Risk management
Shh! Quiet time in the ICU By Michelle Harrington, BSN, RN, CCRN, and Kathleen DeLeskey, DNP, RN, CNE, JBI-f
D
ue to the high cost of healthcare today, those who are ill aren’t hospitalized without serious and imminent health issues. ICU patients have significant comorbidities in addition to the illness that triggered the need for hospitalization. Hospital care is undertaken with the promise of medical treatment, close assessment, observation, and supportive care during health crises. However, progress and advances in care have moved healthcare away from care centered on patient needs to care that focuses on provider needs. This is demonstrated by changing and/or cancelling scheduled tests; surgery, care, or exams that interfere with meals; early morning phlebotomy; late night radiology procedures; unscheduled visits by various healthcare professionals; and an environment filled with loud and unsettling sounds. One of the major mandates set forth by the Institute of Medicine’s 2001 Crossing the Quality Chasm report was patient-centered care, which is described as respect for patient preferences and beliefs in all care and decision making.1 Fourteen years later, changes are appearing in the way healthcare functions. One of these patient-centered changes is specifically allotted, concentrated time for patient sleep, often referred to as quiet time. The phenomenon known a quiet time is of extreme value because noise in hospital ICUs frequently exceeds levels recommended by the U.S. Environmental Protection Agency (EPA).2 Cardiac monitors, ventilators, oximetry and capnography machines, alarms, emergency activities, and staff voices add to the cacophony. The incredible level of noise occurring almost constantly in the ICU is well established in the literature.3,4 It should also be noted that sleep deprivation is rampant and severe in ICU settings.5-7 In addition to the elevated noise level, nurse-patient interactions every hour include measuring vital signs, checking arterial catheters, assessing intake and output, measuring catheter output, administering medications,
www.nursingmanagement.com
assessing the patient’s skin, repositioning the patient, checking ventilators, obtaining blood samples, and cleaning the patient.8 Prolonged lack of sleep leads to irritable, short tempered behavior and an inability to cope in healthy persons.9 Among sick patients, immune function is also altered, which can lead to ineffective wound healing and cardiac instability, increases in BP, and elevations in respiratory and heart rate.4,10 This quality improvement project to institute quiet time on an ICU was initiated out of respect for a peaceful and healing environment, and recognition that extremely ill patients were exhausted most of the time. Promoting healing, satisfaction The purpose of the practice change was to provide patients with a quiet environment to promote healing and patient satisfaction. The project took place on a 10-bed ICU and cardiac unit within a community healthcare system. Data were collected over a 3-month period. All patients admitted to the ICU between December 5, 2011, and March 5, 2012, were provided with a formalized, 2-hour quiet time period between 2 p.m. and 4 p.m. each day. Four-hundred-and-seventy-three patients were observed during the study, with an age range from 23 to 96. During quiet time, patient assessments were observational only unless a patient’s condition indicated otherwise. Each nurse observed his or her Nursing Management • May 2015 21
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Risk management own patients every 15 minutes for the 2-hour period. Data were collected using an investigatordeveloped critical care sleep assessment tool to document patients as asleep, not asleep, or couldn’t tell. The nurse observation checklist was used every day for the 3-month period. All nurses and unlicensed assistive personnel working on the day shift were instructed by the primary investigator on the use of the tool. All lights, televisions, and personal devices in patient rooms were turned off to create a peaceful atmosphere. The wall suction units in the rooms were also shut off unless they were absolutely essential. Lights on the rest of the unit were dimmed and quiet time signage was posted on and outside the closed unit. Families and patients were informed about the process; families were encouraged to leave the unit during quiet time. Lab sampling, radiology procedures, and physical exams by healthcare team members were
prohibited unless an emergency situation occurred. Is it effective? The Duke University Quiet Time Protocol was used for the project. Decibel readings on the unit, national patient satisfaction survey data, and patient subjective comments were all used to measure the effectiveness of quiet time. The EPA has recommended that hospital noise levels not exceed 45 decibels during the day and 35 at night.2 Decibel readings were obtained on February 17, 2012; February 22, 2012; and April 4, 2012. The readings were taken by members of the system’s engineering department. Measurement readings were recorded twice on each day: once before quiet time and once during quiet time. The readings clearly showed a decrease in noise during quiet time. As noted in Table 1, during most of quiet time, the noise remained below the recommended EPA decibel level with the exception of outbursts
Table 1: Decibel readings on the unit before and during quiet time February 17
February 22
Before quiet time
51 to 61
56 to 66
During quiet time
43
46
Outbursts
51
53
Recommended EPA day decibel level = 45
-2
+1
Table 2: Patient ratings of quiet hospital environment Scale
October to December (n = 11) Before quiet time implementation
January to March (n = 8) During quiet time implementation
Never
18.2%
n=2
0%
n=0
Sometimes
18.2%
n=2
0%
n=0
Usually
36.4%
n=4
0%
n=0
Always
27.3%
n=3
100%
n=8
22 May 2015 • Nursing Management
such as call-lights, alarms, or coughing as documented by the nurses. Overall, we were able to meet EPA recommendations with minimal variances. Patients were asked to rate whether the hospital environment was quiet never, sometimes, usually, or always. Measurements done for the 3 months before beginning the trial of quiet time and during the implementation of quiet time are noted in Table 2. This national measurement of patient satisfaction only surveys patients who are discharged from the ICU directly to their home, which means that the number of respondents is limited and doesn’t include all of those who were observed. The results of the national patient satisfaction survey also demonstrated that patients evaluated the unit as quieter during quiet time hours and this was supported by the changes in decibel readings during the same time period. Additionally, feedback from the patients who commented on quiet time was very positive. Some of the patients even asked for their quiet time to start early. Many families were pleased with quiet time for their loved ones, whereas some felt that it was an inconvenience. Although stressful to implement, this practice change was a success both on the unit and within the hospital system. Quiet time has now been implemented on most units in our healthcare system and it continues to gain popularity with the staff and patients on the other units. Overcoming challenges Reducing the noise level to provide our patients with a quiet environment promotes healing; however, implementing this practice has been a challenge to the nursing profession. It’s safe to www.nursingmanagement.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Risk management say that nurses are in agreement that providing a quiet environment is important, but when put into practice, nurses are often reticent to allow their patients to sleep without interruptions. ICU nurses are constantly assessing and intervening to provide a higher level of patient care and remaining at a safe distance presents a challenge.4 Nurses must now reorganize their assessments and interventions during the quiet time hours. Additionally, ancillary staff members have been directed to plan their tasks around quiet time. Necessarily, patients from the ED and surgical services must still be accepted on the unit during quiet time. Staff members take bedside report, perform an initial assessment, and then allow the patient quiet time. The admission assessment is completed after quiet time. Initially, nursing staff members found it difficult to allow their patients to remain undisturbed for 2 hours. However, after they adapted, they were able to utilize the time to complete education modules, read journal articles, and keep abreast of new healthcare policies. Occasionally, the nurses must gently remind physicians and other members of the healthcare team to remain cognizant of patient needs and the importance of quiet time, but overall the evidence for supporting our patients with this special time is overwhelming. A positive hush The results of this practice change project were positive for patients and staff. These successful results allowed the remainder of our healthcare system to implement quiet time successfully. A large study using multiple healthcare systems would add to the data www.nursingmanagement.com
showing that patients need extra rest to improve health and support healing. NM
REFERENCES 1. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2001. 2. U.S. Environmental Protection Agency. Information on Levels of Environmental Noise Requisite to Protect Public Health and Welfare with an Adequate Margin of Safety. Washington, DC: Environmental Protection Agency; 1974. 3. Christensen M. The physiological effects of noise: considerations for intensive care. Nurs Crit Care. 2002;7(6):300-305. 4. Christensen M. What knowledge do ICU nurses have with regard to the effects of noise exposure in the intensive care unit? Intensive Crit Care Nurs. 2005;21(4): 199-207. 5. Dennis CM, Lee R, Woodard EK, Szalaj JJ, Walker CA. Benefits of quiet time for neuro-intensive care patients. J Neurosci Nurs. 2010;42(4):217-224. 6. Edwards GB, Schuring LM. Pilot study: validating staff nurses’ observations of sleep and wake states among critically ill patients, using polysomnography. Am J Crit Care. 1993;2(2):125-131. 7. Ruggiero C, Dziedzic L. Promoting a healing environment: quiet time in the intensive care unit. Jt Comm J Qual Saf. 2004; 30(8):465-467. 8. Tamburri LM, DiBrienza R, Zozula R, Redeker NS. Nocturnal care interactions with patients in critical care units. Am J Crit Care. 2004;13(2):102-112. 9. Honkus VL. Sleep deprivation in critical care units. Crit Care Nurs Q. 2003;26(3): 179-189. 10. King KJ, Halley N, Olson DM. To sleep, perchance to heal: a tale of quiet time and sleep promotion in the ICU. Am Nurse Today. 2007;2(10):44-46. Michelle Harrington is a clinical practice leader of the Medical ICU at MelroseWakefield Hospital in Melrose, Mass. Kathleen DeLeskey is an associate faculty member at Lawrence Memorial/Regis College of Nursing in Medford, Mass. The authors have disclosed that they have no financial relationships related to this article. DOI-10.1097/01.NUMA.0000463894.82790.33
Nursing Management • May 2015 23
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Shh! Quiet time in the ICU By Michelle Harrington, BSN, RN, CCRN, and Kathleen DeLeskey, DNP, RN, CNE, JBI-f
D
ue to the high cost of healthcare today, those who are ill aren’t hospitalized without serious and imminent health issues. ICU patients have significant comorbidities in addition to the illness that triggered the need for hospitalization. Hospital care is undertaken with the promise of medical treatment, close assessment, observation, and supportive care during health crises. However, progress and advances in care have moved healthcare away from care centered on patient needs to care that focuses on provider needs. This is demonstrated by changing and/or cancelling scheduled tests; surgery, care, or exams that interfere with meals; early morning phlebotomy; late night radiology procedures; unscheduled visits by various healthcare professionals; and an environment filled with loud and unsettling sounds. One of the major mandates set forth by the Institute of Medicine’s 2001 Crossing the Quality Chasm report was patient-centered care, which is described as respect for patient preferences and beliefs in all care and decision making.1 Fourteen years later, changes are appearing in the way healthcare functions. One of these patient-centered changes is specifically allotted, concentrated time for patient sleep, often referred to as quiet time. The phenomenon known a quiet time is of extreme value because noise in hospital ICUs frequently exceeds levels recommended by the U.S. Environmental Protection Agency (EPA).2 Cardiac monitors, ventilators, oximetry and capnography machines, alarms, emergency activities, and staff voices add to the cacophony. The incredible level of noise occurring almost constantly in the ICU is well established in the literature.3,4 It should also be noted that sleep deprivation is rampant and severe in ICU settings.5-7 In addition to the elevated noise level, nurse-patient interactions every hour include measuring vital signs, checking arterial catheters, assessing intake and output, measuring catheter output, administering medications,
www.nursingmanagement.com
assessing the patient’s skin, repositioning the patient, checking ventilators, obtaining blood samples, and cleaning the patient.8 Prolonged lack of sleep leads to irritable, short tempered behavior and an inability to cope in healthy persons.9 Among sick patients, immune function is also altered, which can lead to ineffective wound healing and cardiac instability, increases in BP, and elevations in respiratory and heart rate.4,10 This quality improvement project to institute quiet time on an ICU was initiated out of respect for a peaceful and healing environment, and recognition that extremely ill patients were exhausted most of the time. Promoting healing, satisfaction The purpose of the practice change was to provide patients with a quiet environment to promote healing and patient satisfaction. The project took place on a 10-bed ICU and cardiac unit within a community healthcare system. Data were collected over a 3-month period. All patients admitted to the ICU between December 5, 2011, and March 5, 2012, were provided with a formalized, 2-hour quiet time period between 2 p.m. and 4 p.m. each day. Four-hundred-and-seventy-three patients were observed during the study, with an age range from 23 to 96. During quiet time, patient assessments were observational only unless a patient’s condition indicated otherwise. Each nurse observed his or her Nursing Management • May 2015 21
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Risk management own patients every 15 minutes for the 2-hour period. Data were collected using an investigatordeveloped critical care sleep assessment tool to document patients as asleep, not asleep, or couldn’t tell. The nurse observation checklist was used every day for the 3-month period. All nurses and unlicensed assistive personnel working on the day shift were instructed by the primary investigator on the use of the tool. All lights, televisions, and personal devices in patient rooms were turned off to create a peaceful atmosphere. The wall suction units in the rooms were also shut off unless they were absolutely essential. Lights on the rest of the unit were dimmed and quiet time signage was posted on and outside the closed unit. Families and patients were informed about the process; families were encouraged to leave the unit during quiet time. Lab sampling, radiology procedures, and physical exams by healthcare team members were
prohibited unless an emergency situation occurred. Is it effective? The Duke University Quiet Time Protocol was used for the project. Decibel readings on the unit, national patient satisfaction survey data, and patient subjective comments were all used to measure the effectiveness of quiet time. The EPA has recommended that hospital noise levels not exceed 45 decibels during the day and 35 at night.2 Decibel readings were obtained on February 17, 2012; February 22, 2012; and April 4, 2012. The readings were taken by members of the system’s engineering department. Measurement readings were recorded twice on each day: once before quiet time and once during quiet time. The readings clearly showed a decrease in noise during quiet time. As noted in Table 1, during most of quiet time, the noise remained below the recommended EPA decibel level with the exception of outbursts
Table 1: Decibel readings on the unit before and during quiet time February 17
February 22
Before quiet time
51 to 61
56 to 66
During quiet time
43
46
Outbursts
51
53
Recommended EPA day decibel level = 45
-2
+1
Table 2: Patient ratings of quiet hospital environment Scale
October to December (n = 11) Before quiet time implementation
January to March (n = 8) During quiet time implementation
Never
18.2%
n=2
0%
n=0
Sometimes
18.2%
n=2
0%
n=0
Usually
36.4%
n=4
0%
n=0
Always
27.3%
n=3
100%
n=8
22 May 2015 • Nursing Management
such as call-lights, alarms, or coughing as documented by the nurses. Overall, we were able to meet EPA recommendations with minimal variances. Patients were asked to rate whether the hospital environment was quiet never, sometimes, usually, or always. Measurements done for the 3 months before beginning the trial of quiet time and during the implementation of quiet time are noted in Table 2. This national measurement of patient satisfaction only surveys patients who are discharged from the ICU directly to their home, which means that the number of respondents is limited and doesn’t include all of those who were observed. The results of the national patient satisfaction survey also demonstrated that patients evaluated the unit as quieter during quiet time hours and this was supported by the changes in decibel readings during the same time period. Additionally, feedback from the patients who commented on quiet time was very positive. Some of the patients even asked for their quiet time to start early. Many families were pleased with quiet time for their loved ones, whereas some felt that it was an inconvenience. Although stressful to implement, this practice change was a success both on the unit and within the hospital system. Quiet time has now been implemented on most units in our healthcare system and it continues to gain popularity with the staff and patients on the other units. Overcoming challenges Reducing the noise level to provide our patients with a quiet environment promotes healing; however, implementing this practice has been a challenge to the nursing profession. It’s safe to www.nursingmanagement.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Risk management say that nurses are in agreement that providing a quiet environment is important, but when put into practice, nurses are often reticent to allow their patients to sleep without interruptions. ICU nurses are constantly assessing and intervening to provide a higher level of patient care and remaining at a safe distance presents a challenge.4 Nurses must now reorganize their assessments and interventions during the quiet time hours. Additionally, ancillary staff members have been directed to plan their tasks around quiet time. Necessarily, patients from the ED and surgical services must still be accepted on the unit during quiet time. Staff members take bedside report, perform an initial assessment, and then allow the patient quiet time. The admission assessment is completed after quiet time. Initially, nursing staff members found it difficult to allow their patients to remain undisturbed for 2 hours. However, after they adapted, they were able to utilize the time to complete education modules, read journal articles, and keep abreast of new healthcare policies. Occasionally, the nurses must gently remind physicians and other members of the healthcare team to remain cognizant of patient needs and the importance of quiet time, but overall the evidence for supporting our patients with this special time is overwhelming. A positive hush The results of this practice change project were positive for patients and staff. These successful results allowed the remainder of our healthcare system to implement quiet time successfully. A large study using multiple healthcare systems would add to the data www.nursingmanagement.com
showing that patients need extra rest to improve health and support healing. NM
REFERENCES 1. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2001. 2. U.S. Environmental Protection Agency. Information on Levels of Environmental Noise Requisite to Protect Public Health and Welfare with an Adequate Margin of Safety. Washington, DC: Environmental Protection Agency; 1974. 3. Christensen M. The physiological effects of noise: considerations for intensive care. Nurs Crit Care. 2002;7(6):300-305. 4. Christensen M. What knowledge do ICU nurses have with regard to the effects of noise exposure in the intensive care unit? Intensive Crit Care Nurs. 2005;21(4): 199-207. 5. Dennis CM, Lee R, Woodard EK, Szalaj JJ, Walker CA. Benefits of quiet time for neuro-intensive care patients. J Neurosci Nurs. 2010;42(4):217-224. 6. Edwards GB, Schuring LM. Pilot study: validating staff nurses’ observations of sleep and wake states among critically ill patients, using polysomnography. Am J Crit Care. 1993;2(2):125-131. 7. Ruggiero C, Dziedzic L. Promoting a healing environment: quiet time in the intensive care unit. Jt Comm J Qual Saf. 2004; 30(8):465-467. 8. Tamburri LM, DiBrienza R, Zozula R, Redeker NS. Nocturnal care interactions with patients in critical care units. Am J Crit Care. 2004;13(2):102-112. 9. Honkus VL. Sleep deprivation in critical care units. Crit Care Nurs Q. 2003;26(3): 179-189. 10. King KJ, Halley N, Olson DM. To sleep, perchance to heal: a tale of quiet time and sleep promotion in the ICU. Am Nurse Today. 2007;2(10):44-46. Michelle Harrington is a clinical practice leader of the Medical ICU at MelroseWakefield Hospital in Melrose, Mass. Kathleen DeLeskey is an associate faculty member at Lawrence Memorial/Regis College of Nursing in Medford, Mass. The authors have disclosed that they have no financial relationships related to this article. DOI-10.1097/01.NUMA.0000463894.82790.33
Nursing Management • May 2015 23
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
