ICU who can be safely undisturbed for a period of time. Four hours, six hours.”

Friese and his co-authors monitored the sleep patterns of 16 ICU patients at Parkland Memorial Hospital in Dallas. They had either sustained traumatic injuries or undergone abdominal surgery.

The researchers found that although the patients slept nearly eight hours during a 24-hour period, their sleep was fragmented and significantly abnormal. Nearly all of their sleep was in a superficial stage, which represents only about half of a normal night’s sleep. The ICU patients were getting virtually no deeper stage 3, stage 4 or rapid-eye-movement, or REM, sleep.

“The problem is you can’t get into REM sleep unless you’ve been asleep long enough to get there,” Reishtein says. Among ICU patients on ventilators, only half of sleep occurs during the normal sleep hours of 10 p.m. to 6 p.m., and, sometimes, they get no REM sleep at all, Reishtein wrote in a 2005 review article in Critical Care Nursing Clinics of North America.

In a 2003 paper in that same journal, Richards, now director of the Polisher Research Institute in North Wales, Pa., and co-authors from the Central Arkansas Veterans Healthcare System recommended that ICU nurses use such alternative therapies as music, therapeutic touch and massage to promote sleep in their patients.

And in a study published last month in Nursing Critical Care, British researchers found that earplugs and eye masks, which cost a little more than $5 a patient, appeared to improve such patients’ sleep. In Dallas, Friese is planning to conduct a small pilot study that will randomly assign patients to standard ICU care or standard care plus an eye mask, earplugs and Ambien, a sleeping pill.

“There are some skeptics who say no matter what you do with the environment, patients are still not going to sleep well,” Friese says. “I think it’s likely that if we improve sleep, we’re going to have better outcomes.”

Courtesy of © 2008, YellowBrix, Inc.

---