Factors affecting Quality of Sleep in Intensive Care Unit

Background: The etiology of sleep disruption in intensive care unit is poorly known and often ignored complication. It is caused by the environmental factors especially pain, noise, diagnostic testing and human interventions that cause sleep disruption. Light, medications and activities related to patient care interfere with patient’s ability to have good sleep. There are multi-factorial environmental etiologies for disruption of sleep in ICU. Objective: The objective of this study was to evaluate the factors disturbing the sleep quality in intensive care unit (ICU) admitted patients. Methodology: A cross sectional study was designed involving 150 patients admitted in intensive care unit and high dependency unit of Gulab Devi Chest Hospital. The duration of study was from September 2015 to March 2016. The questionnaire was made and filled with the help of patients. The data was analyzed using SPSS version 16.00. Results: Mean age of patients was 50.46+10.96 with maximum age of 65 and minimum age of 30 years. There was 53.33% male patients and 46.67% females participating in this study. The sleep quality was significantly poor in ICU than at home. After analysis, 54.67% patients were with poor quality of sleep due to pain and 48.67% were due to noise of environmental stimuli. The other factors were alarms, light and loud talking. Conclusion: Current study shows that reduced sleep quality is a common problem in ICU with multifactorial etiologies. Patient reported the poor sleep quality in ICU due to environmental issues that are potentially modifiable. Introduction Sleep is normal and episodic condition of immobility and dynamic physiological process in which individual is unresponsive to external sensory stimuli and unaware of environment. All voluntary muscles are inactive and metabolic rate is decreased during sleep. It rules almost a third of lives. (1) The particular functions of sleep is unknown but for proper functioning of host defense system it is important. There are two types of sleep: rapid eye movement (REM) or non-rapid eye movements (NREM). Both stages have specific anatomical, physiological and behavioral characteristics. Rapid eye movement and non-rapid eye movement both alternate cyclically. (2) Sleep fragmentation and deprivation have negative effect on respiratory system by reducing the respiratory muscles functions and the ventilator response to CO2. Sleep disturbance has significant physiological and psychological effect in patients of intensive care unit patients that protract recovery and maximize mortality. The etiologies responsible for sleep disruption are multi-factorial i.e noise, light and clinical care interactions. (3) In respiratory failure patients, sleep deprivation impairs the recovery and mechanical ventilation weaning. The factors which cause sleep disturbance and disruption of circadian rhythm are sound, light and weaning levels interruption. (4) In critical care units, the disruption of sleep is a basic problem for patients. It is complex and active process. Different factors which are responsible for patient’s inability to sleep are noise, lights, pain, discomfort, stress and medications. (5) Environmental noise is main cause of sleep disturbance in intensive care unit. (6) Sleep loss is common in patients having respiratory disorders. (7) Stress have damaging effects on patient sleep in ICU and the nursing interventions also increase the patients sleep disruption. It is required to minimize the stressors to encourage sleep in ICU. (8) In intensive care units, there is bedside measurement of vital signs. (9) Intensive care unit bed numbers vary between countries. (10) Multifactorial issues that are disturbing the sleep include noise lighting, patient care activities, vital sign monitoring, phlebotomy and medication administration. (11) Pain and poor ventilation of hospital rooms also affect quality of sleep in ICU. (12) In intensive care units, the presence of strange machinery alarms, unpleasant smells, unfamiliar 1. Gulab Devi Educational Complex, Lahore, Pakistan 2. The University of Lahore, Lahore, Pakistan *Correspondence: areebajutt31@gmail.com


Introduction
Sleep is normal and episodic condition of immobility and dynamic physiological process in which individual is unresponsive to external sensory stimuli and unaware of environment. All voluntary muscles are inactive and metabolic rate is decreased during sleep. It rules almost a third of lives. (1) The particular functions of sleep is unknown but for proper functioning of host defense system it is important. There are two types of sleep: rapid eye movement (REM) or non-rapid eye movements (NREM). Both stages have specific anatomical, physiological and behavioral characteristics. Rapid eye movement and non-rapid eye movement both alternate cyclically. (2) Sleep fragmentation and deprivation have negative effect on respiratory system by reducing the respiratory muscles functions and the ventilator response to CO2. Sleep disturbance has significant physiological and psychological effect in patients of intensive care unit patients that protract recovery and maximize mortality. The etiologies responsible for sleep disruption are multi-factorial i.e noise, light and clinical care interactions. (3) In respiratory failure patients, sleep deprivation impairs the recovery and mechanical ventilation weaning. The factors which cause sleep disturbance and disruption of circadian rhythm are sound, light and weaning levels interruption. (4) In critical care units, the disruption of sleep is a basic problem for patients. It is complex and active process. Different factors which are responsible for patient's inability to sleep are noise, lights, pain, discomfort, stress and medications. (5)

Significance:
The environment of intensive care units is mostly responsible for disturbance of patient behavior and sleep than the underlying disease. Mostly noises have sound peaks >80 dBA are amendable to behavior modification and the intensive care unit noise can be decreased through behavior modification program. In ICU the alarms are responsible for most irritating noise. The hospital management should pay great intention to internal noise.

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Volume 4 (Issue 1)   There was poor quality of sleep at home in 20% participants, 41.33% had good sleep at home and 27.33% had very good sleep at home. There were 11.33% individuals with excellent quality of sleep at home shown in Figure 1. Out of 150 patients who were admitted in ICU 54% were with disturbed sleep, 23.33% with good sleep, 21.33% with very good sleep and 1.22% were with excellent sleep in intensive care unit as shown in Figure 2. In study population, 46.67% had good quality of daytime sleepiness, 34% had poor daytime sleep, 12.67% had very good daytime sleep and the daytime sleep quality was excellent in 6.67% as shown in Figure 3. Majority of study population was with good quality of daytime sleep after extubation. 50.67% had good sleep, 27.33% had very good sleep, 1.33% had excellent sleep and 20.67% had poor quality of daytime sleepiness after extubation. (Figure 4) Majority of patients had poor quality of sleep due to pain. 54.67% of patients had poor sleep due to pain. 21.335 had good, 14% had very good sleep and only 10% had excellent sleep quality during pain. ( Figure  5) In current study, 48.67% of patients had poor sleep quality due to noise in intensive care unit, 20.67% had good sleep, 17.33% had very good sleep and only 13.33% patients had excellent sleep. Mostly patients had disturbed sleep in ICU due to noise which is often overlooked. (Figure 6) Sleep quality was good in 37.33% (56) patients due to light, 25.33% (38) were with very good sleep and 27.33% (41) were with excellent sleep due to light. Others having poor sleep due to light were only 10% (15). Lights had little effect on sleep quality of patients on ICU. (Figure 7)

Quality of Sleep in ICU
Nursing interventions had little effect on sleep quality in ICU. Only 4.67% had poor sleep quality, 21.33% had good sleep, 36% had very good sleep quality and 38% had excellent quality of sleep due to nursing interventions. (Figure 8) In this study majority of patients had excellent sleep with minimum effect of diagnostic testing. The 41.33% of patient population was with excellent sleep, 36% with very good sleep and 19.33% were with good sleep. Patients population with poor sleep quality was only 3.33%. (Figure 9) The vital signs measurement also has little effect on patient sleep quality. Only 2.67% were with poor sleep due to vital sign measurement, 17.33% with good quality, 40.67% with very good quality of sleep and 38.67% were with excellent sleep. (Figure 10) In current study only 7.33% patients had poor sleep due to blood samples while others 32% were with good sleep, 31.33% with very good sleep and 29.33% were with excellent sleep quality with little or no effect of blood samples. (Figure 11) Cardiac monitor alarm in ICU was found to affect the sleep quality of mostly patients. In ICU patients, there was poor sleep in 39.33% of study population, 40.67% were with good sleep, 15.33% with very good sleep and 4.67% were with excellent sleep. (Figure 12) Majority of ICU patients had disturbed sleep due to ventilator alarms. According to current study results only 4% were with excellent sleep in presence of ventilator alarms. While other 16% were with very good sleep, 42% with good sleep and study population with poor sleep was 38%. (Figure 13) Sleep quality was good due to oxygen finger probe it has little or no effect on patient sleep in ICU. Only 1.33% were with poor sleep and sleep was good in 7.33%, very good sleep in 57.33% and excellent sleep in 34% patients due to oxygen finger probe. ( Figure  14) Talking in ICU also found to affect patient sleep quality. According to this study results, 24.67% of study population was with poor sleep in ICU which was due to talking while other 53.33% were with good sleep, 17.33% with very good sleep and 4.67% were with excellent sleep. (Figure 15) Sleep quality was good due to intravenous pump alarms in ICU. Patient with poor sleep quality were only 2.67% while other 20.67% were with good sleep, 50% with very good sleep and 20.67% were with excellent sleep due to intravenous alarms. (Figure 16)

Conclusion:
According to results of this study, it was concluded that poor quality of sleep is common in ICU. Sleep disruption is caused by multi-factorial etiologies.

Quality of Sleep in ICU
Majority of patients with poor quality of sleep in ICU are because of pain, noise and alarms. Other factors have minor role for sleep disruption. Due to these factors the quality of sleep is minimized in ICU as compared to home. These factors can be potentially modified to better the quality of sleep.