Effects of guidelines implementation in a surgical intensive care unit to control nighttime light and noise levels.

A Review of the Research Literature on Evidence-Based Healthcare Design

Abstract: Objective:This report surveys and evaluates the scientific research on evidence-based healthcare design and extracts its implications for designing better and safer hospitals.Background:It builds o...

Contribution of the Intensive Care Unit Environment to Sleep Disruption in Mechanically Ventilated Patients and Healthy Subjects

Abstract: 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). We characterized potentially disruptive ICU noise stimuli and patient-care activities and determined their relative contributions to sleep disruption. Furthermore, we studied the effect of noise in isolation by placing healthy subjects in the ICU in both normal and noise-reduced locations. Seven mechanically ventilated patients and six healthy subjects were studied by continuous 24-hour polysomnography with time-synchronized environmental monitoring. Sound elevations occurred 36.5 ± 20.1 times per hour of sleep and were responsible for 20.9 ± 11.3% of total arousals and awakenings. Patient-care activities occurred 7.8 ± 4.2 times per hour of sleep and were responsible for 7.1 ± 4.4% of total arousals and awakenings. Healthy subjects slept relatively well in the typically loud ICU environment and experienced a quantitative, but not qua...

Efficacy and safety of quetiapine in critically ill patients with delirium: a prospective, multicenter, randomized, double-blind, placebo-controlled pilot study.

Abstract: Objective:To compare the efficacy and safety of scheduled quetiapine to placebo for the treatment of delirium in critically ill patients requiring as-needed haloperidol.Design:Prospective, randomized, double-blind, placebo-controlled study.Setting:Three academic medical centers.Patients:Thirty-six a

A simplified acute physiology score for ICU patients.

Abstract: We used 14 easily measured biologic and clinical variables to develop a simple scoring system reflecting the risk of death in ICU patients. The simplified acute physiology score (SAPS) was evaluated in 679 consecutive patients admitted to eight multidisciplinary referral ICUs in France. Surgery accounted for 40% of admissions. Data were collected during the first 24 h after ICU admission. SAPS correctly classified patients in groups of increasing probability of death, irrespective of diagnosis, and compared favorably with the acute physiology score (APS), a more complex scoring system which has also been applied to ICU patients. SAPS was a simpler and less time-consuming method for comparative studies and management evaluation between different ICUs.

Simplified Therapeutic Intervention Scoring System: the TISS-28 items--results from a multicenter study.

Abstract: Objectives: To validate a simplified version of the Therapeutic Intervention Scoring System, the TISS-28, and to determine the association of TISS-28 with the time spent on scored and nonscored nursing activities. Design: Prospective, multicenter study. Setting: Twenty-two adult medical, surgical, and general Dutch intensive care units (ICUs). Patients: A total of 903 patients consecutively admitted to the ICUs. Interventions: TISS-28 was constructed from a random sample of 10,000 records of TISS-76 items. The respective weights were calculated using multivariable regression analysis through the origin; TISS-76 scores were used as predicted values. Cross validation was performed in another random sample of 10,000 records and the scores of TISS-76 were compared with those scores obtained with TISS-28 (r = .96, r(2) = .93). Nursing activities in the ICU were inventoried and divided into six categories: a) activities in TISS-28; b) patient care activities not in TISS-28; c) indirect patient care (activities related to but not in direct contact with the patient, such as contact with family, maintaining supplies); d) organizational activities (e.g., meetings, trainee supervision, research); e) personal activities (for the nurse him/herself, such as taking a break, going to the bathroom); f) other. During a 1-month period, TISS-76 and TISS-28 scores were determined daily from the patient's records by independent raters. During a 1-wk period, all of the nurses on duty scored their activities using a method called ''work sampling.'' Measurements and Main Results: The analysis of validation included 1,820 valid pairs of TISS-76 and TISS-28 records. The mean value of TISS-28 (28.8 +/- 11.1) was higher (p 500 beds, 7.1% from hospitals with 300 to 500 beds, and 5.8% from hospitals with 60 points). In the successive groups of TISS scores, there was a significant increase in the proportion of time spent on the activities scored with TISS-28. In the lower TISS score group (0 to 20 points), there was a significantly larger proportion of time allocated to patient care activities not in TISS-28. There was no significant difference in the proportion of time spent when associating indirect patient care and organizational activities with the level of TISS score. There was a significant decrease in the proportion of time spent on personal activities in the successive groups of TISS scores. The mean time spent per shift with personal activities varied between 1 hr and 40 mins (group 0 to 20 points TISS), and 1 hr and 16 mins (group >60 points TISS). Significantly more time was used for patient care activities during the evening shift than during the day or the night shift. Conversely, nurses spent significantly less time on activities regarding their personal care during the evening shift. The time consumed for the activities of indirect patient care did not differ significantly among the three shifts. A typical nurse was capable of delivering work equal to 46.35 TISS-28 points per shift (one TISS-28 point equals 10.6 mins of each nurse's shift). Conclusions: The simplified TISS-28 explains 86% of the variation in TISS-76 and can therefore replace the original version in the clinical practice in the ICU. Per shift, a typical nurse is capable of delivering nursing activities equal to 46 TISS-28 points. This information, together with the information concerning the association of TISS score with the time spent in the various nursing activities within the ICU, is relevant to the management of nursing manpower in the ICU.

Leukocytosis and natural killer cell function parallel neurobehavioral fatigue induced by 64 hours of sleep deprivation.

Abstract: The hypothesis that sleep deprivation depresses immune function was tested in 20 adults, selected on the basis of their normal blood chemistry, monitored in a laboratory for 7 d, and kept awake for 64 h. At 2200 h each day measurements were taken of total leukocytes (WBC), monocytes, granulocytes, lymphocytes, eosinophils, erythrocytes (RBC), B and T lymphocyte subsets, activated T cells, and natural killer (NK) subpopulations (CD56/CD8 dual-positive cells, CD16-positive cells, CD57-positive cells). Functional tests included NK cytotoxicity, lymphocyte stimulation with mitogens, and DNA analysis of cell cycle. Sleep loss was associated with leukocytosis and increased NK cell activity. At the maximum sleep deprivation, increases were observed in counts of WBC, granulocytes, monocytes, NK activity, and the proportion of lymphocytes in the S phase of the cell cycle. Changes in monocyte counts correlated with changes in other immune parameters. Counts of CD4, CD16, CD56, and CD57 lymphocytes declined after one night without sleep, whereas CD56 and CD57 counts increased after two nights. No changes were observed in other lymphocyte counts, in proliferative responses to mitogens, or in plasma levels of cortisol or adrenocorticotropin hormone. The physiologic leukocytosis and NK activity increases during deprivation were eliminated by recovery sleep in a manner parallel to neurobehavioral function, suggesting that the immune alterations may be associated with biological pressure for sleep.

Adverse environmental conditions in the respiratory and medical ICU settings

Abstract: Sleep deprivation and fragmentation occurring in the hospital setting may have a negative impact on the respiratory system by decreasing respiratory muscle function and ventilatory response to CO2 Sleep deprivation in a patient with respiratory failure may, therefore, impair recovery and weaning from mechanical ventilation We postulate that light, sound, and interruption levels in a weaning unit are major factors resulting in sleep disorders and possibly circadian rhythm disruption As an initial test of this hypothesis, we sampled interruption levels and continuously monitored light and sound levels for a minimum of seven consecutive days in a medical ICU, a multiple bed respiratory care unit (RCU) room, a single-bed RCU room, and a private room Light levels in all areas maintained a day-night rhythm, with peak levels dependent on window orientation and shading Peak sound levels were extremely high in all areas representing values significantly higher than those recommended by the Environmental Protection Agency as acceptable for a hospital environment The number of sound peaks greater than 80 decibels, which may result in sleep arousals, was especially high in the intensive and respiratory care areas, but did show a day-night rhythm in all settings Patient interruptions tended to be erratic, leaving little time for condensed sleep We conclude that the potential for environmentally induced sleep disruption is high in all areas, but especially high in the intensive and respiratory care areas where the negative consequences may be the most severe

Sleep deprivation and the control of ventilation.

Abstract: Sleep deprivation is common in acutely ill patients because of their underlying disease and can be compounded by aggressive medical care. While sleep deprivation has been shown to produce a number of psychological and physiologic events, the effects on respiration have been minimally evaluated. We therefore studied resting ventilation and ventilatory responses to hypoxia and hypercapnia before and after 24 h of sleeplessness in 13 healthy men. Hypoxic ventilatory responses (HVR) were measured during progressive isocapnic hypoxia, and hypercapnic ventilatory responses (HCVR) were measured using a rebreathing technique. Measures of resting ventilation, i.e., minute ventilation, tidal volume, arterial oxygen saturation, and end-tidal gas concentrations, did not change with short-term sleep deprivation. Both HVR and HCVR, however, decreased significantly after a single night without sleep. The mean hypoxic response decreased 29% from a slope of 1.20 ± 0.22 (SEM) to 0.85 ± 0.15 L/min/% saturation (p < 0.02), a...