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Nocturnal care interactions with patients in critical care units
Australian Critical Care
Research Review N o c t u r n a l care interactions with p a t i e n t s in critical care units. Dr Marion
L Mitchell
Lecturer, SON Griffith University, L o g a n c a m p u s , Brisbane.
Tamburri LM, DiBrienza R, Zozula R & Redeker NS. Nocturnal care interactions with patients in critical care units. American Journal of Critical Care 2004; 13(2): 102-12 The most frequent interventions performed included blood pressure
INTRODUCTION
measurement with a standard blood pressure cuff and giving Sleep deprivation is a recognised adverse outcome for many Intensive Care Unit (ICU) patients. Reducing the impact of sleep deprivation has attracted attention due to the reporting of long term effects of reduced immune function and wound healing in the mid 1990s. Whilst in ICU, patients may also exhibit immediate adverse effects such as emotional distress and reduced functioning ability. Sleep promoting protocols and interventions have been developed to try to address this issue but remain untested.
medications. Routine daily baths were performed on 61% of study nights between 2am and 6am. There was one record out of the 147 nights of data where the nurse indicated an intervention to promote sleep. Acuity levels were positively correlated with frequency of interactions (r=0.32-0.56, P<0.05). The busier time periods (Spin, 12ran and 6am) correspond to the 12 hour nursing shift time changes (7pro to 7am).
The purposes of this study were to: examine the frequency, pattern, and types of nocturnal care interactions with patients in four
CONCLUSION
critical care units; analyse the relationships among frequency, temporal patterns, and types of nocturnal interactions and patient related selected variables; and analyse the differences in patterns of nocturnal care activities among the four units.
There is a need for monitoring and managing critically ill patients at night and these interactions play a significant role in promoting undisturbed periods for sleep. Although technological advancements such as arterial catheters provide continuous monitoring without
METHOD
disturbing patients, numerous other activities must be performed. Bathing patients at a time when it is most likely to maximise
A retrospective review of patient's charts was used. Patients 21 years and older who were admitted to one of the four units provided the sample. The units included a surgical ICU, a neurosurgical ICU, a medical ICU and a coronary care unit in the one hospital. To be included in the sample, patients needed to stay in the unit for at least four consecutive nights, although the first night a patient was in the unit was not included in the study. Patients were excluded if they were undergoing treatment with neuromuscular blocking agents, intra-aortic balloon pumps, or continuous venovenous haemofiltration because of the continuous bedside care required.
comfort or sleep should be the prime consideration rather than for work flow convenience. There needs to be an increased awareness of the problems of sleep deprivation in the ICU.
CRITIQUE The study site was a tertiary referral centre in the United States with four critical care units.
The study suggests that critical
care patients experience little uninterrupted periods for sleep during the night. The authors' aims have been clearly outlined, and the chart audit method used for data collection represents
A n activity list was developed by the researchers to record care activities involving patient interaction with a health care provider between 7pro and 7am. Patient acuity scores were recorded along with other demographic data. The chart reviewers randomly chose days where they reviewed medical records of patients in the units for more than four nights. Care activities between 7pro and 7am were tallied using the checklist from the medical records.
an effective time-efficient way to measure care interventions. Although augmenting this data with non-participant observation of the way the interactions disturbed or do not disturb patients may have achieved more meaningful data, this study was not aimed at documenting this. The study implies, however, that care interventions equate to disturbed rest and sleep and needs to be considered in the context of ICU nursing practices in the United
RESULTS
States. There is room for argument that, with the activity of giving
Records of 50 patients for 147 nights were reviewed. Interactions were most frequent at 8pro, midnight and 6am, with midnight scoring the highest, and 3am the lowest number of interactions. The researchers were interested in two-hourly blocks of time in line with sleep cycles which last 90 minutes. Nine lots of two hour periods from 10pm to 6am during the 147 nights were found to have no interventions and uninterrupted time available for sleep.
medications, (which are generally administered intravenously in
Volume 18
Number 2
April 2005
ICU) there is little risk of waking or disturbing patients.
The
authors go some way to acknowledge this limitation when they correct the number of interventions, taking into account the presence of al"terial catheters for blood pressure readings and indwelling catheters for urine measurements which do not require contact with the patient. 86
A u s t r a l i a n Critical Care
The statistical analyses were compatible with the research aims.
This study provides foundation data for further research into
The discussion section highlighted major findings and ably related
promoting sleep in ICU patients and therefore makes a positive
these to prior research.
contribution to nursing research.
Although the authors dedicated a
paragraph to reasoned discussion on the high number of routine
It encourages discussion and
consideration of ways ICU nursing practices can reorganise night
daily baths conducted between 2am and 5am (55 out of 147 study
time activities with sleep promotion a goal rather than an
nights), there is little evidence of particular concern at the results.
unexpected outcome.
This may reflect the fact that this practice is the norm in ICUs in this region.
REFERENCES
The authors highlight that only one reference was made to a care
1.
Freedman N, Gazendam J, Levan L, Pack A, Schwab R. Abnormal
intervention to promote sleep and they equate this to a lack of
sleep/wake cycles and the effect of environmental noise on sleep
awareness by the nurses of the problem of sleep deprivation. Their
disruption in the intensive care unit. American Journal of Respiratory
conclusion may be a little unforgiving as, although there is a space
and Critical Care Medicine 2001;163(2):451-457.
for "other" interventions at the end of a checklist, one may need
2.
Gabor J, Cooper A, Crombach S, Lee B, Kadikar N, Bettger H,
some prompting on what "other" may include by the time 22 items
et al.
have been checked.
sleep deprivation in mechanically ventilated patients and healthy subjects. American Journal of Respiratory Critical Care Medicine
The assumption the authors make, that critically ill patients will
2003;167(5):708-715.
sleep if left alone, is somewhat simplistic when environmental 3.
factors such as noise and lights 1.3 , the absence of pain, and provision of comfort 4 are important influencing factors.
Contribution of the intensive care unit environment to
OIson DM, Borel CO, Laskowitz DT, Moore DT, McConnell ES. Quiet time: a nursing interveRtio~ to promote sleep in ~euroIogical
In
care units. American Journal of Critical Care 2001;10(2):74-78.
addition, it is essential, in further studies, to consider including 4.
data from the patient's perspective if causal relationships are to be
Dines-Kalinowski CM. Nature's nurse: promoting sleep in the ICU. Dimensions in Critical Care Nursing 2002;21 ( 1):32-34.
considered.
Chest x-ray quiz A n s w e r & discussion r
The chest x-ray shows bilateral hilar lymph node enlargement and also enlargement of paratracheal lymph node. The enlarged lymph nodes are referred to as lymphadenopathy and occur in a condition called sarcoidosis. The appearance o f paratracheal and hilar lymph node enlargement give a 'shamrock' appearance. It is reported that 95% o f patients with sarcoidosis have abnormal chest radiography with lymphadenopathy and~or lung opacities. Most patients have a good prognosis with resolution in <2 years (Gurney & Wine> Muram, 2003). I f sarcoid progresses it can lead to massive pulmonary fibrosis. Other conditions that can cause bilateral hilar lymphadenopathy are turnouts e.g. lymphoma, bronchial carcinoma, metastatic tumours (Come, Carroll, Brown & Delaney, 1997). However patients with any of those conditions would not feel very welt. References
Come, J., Carroll M., Brown, I. & Delaney, D, (1997) Chest X-Ray Made Easy. Churchill-Livingston, New York, Edinburgh Gurney, J.W. & Winer-Muram, H.T. (2003) Pocket Radiologist Chest Top 100 Diagnosis. Saunders and Elsevier Science Company. Salt Lake City, Utah
87
Volume 18
Number 2
April 2005
Research Review N o c t u r n a l care interactions with p a t i e n t s in critical care units. Dr Marion
L Mitchell
Lecturer, SON Griffith University, L o g a n c a m p u s , Brisbane.
Tamburri LM, DiBrienza R, Zozula R & Redeker NS. Nocturnal care interactions with patients in critical care units. American Journal of Critical Care 2004; 13(2): 102-12 The most frequent interventions performed included blood pressure
INTRODUCTION
measurement with a standard blood pressure cuff and giving Sleep deprivation is a recognised adverse outcome for many Intensive Care Unit (ICU) patients. Reducing the impact of sleep deprivation has attracted attention due to the reporting of long term effects of reduced immune function and wound healing in the mid 1990s. Whilst in ICU, patients may also exhibit immediate adverse effects such as emotional distress and reduced functioning ability. Sleep promoting protocols and interventions have been developed to try to address this issue but remain untested.
medications. Routine daily baths were performed on 61% of study nights between 2am and 6am. There was one record out of the 147 nights of data where the nurse indicated an intervention to promote sleep. Acuity levels were positively correlated with frequency of interactions (r=0.32-0.56, P<0.05). The busier time periods (Spin, 12ran and 6am) correspond to the 12 hour nursing shift time changes (7pro to 7am).
The purposes of this study were to: examine the frequency, pattern, and types of nocturnal care interactions with patients in four
CONCLUSION
critical care units; analyse the relationships among frequency, temporal patterns, and types of nocturnal interactions and patient related selected variables; and analyse the differences in patterns of nocturnal care activities among the four units.
There is a need for monitoring and managing critically ill patients at night and these interactions play a significant role in promoting undisturbed periods for sleep. Although technological advancements such as arterial catheters provide continuous monitoring without
METHOD
disturbing patients, numerous other activities must be performed. Bathing patients at a time when it is most likely to maximise
A retrospective review of patient's charts was used. Patients 21 years and older who were admitted to one of the four units provided the sample. The units included a surgical ICU, a neurosurgical ICU, a medical ICU and a coronary care unit in the one hospital. To be included in the sample, patients needed to stay in the unit for at least four consecutive nights, although the first night a patient was in the unit was not included in the study. Patients were excluded if they were undergoing treatment with neuromuscular blocking agents, intra-aortic balloon pumps, or continuous venovenous haemofiltration because of the continuous bedside care required.
comfort or sleep should be the prime consideration rather than for work flow convenience. There needs to be an increased awareness of the problems of sleep deprivation in the ICU.
CRITIQUE The study site was a tertiary referral centre in the United States with four critical care units.
The study suggests that critical
care patients experience little uninterrupted periods for sleep during the night. The authors' aims have been clearly outlined, and the chart audit method used for data collection represents
A n activity list was developed by the researchers to record care activities involving patient interaction with a health care provider between 7pro and 7am. Patient acuity scores were recorded along with other demographic data. The chart reviewers randomly chose days where they reviewed medical records of patients in the units for more than four nights. Care activities between 7pro and 7am were tallied using the checklist from the medical records.
an effective time-efficient way to measure care interventions. Although augmenting this data with non-participant observation of the way the interactions disturbed or do not disturb patients may have achieved more meaningful data, this study was not aimed at documenting this. The study implies, however, that care interventions equate to disturbed rest and sleep and needs to be considered in the context of ICU nursing practices in the United
RESULTS
States. There is room for argument that, with the activity of giving
Records of 50 patients for 147 nights were reviewed. Interactions were most frequent at 8pro, midnight and 6am, with midnight scoring the highest, and 3am the lowest number of interactions. The researchers were interested in two-hourly blocks of time in line with sleep cycles which last 90 minutes. Nine lots of two hour periods from 10pm to 6am during the 147 nights were found to have no interventions and uninterrupted time available for sleep.
medications, (which are generally administered intravenously in
Volume 18
Number 2
April 2005
ICU) there is little risk of waking or disturbing patients.
The
authors go some way to acknowledge this limitation when they correct the number of interventions, taking into account the presence of al"terial catheters for blood pressure readings and indwelling catheters for urine measurements which do not require contact with the patient. 86
A u s t r a l i a n Critical Care
The statistical analyses were compatible with the research aims.
This study provides foundation data for further research into
The discussion section highlighted major findings and ably related
promoting sleep in ICU patients and therefore makes a positive
these to prior research.
contribution to nursing research.
Although the authors dedicated a
paragraph to reasoned discussion on the high number of routine
It encourages discussion and
consideration of ways ICU nursing practices can reorganise night
daily baths conducted between 2am and 5am (55 out of 147 study
time activities with sleep promotion a goal rather than an
nights), there is little evidence of particular concern at the results.
unexpected outcome.
This may reflect the fact that this practice is the norm in ICUs in this region.
REFERENCES
The authors highlight that only one reference was made to a care
1.
Freedman N, Gazendam J, Levan L, Pack A, Schwab R. Abnormal
intervention to promote sleep and they equate this to a lack of
sleep/wake cycles and the effect of environmental noise on sleep
awareness by the nurses of the problem of sleep deprivation. Their
disruption in the intensive care unit. American Journal of Respiratory
conclusion may be a little unforgiving as, although there is a space
and Critical Care Medicine 2001;163(2):451-457.
for "other" interventions at the end of a checklist, one may need
2.
Gabor J, Cooper A, Crombach S, Lee B, Kadikar N, Bettger H,
some prompting on what "other" may include by the time 22 items
et al.
have been checked.
sleep deprivation in mechanically ventilated patients and healthy subjects. American Journal of Respiratory Critical Care Medicine
The assumption the authors make, that critically ill patients will
2003;167(5):708-715.
sleep if left alone, is somewhat simplistic when environmental 3.
factors such as noise and lights 1.3 , the absence of pain, and provision of comfort 4 are important influencing factors.
Contribution of the intensive care unit environment to
OIson DM, Borel CO, Laskowitz DT, Moore DT, McConnell ES. Quiet time: a nursing interveRtio~ to promote sleep in ~euroIogical
In
care units. American Journal of Critical Care 2001;10(2):74-78.
addition, it is essential, in further studies, to consider including 4.
data from the patient's perspective if causal relationships are to be
Dines-Kalinowski CM. Nature's nurse: promoting sleep in the ICU. Dimensions in Critical Care Nursing 2002;21 ( 1):32-34.
considered.
Chest x-ray quiz A n s w e r & discussion r
The chest x-ray shows bilateral hilar lymph node enlargement and also enlargement of paratracheal lymph node. The enlarged lymph nodes are referred to as lymphadenopathy and occur in a condition called sarcoidosis. The appearance o f paratracheal and hilar lymph node enlargement give a 'shamrock' appearance. It is reported that 95% o f patients with sarcoidosis have abnormal chest radiography with lymphadenopathy and~or lung opacities. Most patients have a good prognosis with resolution in <2 years (Gurney & Wine> Muram, 2003). I f sarcoid progresses it can lead to massive pulmonary fibrosis. Other conditions that can cause bilateral hilar lymphadenopathy are turnouts e.g. lymphoma, bronchial carcinoma, metastatic tumours (Come, Carroll, Brown & Delaney, 1997). However patients with any of those conditions would not feel very welt. References
Come, J., Carroll M., Brown, I. & Delaney, D, (1997) Chest X-Ray Made Easy. Churchill-Livingston, New York, Edinburgh Gurney, J.W. & Winer-Muram, H.T. (2003) Pocket Radiologist Chest Top 100 Diagnosis. Saunders and Elsevier Science Company. Salt Lake City, Utah
87
Volume 18
Number 2
April 2005