• Implementation of a Nurse-Driven Nonpharmacological Sleep Bundle to Reduce Delirium in a Surgical Intensive Care Unit

      Turnbaugh, Lindsey D.; Hammersla, Margaret (2019-05)
      Background: The prevalence of delirium, an acute syndrome causing changes or fluctuations in baseline mental status leading to inattention, disorganized thinking, and altered levels of consciousness, afflicts patients residing in the intensive care unit. Several negative outcomes may occur in patients diagnosed with delirium in the intensive care unit, including increased mortality, hospital length of stay, cost of care, and long-term cognitive impairment. Sleep, a critical component of health and recovery, is noted to be disrupted in intensive care unit settings resulting in a correlative effect between sleep deprivation and delirium. Multicomponent nonpharmacological interventions are intended to reduce the predisposing factors of this syndrome and have been shown in randomized control trials and systematic reviews to be effective in preventing delirium. Local Problem: The purpose of this quality improvement project was to implement a nursedriven non-pharmacological sleep bundle with a checklist of interventions to reduce intensive care unit delirium, which was noted by staff as an increasing problem, in an adult 12-bed Surgical Intensive Care Unit at a community hospital in Towson, Maryland. Interventions: An evidence-based checklist of nonpharmacological interventions related to reducing noise, light, and patient care interruptions was implemented by the Surgical Intensive Care Unit nurses on patients admitted over an eight week period. Checklist compliance was measured during the eight weeks of implementation by counting the number of completed checklists and comparing that to the number of admissions per week. The interventions performed on all completed checklists were evaluated using descriptive statistics. Delirium was measured by the Confusion Assessment Method Intensive Care Unit tool in the electronic health record and evaluated through an electronic chart review. A data analysis was performed using a chi-square test and odd’s ratio to compare the Confusion Assessment Method Intensive Care Unit scores pre-implementation versus post-implementation of the sleep bundle. Results: During the first four weeks of project implementation, the weekly completed checklist compliance rate was 98%, however, the remainder of the implementation phase was at 100%. There was a high rate of noise, light, and patient care interventions labeled as “not-complete” due to patient refusal or “not-applicable” due to the inappropriateness of the intervention for the patient population. In the pre-implementation phase, delirium was reported as positive on the Confusion Assessment Method Intensive Care Unit tool 22% of the time versus 51% of the time in the post-implementation phase. A chi-square test determined a statistically significant association between the variables (p<0.001), though an odd’s ratio test (OR=0.26) revealed no association between the nonpharmacological sleep bundle and delirium scores. Conclusions/Implications: Documentation compliance was sustained by having the Confusion Assessment Method Intensive Care Unit documentation already embedded in the electronic health record. There was an increase in the awareness and nursing documentation of Confusion Assessment Method Intensive Care Unit scores during and after project implementation. Despite an increase in delirium among patients post-implementation, the literature still suggests a correlative effect between sleep deprivation and ICU delirium. Further studies are needed to determine whether multicomponent nonpharmacological sleep bundles can reduce delirium.