Ssshhh…Healing Brains at Rest Marlienne Goldin, RN, BSN, MPA

1. Ssshhh…Healing Brains at Rest Marlienne Goldin, RN, BSN, MPA Director, Neuro Surgical ICU, Moses Cone Health Care System, Greensboro, NC Faculty Associate, Watson Caring Science Institute, Boulder, CO Abstract Scope of Problem Methods Conclusion • Effects of environmental stimuli on sleep disruption in ICUs has never been examined in a large scale study. • Rest is essential to healing. • 40 to 50% of sleep in the ICU occurs during the day. • Deprivation causes physical and psychological stress. • Impedes recovery. • Most studies used small, non random, samples. • Lack of research and evidence, is a barrier to delivery of evidenced based sleep promotion interventions. • Predominance of stage 1 and 2 sleep. • Decreased or absent stage 3, 4 and REM • Frequent arousals and sleep fragmentation. • Decreased immune function - impaired defenses • Increase serum cortisol. • Decrease growth hormone, decreased healing. • Poor quality of life. • PTSD. • Delirium. • Decreased electrolytes. • Increased metabolic rate. Visiting hours in the ICU have shifted from an hour twice a day, to 15 minutes every two hours, to open visiting 24 hours a day, and every combination in between. In our desire to accommodate the need for families to be at their loved one’s bedside, have we acted in our patient’s best interests? In order to heal, patients need rest. That need is even greater for brain injured patients. Sleep disruption and deprivation are particularly prevalent in the critical care environment. Several studies over the past twenty years have demonstrated that critically ill patients have frequent awakenings and arousals, and little to no REM sleep. At a time when critical patients need the most rest, the ICU environment deprives them of it. It is a common perception that the loss of sleep increases an individual’s risk for infection and disease. Optimizing patient comfort and ensuring that patients get the rest they need is a difficult task in the ICU. • Instituted daily two hour quiet time from 2 to 4 PM. • Families advised of Quiet Time upon admission. • Patient – ventilator synchrony, RT Rounding. • Pain therapy. • Relaxation techniques, music therapy. • Communication with other departments. • Signage. • Decreased lighting • Physician awareness and communication. • Appropriate pharmacological interventions. • Noise levels, phones, staff conversation. • Adequate length of time. • Culture change, patient centered. Efforts to promote rest in our ICUs need to be ongoing if we truly strive to create a healing environment. References Bourne, Richard S. et all. Sleep Measurement in Critical Care Patients: Research and Clinical Implications. Critical Care. Critical Care 2007 11:226. Conrad, Claudius, MD PhD et all. Overture for Growth Hormone: Requiem for Interlukin-6?. Critical care medicine 2007 Vol 35. No.12. Dines-Kalinowski, Christianne, RN, CS, NP, MS. Dream Weaver: Patients who need the most sleep often get the least. Nursing Management April 2002 Vol.33 pg. 48-49. Freedman, Neil S. et all. Abnormal Sleep/Wake Cycles and the Effect of Environmental Noise on Sleep Disruption in the Intensive Care Unit. American Journal of Respiratory Care Medicine 2001. Vol. 163. pp 451-457. Freedman, Neil S, Kotzer, Natalie, et all. Patient Perception of Sleep Quality and Etiology of Sleep Disruption in the IntensiveCare Unit. American Journal Resp. Crit. Care Med. Vol 159 No.4 April 1999, pp1155-1162. Friese, Randall S, MD. Sleep and Recovery from Critical Illness and Injury: A review of theory, current practice and future directions. Critical care medicine 2008 Vol.36, No. 3. Gabor, Jonathan Y. MSc, Cooper, Andrew B. MD, Sleep Disruption in the ICU. Current Opinion in Critical care. 2001 Vol 7. pp 21-27 Redeker, Nancy S. PhD, RN. Challenges and Opportunities Associated with Studying Sleep in Critically Ill Adults. AACN Advanced Critical Care Vol. 19 No.2 pp178-185 “It may seem a strange principle to enunciate as the very first requirement in a hospital that it should do the sick no harm”… Florence Nightingale . Results • Families appreciate the break from the bedside. • Patients get 2 hours of uninterrupted rest. • RNs get caught up on documentation. • Everyone appreciates the change in environment. • Spread to other ICUs in the hospital. • Implemented system wide to all 5 hospitals. Marlienne.goldin@mosescone.com