Sleep Deprivation Is Frequently a Direct Result

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 it in hospital settings. 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 the National Institute of Neurological Disorders and Stroke report that, "Sleep-deprived rats also develop abnormally low body temperatures and sores on their tail and paws. The sores may develop because the rats' immune systems become impaired" (Understanding sleep, 2013, para. 3). Some studies suggest that sleep deprivation affects the immune system in detrimental ways (Hultman et al., 2012). Additionally, a lack of sleep in hospitalized patients is now regarded as a dissatisfier in evaluations of the hospital experience on patient satisfaction surveys mandated by the Joint Commission and other accrediting agencies (Hultman et al., 2012).

Organization of the Study

The study was organized into five chapters. The first chapter was used to introduce the issues of interest, the guiding research questions, and why this study was timely and important. Chapter two of the study presents a critical review of the relevant peer-reviewed and scholarly literature concerning sleep, its stages and the implications of its disruption in hospital settings in general and on intensive care units in particular. Chapter three of the study was used to describe more fully the research methodology used, and chapter four presents the analysis of the primary data gathered for the study. Finally, chapter five provides a discussion of the study's findings and applications to nursing practice.

Chapter Two: Synthesis of Review of Literature

Background and Overview

Everyone does it, of course, but like fire, sleep is difficult to accurately define. For instance, the National Institute of Neurological Disorders and Stroke reports that, "Until the 1950s, people thought of sleep as a passive, dormant part of daily life. We now know that sleep affects our daily functioning and our physical and mental health in many ways that we are just beginning to understand" (Understanding sleep, 2013, para. 1). Some sleep scientists sleep as "a period of behavioral quiescence and non-responsiveness to the environment that is electroencephalographically, physiologically, and behaviorally distinct from the waking state" (Kushida, 2005, p. 1). Likewise, it is difficult to quantify the effects of noise on sleep because human hears things in different ways and intensities. In sum, sound is measured in terms of its pressure as a sound level, or sound pressure level termed "SPL" which is noise measured in decibels using a sound level meter, or "SLM" (Lawson, Thompson, Saunders, Saiz, Richard, Brown, et al., 2010).

As the ratio between a measured and referential level, decibels are recorded along a nonlinear logarithmic scale (Lawson et al., 2010). Because human hearing detects different frequencies with different sensitivities, some people hear sounds more loudly than others and others hear different frequencies with more intensity compared to others (Lawson et al., 2010). Taken together, Lawson and her associates conclude that, "For these reasons, sound can be relatively complex to quantify and define" (2010, p. 89). In addition, Lawson et al. found that, "Evidence suggests that continuous levels of noise, even those as low as 60 dB (A), have physiological effects on blood pressure and salivary cortisol levels" (p. 90).

In their study of noise in critical care units, Xie, Kang and Mills (2009) defined noise as "as unwanted sounds [that] could affect people both psychologically and physiologically" (p. 1). An important point made by Wenham and Pittard (2009) is that noise "is subjective and influenced by several factors such as individual sensitivities, cultural and social factors, the sense of having control over the sound, and whether it is appropriate to the situation" (p. 178). At present, the stages of sleep are divided into two states: (a) rapid-eye-movement (REM, or "paradoxical" sleep in animals) and (b) non-REM (NREM) sleep which are electroencephalographically, physiologically, and behaviorally discrete (Kushida, 2005). According to Patel et al., the deepest stage of sleep, REM, is especially important for restful sleep. In this regard, Patel and her associates emphasize that, "Rapid eye movement sleep is characterized by an active brain activity with absent muscle activity and is the stage where most dreaming is believed to take place" (2008, p. 309). The NREM stage of sleep is currently further subdivided into four stages 1-4 (or I-IV) that indicate the depth of sleep that is being experienced, as well as the presence of specific electrophysiologic markers that reflect brain activity (Kushida, 2005).

When this normal architecture of sleep is disrupted, sleep deprivation can occur with a wide range of adverse clinical outcomes. In this regard, sleep deprivation is defined as "the partial or near-complete removal of sleep in an organism" (Kushida, 2005, p. 1). Although it is not possible to accumulate extra sleep like money in the bank, it is possible to overcome sleep deficits by getting extra sleep (Kushida, 2005). According to the clinicians at the National Institute of Neurological Disorders and Stroke, "The amount of sleep each person needs depends on many factors, including age. Infants generally require about 16 hours a day, while teenagers need about 9 hours on average. For most adults, 7 to 8 hours a night appears to be the best amount of sleep" (Understanding sleep, 2013, para. 2).

These averages, though, also mean that some people may require far less sleep and some, pregnant women and infants or those recovering from an illness, for example, may require far more in order to maintain their "normal" sleeping patterns (Understanding sleep, 2013). When humans are deprived of sleep for long periods of time, though, they find it harder and harder to remain wakeful to the point where they engage in spontaneous micro-sleeps that are difficult to discern (Kushida, 2005). These so-called "microsleeps" are "an inevitable consequence of sleep deprivation, and the accumulation of these very brief sleep periods may add up to significant amounts of sleep as the deprivation period progresses" (Kushida, 2005, p. 2).

There are number of different levels of sleep deprivation besides being totally sleep deprived; for instance, partial sleep deprivation refers to two different constructs, with the first being situations wherein sleep is limited to levels that are less than normal sleep amounts, regardless of the sleep state or stage involved (Kushida, 2005). As an example, Kushida reports that, this type of partial sleep deprivation may involve a human getting less than 50% of their benchmark sleep amount each night. The second type of partial sleep deprivation may be state specific; in other words, where a subject may be denied NREM or REM sleep, or sleep stage specific wherein subjects are specifically deprived of any of the various stages of NREM sleep (Kushida, 2005).

An important point made by Kushida is that it is not possible to deprive humans of a stage or state of sleep without also affecting the other stages or states of sleep. According to Kushida, "Deprivation of REM sleep will inevitably result in a decrease in NREM sleep amounts, and vice versa. Subjects may also be acutely or chronically sleep deprived, with increased effort required, for the longer periods of deprivation" (p. 1). Yet another type of sleep deprivation occurs during sleep fragmentation, a process that involves people waking during their sleep; fragmented sleeps can be sleep stage/state specific or not, but subjects can also be denied sleep as the result of various sleep disorders or medical problems that hinder restful sleep (Kushida, 2005). According to Hardin (2009), "Partial sleep deprivation may be chronic and may constitute insufficient hours of sleep, a reduction or absence of a specific sleep stage, and, often overlooked, the lack of consolidated sleep due to one or more factors that elicit awakening or arousals and impair the normal progression/pattern of sleep stages" (p. 264).

There are some theoretical frameworks that have been advanced in recent years to help explain why people sleep, with behavioral adaptation sleep theory maintaining that humans sleep in an effort to remain static when there was insufficient light for hunting (Lavie, Pillar & Malhortra, 2002). Similarly, but somewhat differently, the Benington/Heler theory argues that sleep satisfies humans' energy conservation needs, and this theory has received some support from research that confirms during periods of wakefulness, energy levels in the brain decrease and then increase again during periods of sleep when energy expenditures and oxygen consumptions are suppressed (Lavie et al., 2002).

Finally, the restorative theory of sleep maintains that this is period restoration and growth for the brain and the body (Lavie et al., 2002). According to Lavie and his associates, "The finding that sleep increases after rigorous exercise supports this theory, as does the observation that growth hormone is mainly released during sleep, especially during deep sleep" (2002, p. 137). Still other researchers argue that brain processing and the organization of the enormous amounts of data acquired throughout the waking period compels the body to sleep in order to use this information in the future; the REM sleep stage is believed to play a specific role in this area (Lavie et al., 2002). Irrespective of its precise etiology, the adverse clinical implications of sleep disruption and altered sleep patterns on ICU patients are well documented, and these issues are discussed further below.

Clinical Implications of Sleep Disruption and Altered Sleep

Healthcare providers from Galen's Regimen sanitatis Salernitanum to Florence Nightingale's advice to "tailor interventions that take into account the unique characteristics of the person receiving care, including affective state, biological state, cognition, ethnicity, beliefs, goals, needs, preferences, and resources" have all stressed the need for ensure people receive sufficient rest and sleep (Richards & Enderlin, 2007). According to Neergaard (2013), insufficient sleep can cause a wide range of adverse healthcare outcomes, including high blood pressure, obesity, depression, memory problems and a diminished immune system. Moreover, Neergaard emphasizes that, "There's been far less research on how much sleep disruption interferes with recovery from illness. But some studies show patients in noisier wards require more medications and sedatives" (p. 3).

Furthermore, critically ill patients in the ICU are routinely prescribed sedatives to facilitate their treatment and to increase their comfort levels, and these medications also allow some patients to better tolerate mechanical ventilation, provide an adjunct to pain management, and assist patients in coping with the psychosocial stresses of their critical illnesses (Weinhouse & Watson, 2009). They have also been believed to facilitate sleep; however, the relationship between sedation and sleep is complex. Patients under the influence of sedation may appear to be asleep; however, sedation differs from sleep physiologically and clinically. This relationship may be important because it has become apparent that intensive care unit (ICU) patients sleep poorly and that this poor sleep is associated with poor ICU outcomes (Weinhouse & Watson, 2009). According to Weinhouse and Watson:

It is known that patients respond to anesthetic agents differently when sleep-deprived than when allowed to sleep, and animal models further suggest that there may be a genetic relationship between sleep and sedation. Ultimately, because the functions of sleep are not known, it is not possible to determine if the essential benefits of sleep are recovered during sedation" (pp. 540-541)

What is also known is that patient reports of satisfaction with the quietness of their hospital rooms is a quality indicator in survey used by Press Ganey in their Hospital Consumer Assessment of Healthcare Providers and Systems scores (Wessel, 2012). Moreover, while there is a growing body of evidence that confirms the connection between disrupted sleep on the ICU and adverse clinical outcomes, clinical studies are confounded by the ethics involved in experimenting with sick people in the first place and the fact that the quality of sleep obtained on an ICU may be fundamentally different yet quantitatively the same as sleep obtained elsewhere. For instance, Freedman, Gazendam, Levan et al. (2001) report that, "Although previous investigators evaluating sleep patterns in ICU patients have demonstrated altered sleep architecture and sleep deprivation, little is actually known about sleep in the critically ill. Most of our current knowledge is based on studies evaluating only nocturnal sleep, rather than over 24-hour period" (p. 451).

The two clinical studies to date in this area have found reduced levels of total sleep time, an altered sleep architecture with a predominance of stage 1 and 2 sleep, decreased or absent stage 3, stage 4, and rapid eye movement (REM) sleep, shortened REM periods, and sleep fragmentation (Freedman et al., 2001). In addition, the distribution of sleep experienced on ICUs in these two studies showed that as much as half of all sleep was obtained during the daylight hours (Freedman et al., 2001).

Indeed, because peaceful sleep has been shown time and again to contribute to the convalescence process, the negative implications of noise in hospital units can be severe and include cardiovascular stimulation, hearing loss, increased gastric secretion, pituitary and adrenal gland stimulation, suppression of the immune response to infection, as well as diminished female reproduction and fertility levels (Xie et al., 2009). Citing World Health Organization (WHO) recommendations for noise levels inside hospital wards that should not exceed 30 dBA at night in terms of sleep disturbance, Xie and her associates emphasize that, "Unfortunately, most case studies, especially the recent data, show that noise levels inside hospitals are much higher than the guideline values" (p. 1). Furthermore, the problem has even become more severe in recent years, with the average noise levels inside hospitals increasing by an average of 0.38 dBA (day) and 0.42 dBA (night) per year since the 1960s (Xie et al.). Some representative noise levels and their associated sound pressures levels are set forth in Table 1 and depicted graphically in Figure 1 below.

Table 1

Examples of Commonplace Noise Levels

Example of noise

Sound pressure level [dB (A)]

Jet aircraft taking off at 50 meters/ship's engine room

Loud music in a disco

Lawn mower at 1 meter

90

Vacuum cleaner at 1 meter

70

Average ICU sound level

60 -- 70

Conversation at 50 meters

55

Soft whisper in a library

40

Source: Wenham & Pittard, 2009, p. 180

Figure 1. Examples of Commonplace Noise Levels

Source: Based on tabular data in Wenham & Pittard, 2009, p. 180

These are particularly important issues in intensive care units (ICU) where the need for recuperative periods of rest is crucial and the need has been long known (Baker, 1984). In this regard, Bihan, McEvoy, Mathieson et al. (2012) report that, "Disrupted sleep is associated with immune system dysfunction, impaired resistance to infection, alterations in nitrogen balance, impaired wound healing, and cardiorespiratory and neurological consequences" (p. 301). A number of polysomnographic studies have shown decreased total sleep time, sleep fragmentation, and altered sleep architecture in patients recovering in ICU wards (Bihan et al., 2012). Likewise, Tembo and Parker (2012) report that sleep is vital for the healing process to occur in order to survive critical illness. These researchers report that sleep deprivation adversely affects patient recovery and their ability to resist infection.

Moreover, sleep deprivation frequently contributes to the onset of neurological problems such as delirium and causes respiratory problems due to the weakening of the upper airway muscles (Tembo & Parker, 2012). Likewise, Wenham and Pittard (2009) report that, "Delirium in the ICU has an incidence of 15 -- 80%, and, in the past, has been notoriously difficult to quantify" (p. 180). These are especially salient issues for ICU practitioners because of the inherently noisy environment and the fact that the most ill patients are in the ICU in the first place. For instance, according to Lawson et al. (2010), "In the ICU, the primary health effect of noise is disturbed sleep, which can lead to problems such as slower healing, a poorer immune response, and decreased cognitive function. A lack of sleep has also been associated with ICU delirium" (p. 90).

Likewise, in an interview with Dr. Jeffrey Ellenbogen, sleep medicine chief at Massachusetts General Hospital, Neergaard (2012) reports that, "In fact, the wards with the sickest patients -- the intensive care units -- can be the loudest. One study found the decibel level in ICUs reaches that of a shout about half the time" (emphasis added) (p. 3). There has also been research by nurses that has provided support for the conclusion that ICU-generated noise places patients at increased risk for experiencing sleep-related problems (Topf, Bookman & Arand, 1996). According to Topf and her associates, "Technological advances contribute to this problem. Although data on the negative effects of ICU noise on physiological sleep are available, less attention has been given to self-reports of the subjective quality of sleep following exposure to this stressor" (p. 545). Practitioners at Johns Hopkins Hospital have also recognized noisy ICUs as a major source of concern and have taken steps to address the problem. According to Levitt (2013):

A hospital is not the best place to get a good night's sleep, especially in a noisy intensive care unit. It's a cause for concern because studies have shown that a lack of sleep can cause patients to experience delirium - an altered mental state that may delay their recovery and lead to short- and long-term confusion and memory problems. (para 2)

More troubling still, these researchers found that many ICU patients were unable to recall all of the arousing events that disturbed their sleep, but the telemetry provided by monitors indicated that just a very small fraction of these arousing events were recalled, suggesting the problem may be far more severe than many researchers currently believe (Levitt, 2013). In response to their noisy intensive care unit environments, a team of clinicians, including physicians, nurses, psychologists and pharmacists collaborated on potential noise-mitigation strategies and succeeded in reducing the chances of ICU patients experiencing delirium by more than one half, even for those requiring mechanical ventilation (54%) (Levitt, 2013). Moreover, a team member reports that, "In addition, many patients said that the ICU was quiet and comfortable enough for them to get a good night's sleep" (cited in Levitt, 2013, para. 2). The noise-mitigation strategies developed by the multidisciplinary team at Johns Hopkins consisted of three stages of interventions as follows:

1. Stage One: This stage consisted of a 10-item environmental checklist that included turning off televisions, room and hallway lights, safely consolidating the number of staff visits to patient rooms overnight for drawing blood and giving medications to reduce interruptions, reducing overhead pages and minimizing unnecessary equipment alarms.

2. Stage Two: In this stage, patients were offered eye masks, ear plugs and tranquil music to facilitate sleep.

3. Stage Three: New medication guidelines were introduced that discouraged giving patients certain commonly prescribed drugs for sleep, such as benzodiazepines, that are known to cause delirium (Levitt, 2013, para. 2).

Using baselines obtained from 122 ICU patients over an 8-week period, the Johns Hopkins team evaluated a subsequent set of 178 patients every 12 hours using the Confusion Assessment Method for the ICU (CAM-ICU). After all three stages had been implemented, the researchers reported a significant decrease in the prevalence of patient delirium compared to the baseline group (Levitt, 2013). Improving the quality of sleep for ICU patients has a number of beneficial outcomes, including an improved ability to participate in physical therapy regimens during the day and an overall reduced length of stay on the ICU (Levitt, 2013). According to the lead researcher of the Johns Hopkins study, Kamdar, "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" (2013, p. 809).

In fact, although the results of the Johns Hopkins Hospital study are recent, the connection between a noisy ICU environment and ICU delirium was made sufficiently long ago that there should no longer be any doubt concerning the importance of noise mitigation strategies in the ICU today. The results of a 1987 study by Wilson found that more than half of all patients experience some type of impaired psychologic response during their stay on an ICU, with 33% experiencing hallucinations. Citing the results of this study, Zalumas (1995) reports that, "Too much noise, losing track of time, hearing doctors or nurses talk about rather than to the patient, and being examined by several doctors and nurses were the most significant stressors that impaired healthy coping" (p. 27).

To date, Wilson and other researchers have consistently found a strong correlation between sleep deprivation and an impaired stress response to ICU environments (Zalumas, 1995). As noted throughout, not only is sleep in general not fully understood, everyone's needs for sleep differ, as well as changing over time and even from time to time. Consequently, analyzing the precise effects of sleep deprivation in the ICU is complicated by the broad-based nature of its antecedents as well as how these affect people in real-world settings when they are experienced extraordinary circumstances. In this regard, Zalumas emphasizes that, "Sleep deprivation is difficult to test as an isolated variable because many factors impair stress responses, including patient age, severity of illness, psychological history, metabolic and drug factors, and the use of cardiopulmonary bypass pumps, as well as environmental factors" (p. 27). Despite this lack of uniformity in potential variables, there is growing recognition in the academic and scientific literature that noise is a potential stressor and is widely regarded as a major factor that adversely affects patient orientation in the ICU (Zalumas, 1995).

The results of a study by Wenham and Pittard (2009) found that in the ICU, "Exposure to noise can be annoying, ranks highly among causes of stressors, and is clearly an individual, subjective, and variable response" (p. 180). Depending on the patients' condition, these variable responses can include adverse effects on cardiac recovery, for instance. In this regard, Wenham and Pittard report that, "Perceived lack of control over noise, for example, may contribute to noise-induced stress. Noise exposure may trigger a response by the sympathetic nervous system, thereby increasing cardiac work and may also have adverse effects on respiratory muscle function" (p. 180). In addition, excessive noise in the ICU may require more sedation for patients who are already critically, a process that can further hamper communication with staff and exacerbate hearing loss and the onset of ICU delirium (Wenham & Pittard, 2009).

A summary of sleep deprivation's effects on the human immune system is shown in Table 2 below.

Table 2

Summary of Sleep Deprivation's Effects on the Human Immune System

Metric

Sleep Deprivation

Metabolic rate

Increased

PMN/lymphocyte counts

Decreased

NK cells

Dysfunctional

PMN

Dysfunctional

Antigen-specific defenses

Impaired

Mortality

Increased

Note: PMN, polymorphonucleocyte; NK, natural killer.

Source: Friese, 2008, p. 698

Despite the growing body of research into the effects of sleep disturbance and disruption in the ICU, there remains a lack of timely and relevant research concerning the wide range of factors that may contribute to the levels of noise in these intensive care wards (Friese, 2008). In this regard, Friese emphasizes that, "As we continue to improve the quality of critical care interventions, we must not overlook the importance of supporting the body's basic needs, namely nutrients, exercise, and sleep" (p. 146).

These issues are also cited by Stanzak who cautions "Constant exposure to 24-hour per day fluorescent lighting plays havoc with the body's biological clock. This disruption of biorhythms increases the amount of stress on an already over-stressed system and may result in a phenomenon known as ICU psychosis" (p. 94). Although is consistently ranked among the top environmental stressors in the ICU, lighting is also cited time and again by researchers as being a major factor as well. In this regard, Wenham and Pittard (2009) report that, "It is recognized that the human sleep -- wake cycle is closely linked to the environment and, along with social cues and sounds, the light -- dark cycle is probably the most powerful linking factor" (p. 180). The clinical implications of these disrupted sleep patterns may be for more severe for ICU patients compared to their healthier counterparts elsewhere in the hospital or their healthy counterparts at home. As Wenham and Pittard point out, "Sleep -- wake cycles can be prolonged if these linking factors are altered, and in some ICUs, patients are not exposed to any natural light. Patients may then become unable to distinguish night from day and this can contribute to disorientation" (2009, p. 180). In the perpetually and artificially illuminated ICU setting, such disorientation can assume truly severe levels. According to Wenham and Pittard, "Although light intensity on ICU usually reflects a 24-hour circadian rhythm, bright lights from the nurses' station, lights that are not dimmed, and lights that are turned on at night can be very disrupting to patients' sleep" (2009, p. 181). One such consequence is ICU delirium. Patients suffering from ICU psychosis enter a delirious state that is characterized by confusion and agitation (Stanzak, 2006). A number of clinical studies have found that the most disruptive environmental factors were the noises caused by alarms, pain, artificial lights and endotracheal intubation or mechanical ventilation (Stanzak, 2006). The adverse clinical outcomes that can result from these problems include longer periods of ventilation, lengthened stays on the ICU and more complicated periods following extubation (Tembo & Parker, 2012). These findings highlight the importance of the built environment as well as the presence of various medical equipment in contributing to noise and lighting levels that can have an adverse effect on the physical and psychosocial well-being of patients, their families, and hospital staff (Sherman-Bien, Malcarne & Roesch, 2011).

Unfortunately, a growing body of evidence confirms that tertiary healthcare facilities in general and ICUs in particular are noisy places, and the sources of noise are multiple. A seminal study by Baker (1984) cites various environmental factors on the ICU as detracting from the quality of sleep, including the types of lighting used, crowding with unfamiliar people, unpleasant smells, disturbing and/or painful touches, and noise from machinery, people and the background environment. A more recent study by Bihan et al. (2012) determined that the most frequent environmental factors that adversely affected sleep on an ICU ward were noise from intravenous pump alarms, televisions, and bedside telephones. In addition, the types of pharmacological interventions that are used can have a profound impact on sleep (Bihan et al., 2012).

Likewise, a study by Shepley, McCuskey; Raymond et al. (2012) found that the physical environment in the ICU has a significant effect patients, as well as family members and staff. Not surprisingly, Shepley et al. conclude that, "The impact of the design of intensive care units (ICUs) may be particularly significant in light of the levels of stress experienced by staff and the vulnerability of families and patients" (p. 46). Furthermore, beyond the foregoing adverse clinical outcomes, a study by Aslan, Badir, Arli et al. (2009) found that environmental factors in ICUs such as constant light and noise can intensify the feeling of pain by patients which frequently goes unreported because of their inability to adequately communicate these levels following surgery.

The research to date that has sought to identify relevant factors that cause sleep disturbance have concentrated largely on subjective self-reports by patients, empirical observations from nursing staff and various objective data concerning sleep (Hultman et al., 2012). A study by Freedman, Kotzer, and Schwab (1999) used a patient questionnaire that rated the effects of factors related to both environment such as noise as well as human interventions such as diagnostic activities and monitoring vital signs to investigate the discrete environmental contributors that contributed to sleep deprivation in the intensive care unit and the quality of patient sleep. The findings that emerged from the Freeman et al. (1999) were congruent with the findings reached by Simpson, Lee, and Cameron (1996) that also requested patients to rate the environmental factors that most adversely affected their sleep, with the results of both studies shown that patients' sleep was disrupted when they felt uncomfortable, when they were awakened for procedures, and when the ICU environment was noisy.

Further exacerbating the problem of sleep disruption and deprivation on the ICU is the fact that sleep may be elusive for many patients because of fears, anxiety and worries concerning their medical condition (Soh & Soh, 2008). In this regard, Soh and Soh point out that "ICU patients are frequently stressed -- with fear, lack of knowledge or information about their situation, cultural and language barriers, and a feeling of being disempowered being some of the factors" (p. 87). In addition, many ICU patients are already distressed psychologically and physically as a result of having to undergo various invasive and uncomfortable procedures such as being physically examined or having a urinary catheter inserted, making sound sleep especially difficult (Soh & Soh, 2008).

Because of patients' medical conditions, medications, diagnostic procedures, invasive interventions, medical devices, noisy and crowded environments, the rate of agitated patients is very high in the ICU (Intensive Care Unit) (Cohen et al., 2002; Maccioli et al., 2003). In addition, according to Ozdemir and Karabulutmore (2009), more than 70% of ICU patients experience some level agitation while they are on an ICU ward. According to Ozedemir and Karabulutmore, "Agitation can be defined as excessive motor activity, consisting of purposeless behaviors such as pacing, fidgeting or hand-wringing, and a feeling of anxiety or tension. In this sense, agitation is not a medical diagnosis but, rather, a symptom of certain diseases, disorders and conditions common in intensive care patients" (p. 120). Therefore, there is an ongoing need to identify treatable and preventable factors that contribute to sleep disturbances on the ICU. These factors have been shown to include pain, sleep deprivation, unwanted noise, and the unnatural lighting used on ICUs (Ozdemir & Karabulutmore, 2009).

According to Bijwadia and Ejaz (2009), the harsh reality of the ICU environment is that some of these environmental sources are virtually unavoidable. In this regard, Bijwadia and Ejaz emphasize that, "The ICU is geared towards specifically treating organ failures and providing a higher level of nursing care. However, these benefits come at substantial physiological and psychological discomfort to the patient" (p. 25). Likewise, Wenham and Pittard (2009) emphasize that, "The ICU is a potentially hostile environment to the vulnerable critically ill patient. In addition to the physical stress of illness, pain, sedation, interventions, and mechanical ventilation, there are psychological and psychosocial stressors perceived by these patients" (p. 178). Despite receiving sedatives to facilitate sleep, studies have confirmed that critically ill patients are typically unable to sleep well in the ICU. According to Wenham and Pittard:

In general, patients in critical care units may spend 30 -- 40% of their sleep time awake, sleep may be highly fragmented and distributed throughout the day and night, and there is a reduction in slow wave and REM sleep. There may even be a complete absence of definable sleep or wake states in septic patients. (2009, p. 180)

Other factors that are frequently cited by patients as being disruptive and interfering with their recovery is the ICU environment itself that is increasingly believed to contribute to the syndrome known as ICU psychosis/delirium (Wenham & Pittard, 2009). In addition, Wenham and Pittard report that, "Frequently reported stressful environmental factors are noise, ambient light, restriction of mobility, and social isolation" (2009, p. 179).

Consequently, it would seem that the combination of the specialty equipment used in ICUs and the routine sources of noise in all hospitals becomes sufficiently severe to interfere with patient and staff communications, with a concomitant impact on the quality and quantity of sleep obtained. For instance, Walker (2007) emphasizes that, "In most hospitals, quiet surroundings are considered vital to recuperation. In reality, hospital hallways are often the source of a cacophony of seemingly unavoidable noises: beeping monitors, squeaky medication and meal carts, blaring intercoms, late-night conversations between nurses and patients" (para. 1). Nevertheless, many of these environmental sources are intractable to change. For example, Friese (2008) points out that:

Most physicians, if not all, readily support the notion that achieving an adequate amount of quality sleep is essential for speedy recovery from acute illness, and promptly send their patients home with a prescription for adequate rest. However, when these acute illnesses require hospital admission, the importance of attaining adequate rest takes a back seat secondary to the necessities of running a hospital ward. (p. 1)

The substantial physiological and psychological discomforts experienced by many people are inevitable because the most critically ill patients in hospitals are located on their ICUs (Stanzak, 2006). As Stanzak points out, "Due to intensive individualized care and monitoring, these patients often suffer from severe sleep deprivation" (p. 94). As noted throughout, although it may be inevitable, the adverse outcomes associated with sleep impairment and disruption on the ICU are broad-based and severe. According to Stanzak, "By impairing protein synthesis, cell division, and cellular immunity, sleep deprivation can affect the healing process thereby contributing to an increased morbidity and mortality" (p. 94).

Normal sleep architecture divides sleep into 2 main types: (a) REM sleep and (b) NREM sleep, with NREM sleep being further subdivided; Stages 1 and 2 are light stages of sleep (termed N1 and N2) and Stages 3 and 4 of sleep are deeper stages (termed N3) which are collectively referred to as SWS (Lee & Douglass, 2010). According to Lee and Douglass, "SWS is important in CNS energy restoration and declarative memory (memory for facts and [or] events), which has significant consequences for psychiatric disorders with cognitive dysfunction" (p. 404). The function of the transition from SWS to REM sleep is believed to help mitigate the effect of the previous waking experience (Lee & Douglass, 2010).

The current views concerning the architecture of normal sleep stages are set forth in Table 3 below.

Table 3

Normal Sleep Architecture: Stages of Sleep

Stage

Description

Stage I

This stage of sleep, also known as N1, is the transition from wakefulness to sleep and is characterized by replacement of the waking alpha EEG pattern by a low-voltage mixed frequency pattern. It is the lightest stage of sleep and typically occupies 3 -- 8% of the night. An increased amount or percentage of stage I sleep typically suggests sleep fragmentation due to a sleep disorder.

Stage II

Stage II sleep, also known as N2, typically accounts for 40 -- 55% of total sleep time. This stage is characterized by a slowing of EEG frequency and an increase in EEG amplitude. Characteristic EEG patterns called sleep spindles and K. complexes are seen in this stage.

Stages III and IV

These stages, frequently referred to collectively as SWS, or deep sleep or slow wave sleep, typically accounts for 20% of total sleep time in young adults. Stage III is characterized by a transition to an EEG with high-amplitude delta waves, EEG waves with a frequency of 0.5 -- 2Hz and amplitude of at least 75 mV. In rapid eye movement (REM) sleep, the EEG resembles wakefulness in many ways, but muscle activity is greatly reduced. It typically occupies 20 -- 25% of total sleep time. REM sleep is associated with the greatest instability of respiratory and cardiac function during the night. Non-REM and REM alternate in cycles that typically last about 90 minutes. The ratio of non-REM and REM sleep varies in each cycle, with REM predominating in the latter third of the night. The temporal arrangement of sleep stages as they sequentially occur through the night is described graphically by a hypnogram (see Figure 2 below).

Figure 2. Hypnogram of stages of sleep

Source: Adapted from Bijwadia and Ejaz, 2009, pp. 25-26; graphic from Understanding sleep, 2013 at http://www.ninds.nih.gov/disorders/brain_basics/understanding_sleep.htm.

One of the most common complaints of patients that manage to survive a critical illness is a lack of sleep in the ICU, with the current body of knowledge confirming that sleep fragmentation routinely occurs in ICU patients with a concomitant decrease in the percentages of the deeper stages of sleep (Rotondi, Lakshmipathi, Sirio et al., 2002). For instance, according to Rotondi and his associates, "The total number of hours of sleep over a 24-hour period may be relatively normal (7 -- 9 hours), but approximately 50% of sleep hours occur during the day in short bouts (this makes it more difficult for the patient to achieve REM and delta sleep)" (2002, p. 476).

Moreover, even in those cases where patients succeed in acquiring normal total sleep times, there is typically an elevated percentage of wakefulness in which there is more stage I sleep and less stage II, N3, and REM sleep stages experienced (Rotondi et al., 2002). During their stays on ICUs, patients also experience increased arousals and awakenings compared to their normal healthy counterparts (Rotondi et al., 2002). A survey of ICU patients indicated that most of them were "moderately" or "severely" bothered by these disruptions in their sleep (Rotondi et al., 2002). These findings are congruent with the results of a study by Weinhouse and Watson (2009). According to Weinhouse and Watson (2009):

Experimental models of sleep fragmentation and sleep stage deprivation have demonstrated many of the same consequences as with periods of total sleep deprivation, but controlled studies have not been done in the critically ill. It is clear, however, that problems with sleep have had a profound effect on patients who consistently recall their ICU sleep problems as disturbing. (p. 541)

Likewise, Bijwadia and Ejaz (2009) cite the results of another study of ICU patients that found that nearly 40% (38.5%) of patients surviving critical illness and who had spent a minimum of 48 hours on a mechanical ventilator reported being unable to sleep. According to Bijwadia and Ejaz, "Forty percent remembered awakening in the middle of the night and 35% recalled having trouble falling asleep during their ICU admission. The vast majority of these patients were either moderately or extremely bothered by these problems" (2009, p. 25). It is reasonable to suggest that many, if not most, of these patients will recall their ICU experience in these terms rather than the caring and compassionate care that allowed them to remember them in the first place, but the fact remains these perceptions of quality of care frequently translate into suboptimal clinical outcomes.

In truth, these levels and patterns of sleep disruption are not that difficult to understand given the inherently noisy environment of most ICUs (Hardin, 2009). For example, the U.S. Environmental Protection Agency recommendation for hospital noise levels are 80 dB (Hardin, 2009). Therefore, it is little wonder that so many ICU patients have been reporting experiencing difficulties sleeping in these noisy conditions! Indeed, Xie, Kang and Mills (2009) emphasize that, "The noise level in intensive care units (ICUs) ranges from 50 to 75 dBA, with the highest night peak level even reaching 103 dBA. Sleep disturbance is thus a common problem for patients" (p. 10).

Despite the noisy environment, though, only between 10% to 30% of ICU patients in one study reported noise (including staff talking -- cited more than a quarter of the time, various alarms, ventilator noise, suctioning sounds, beepers, telephones and televisions) as the sole causes of their arousals or awakenings. These causes of sleep disruptions became even more pronounced as patients recovered in the ICU, suggesting that as they became more healthy, noise on the ICU was regarded as a more disruptive factor (Hardin, 2009). Nevertheless, given the severe adverse clinical implications of disrupted sleep on the ICU, it appears that far too little attention has been paid to these issues in the past beyond reporting the causes rather than seeking to identify solutions. As Hardin points out, "High-level evidence regarding the effect of sleep deprivation on recovery from acute illness or the morbidity and mortality in ICU patients remains to be described" (2009, p. 284).

Although more research is needed to identify the precise effects of sleep deprivation on patient recovery in the ICU, there are some steps that staff members can take to help mediate these environmental factors, including noise reduction, light reduction, patient comfort improvement and clustering of patient care activities that promote more uninterrupted time for adequate sleep in the ICU (Eliassen & Hopstock, 2011). Because these factors are well-known, Eliassen and Hopstock emphasize the need for staff members to develop strategies to counter them which can be relatively straightforward to implement and monitor for effectiveness. Some of the strategies that proved effective for Eliassen and Hopstock's ICU included three main areas: noise reduction, lighting practices and patient comfort as follows:

1. Noise reduction strategies: reduce alarm levels on monitors, reduce alarm levels on ventilators; avoid bedside staff conversations; and, offer earplugs.

2. Lighting practices: turn off small lamps; turn off ceiling lamps; pull down window shades; and, offer eye masks.

3. Patient comfort: bed adjustments/patient position; patient -- ventilator synchrony; adequate pain relief; and, massage, mouth care.

Beyond the foregoing most commonly used interventions, other strategies reported being used for encouraging nighttime sleep included performing foot- or hand massage, holding the patient's hand, sitting within visual distance if the patient was anxious, or offering television, radio or music if the patient desired such entertainment before sleeping (Eliassen & Hopstock, 2009). Daytime sleep strategies for promoting sleep included massage in connection to caring routines, engaging in all such efforts during all shifts, and informing the patient when it was time to sleep (Eliassen & Hopstock, 2009).

Chapter Three: Data-Gathering Method/Procedures

Data-Gathering Method

Members of the CICU Quiet Initiative Committee designed a survey (see pro forma copy at Appendix A) to be given to current patients. The survey instrument addressed the types of noise that patients experienced, the times they felt were the noisiest, and the respondents' views concerning the response of staff to alarms. The survey instrument was kept simple to facilitate completion by ICU patients who were still recovering from the effects of their surgery and/or pharmacological interventions. The Quiet Initiative Committee members not directly involved in the care of the patients distributed and collected the completed surveys. All told, the sample included 33 patients. The data were collected over a period of 4 weeks, entered into Excel, and downloaded into SAS 9.1 for analysis and the results graphed where appropriate. This data gathering method is highly congruent with the guidance provided by Grinnell and Unrau (2005) who advise that, "Surveys can be designed to achieve a variety of ends, but they all seek to collect data from many individuals in order to understand something about them as a whole" (p. 272).

Procedures

Based on the overarching need for simplicity in survey design, the design of the survey instrument followed the guidance provided by Proctor and Vu (2005) for this purpose as set forth in Table 4 below.

Table 4

Custom Survey Design Principles

Design Principle

Description

Is the language simple?

Write the questions so they will be easily understood by the target users. For example, "use" instead of "utilize." This is the case for both language and sentence structure.

Is the question clear?

Avoid using words that are ambiguous. It is also important to ask only one question at a time. If the item contains "and" or "or," there is a good chance that the researcher has inadvertently asked more than one question.

Is it short?

Long sentences are more likely to contain complex phrases and sentence structure. In addition, long questions are sometimes difficult to follow and increase the workload on the respondent.

Is there any bias present in the question or the response choices?

Do not bias the users' potential response by using leading language in the question. Do not introduce the user to new facts, avoid mentioning one side of a semantic differential scale, and lead users through your choice of response categories.

Does the question have the right level of specificity?

Response choices should not be so general that the user cannot possibly determine the answer; however, they should be specific enough to be useful for the study.

Is the question objectionable?

Each item should be reviewed for the possibility of either inappropriate tone or content. This is of particular concern when a survey is cross-cultural where the questions, sentence structure, and language may be perfectly acceptable in one culture but potentially offensive in others.

Source: Adapted from Proctor & Vu, 2005, p. 311.

Patient room numbers were noted to identify especially noisy areas on the unit. Patient inclusion criteria included having had at least a 24-hour stay, alert and oriented, and able to read and follow instructions on the survey. The use of a custom survey instrument to collect patient satisfaction data concerning their perceptions of noise on the ICU and its effects on the quality and quantity of sleep they obtained is also congruent with the practices used by several other nursing research teams (Wessel, 2012; Rogers, 2009). The findings that emerged from the ICU patient survey are described further in chapter four, data analysis, below and discussed narratively in chapter five, discussion/application to practice, that follows.

Chapter Four: Data Analysis

Results:

The results of the ICU patient survey showed that consistent with much of the literature concerning sources of noise in the ICU, monitor alarms were rated as the most bothersome noise by the most patients (30.3%). Rated in the top three sources of bothersome noise were monitor alarms (57.6%), IV pump alarms (27.3%), staff talking (24.2%), and bed alarms (21.2%) (see Figure 2 below).

Figure 2. Patients' Reports of Most Bothersome ICU Noises

Other salient findings that emerged from the ICU patient survey concerning noise sources included the following:

1. Few patients were bothered by motorized floor cleaners, squeaky wheels/carts, phones ringing or doors closing.

2. The noisiest time of day was 7-11 am, followed by the 4-7 am period.

3. Rooms that were most affected by noise were those nearest the staff conference room and by the back Business Associate desk, where staff members tend to congregate.

4. A majority of patients (82.8%) reported that staff responded to alarms without the patient having to call.

Chapter Five: Discussion/Application to Practice

Discussion

The research showed that sleep deprivation is one of the most, or the most, common complaint among patients in intensive care units. Sleep deprivation was shown to cause a wide range of physiological and psychological dysfunctions that can adversely affect the healing process and increase morbidity and mortality in general and complications in the ICU in particular. The research to date has focused on the environmental factors in the ICU that contribute to patient sleep quality which include a number of noise sources that can be controlled or otherwise mitigated provided staff members are aware of the problem and are also provided with periodic reminders to help them minimize noise to the maximum extent possible. The importance of these steps in promoting improved clinical outcomes must be stressed, and ongoing top-down efforts to keep this issue a priority must be in place.

Some of the main points to emerge from the review of the relevant literature included the following:

1. The intensive care unit (ICU) is a noisy environment that can be harmful to vulnerable critically ill patients;

2. Adverse environmental factors in the ICU can contribute to the onset of ICU delirium;

3. Delirium has been associated with an increased length of hospital stay and increased mortality;

4. Stressful environmental factors that are frequently reported by ICU patients include noise, ambient light, restriction of mobility, and social isolation.

5. Improving the ICU environment requires ongoing education of critical care staff, modification of equipment, and careful consideration to future ICU design (Wenham & Pittard, 2009).

Application to Practice

Our findings highlighted areas staff can easily improve to mitigate noise sources in the intensive care unit. First and foremost, alarms of monitors and IV pumps can be reduced with staff reeducation on tailoring to patient-specific parameters. We have implemented weekly CICU Quiet Initiative tips posted in high traffic areas. Awareness has brought on staff accountability and improved the quality and quantity of sleep ICU patients obtain. A Quiet Time has been implemented from 2:00 PM -- 4:00 PM, encouraging patients to rest quietly without interruption from medical staff if condition allows, during which lights are dimmed. We have limited use of the overhead paging system during the day and virtually no use of this system at all at night. In addition, RN and PCA staff use a phone for contact placed on vibrate mode. We will continue to follow survey results to gauge our success in keeping a quiet and healing environment for our patients. The first and second set of suggestions that emerged from this initiative are shown below.

FIRST SET OF SUGGESTIONS FOR THE CICU QUIET INITIATIVE

Have BA's program Spectralinks to vibrate mode before distribution

Mortar and pestle for pill crushing

Be proactive! Let patients know on admission that the ICU has some level of noise. Always ask patient about problems with noise, ask for their suggestions. Offer them a quiet kit (ear plugs, eye mask and headphones)

If patient condition allows, shut patient doors during change of shift, afternoon quiet time and nighttime.

Cater/adjust your patient's monitor alarms

Sigma pumps have features that you can use so your IV's don't run dry-use them. If you don't know how contact your Sigma pump super users

Remind staff and visitors to turn off ringers on the cell phones

Have "noise police" assigned to particular areas, for example BA's front desk area?5108, and RN for 5110-5116 and 5118-5128, this can be noted on the long board and/or assignment sheet

RNs report not to be disrupted during change of shift 7a-7p and 7p-7a, by patient family calls or personal phone calls unless it is an emergency. This means make sure your patients' needs are attended to prior to report time.

During daily huddles reiterate noise level control-everyone is accountable

SECOND SET OF SUGGESTIONS FOR THE CICU QUIET INITIATIVE

Put your Spectralink on vibrate or soft ring

Use the Silent Knight for pill crushing

Be proactive! Let patients know on admission that the ICU has some level of noise. Always ask patient about problems with noise, ask for their suggestions. Give all patients a quiet kit (ear plugs, eye mask and headphones)