Concise Critical Appraisal: Quality Improvement Intervention on Sleep and Delirium

Delirium is common in the surgical and medical critical care settings and is a focal point on teaching rounds. Delirium is a state of acute confusion combined with the inability to maintain, change, or gain focus. Etiologies are numerous and can include pain, fragmented sleep, medication side effects, metabolic disturbance, or worsening of an underlying pathophysiology. Delirium has been shown to be associated with longer mechanical ventilation duration and longer intensive care unit (ICU) and hospital lengths of stay.¹ It is estimated that direct one-year healthcare costs in the United States due to delirium range from $143 to $152 billion.² Because of significant effects on outcomes and costs, a lot of time and resources have been devoted to identifying risk factors and ways to prevent delirium. Tonna et al evaluated a multicomponent nonpharmacologic quality improvement intervention aimed at the sleep-wake cycle for reducing delirium in critically ill patients in the surgical critical care setting.³

This study was a staggered, pre-/post-design, quality improvement intervention in two surgical ICUs at an academic teaching institution that evaluated 646 admissions (332 baseline, 314 intervention) with a sleep-wake bundle intervention implemented sequentially. This intervention was multifaceted, focusing on environmental interventions that facilitated daytime wakefulness such as turning on lights and restocking only during the day and turning televisions off and dimming lights at night. Following an 8- to 12-week intervention, authors showed that patients experienced fewer days of delirium (15 days ± 27%) compared to the preintervention period (20 ± 31%; P = 0.022), with an adjusted decrease of 4.9% (95% CI, 0.5%-9.2%; P = 0.03).
 
The intervention was implemented before the publication of SCCM’s Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU, but it reinforces the principles recommended by the guidelines of a multicomponent nonpharmacologic intervention.⁴ This quality improvement study has many strengths and a few limitations. One is that it was conducted in a single academic center, which may limit its generalizability. Another is that, because it was a quality improvement intervention, administration was unblinded, which could affect detection and reporting bias.
 
This study builds on the multitude of time that has been devoted to reducing delirium. Nonpharmacologic interventions have the potential to decrease a billion-dollar hospital-acquired etiology with minimal overheard cost. However, larger, multicenter studies are needed to standardize these interventions within the healthcare setting.

References

1. Lat I, McMillian W, Taylor S, et al. The impact of delirium on clinical outcomes in mechanically ventilated surgical and trauma patients. Crit Care Med. 2009 Jun;37(6):1898-1905. https://pubmed.ncbi.nlm.nih.gov/19384221/
2. Leslie DL, Inouye SK. The importance of delirium: economic and societal costs. J Am Geriatr Soc. 2011 Nov;59 Suppl 2(Suppl 2):S241-S243. doi:10.1111/j.1532-5415.2011.03671.x. https://pubmed.ncbi.nlm.nih.gov/22091567/
3. Tonna JE, Dalton A, Presson AP, et al. The effect of a quality improvement intervention on sleep and delirium in critically ill patients in a surgical ICU. Chest. 2021 Sep;160(3):899-908. https://pubmed.ncbi.nlm.nih.gov/33773988/
4. Devlin JW, Skrobik Y, Gélinas C, et al. Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Crit Care Med. 2018 Sep;46(9):e825-e873. https://pubmed.ncbi.nlm.nih.gov/30113379/