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ABSTRACT
The etiology of sleep disruption in patients in intensive care units
(ICUs) is poorly understood, but is thought to be related to
environmental stimuli, especially noise. We sampled 203 patients
(121 males and 82 females) from different ICUs (cardiac [CCU],
cardiac stepdown [CICU], medical [MICU], and surgical [SICU]) by
questionnaire on the day of their discharge from the unit, to
determine the perceived effect of environmental stimuli on sleep
disturbances in the ICU. Perceived ICU sleep quality was significantly
poorer than baseline sleep at home (p = 0.0001). Perceived sleep
quality and daytime sleepiness did not change over the course of
the patients' stays in the ICU, nor were there any significant
differences (p > 0.05) in these parameters among respective units.
Disruption from human interventions and diagnostic testing were
perceived to be as disruptive to sleep as was environmental noise.
In general, patients in the MICU appeared to be more susceptible to
sleep disruptions from environmental factors than patients in the
other ICUs. Our data show that: (1) poor sleep quality and daytime
sleepiness are problems common to all types of ICUs, and affect a
broad spectrum of patients; and (2) the environmental etiologies of
sleep disruption in the ICU are multifactorial.
Several polysomnographic studies have demonstrated sleep
deprivation, sleep fragmentation, and altered sleep architecture in
patients in intensive care units (ICUs) (1-8). Sleep in ICU patients
has been characterized by a predominance of Stages 1 and 2 sleep,
decreased or absent Stage 3 and 4 and rapid eye movement (REM)
sleep, shortened periods of REM sleep, frequent arousals, and sleep
METHODS
Site
The study was conducted between July 1996 and April 1997 at the
University of Pennsylvania Medical Center, and was approved by the
Institutional Review Board of the university.
Questionnaires were given to patients on the day of their discharge
from four ICUs: (1) a 12-bed cardiac care unit (CCU); (2) an 18-bed
cardiac intermediate care unit (CICU); (3) a 24-bed surgical
intensive care unit (SICU); and (4) a 24-bed medical intensive care
unit (MICU).
Patients
Patients were volunteers who received no remuneration for their
participation. Patients scheduled for discharge from their respective
ICU were selected to participate in the study. All patients except
those who had insufficient cognitive function to allow them to
cooperate were candidates for the study. Patients gave oral consent
prior to their participation. Those patients unable to fill out the
questionnaire because of muscle weakness or poor eyesight had the
questionnaire read aloud to them and their verbal responses
recorded.
Questionnaire
A questionnaire was developed that assessed the sleep quality of
ICU patients and the factors that contributed to sleep disruption
among these patients (Figure 1). Patients evaluated their sleep
quality on a scale of 1 to 10 (1 = poor, 10 = excellent) at home and
in the ICU. Sleep quality over the duration of the patients' ICU stay
was assessed with the same scale. Participants were asked to
determine their degree of daytime sleepiness over the duration of
their ICU stay on a scale of 1 to 10 (1 = unable to stay awake, 10 =
fully alert and awake). The effect of environmental stimuli on sleep
disruption was measured on a scale of 1 to 10 (1 = no disruption, 10
= significant disruption). The environmental stimuli that were
evaluated included noise, light, nursing interventions (bathing, etc.),
diagnostic tests (i.e., chest radiographs), evaluation of vital signs,
RESULTS
Demographics
A total of 203 patients completed the questionnaire (Table 1).
Overall, there were significantly more males than females in the
study (p < 0.05), although there were no significant (p > 0.05)
gender differences among ICUs. The MICU patients were
significantly younger than patients in other units (p = 0.003).
Otherwise, there were no age-dependent differences (p> 0.05)
among the ICUs. The durations of stays in the CICU and MICU were
longer than in other units (p = 0.02). The MICU had significantly
more ventilated patients than did other units (p = 0.001).
Table 1
View Larger Version
DEMOGRAPHICSOFSTUDYPOPULATION*
Primary Analysis
Sleep quality in the ICU was perceived as significantly poorer than
sleep at home (p = 0.0001) by all subjects (Figure 2). Neither quality
nor perceived daytime sleepiness changed significantly over the
course of any patient's ICU stay (p > 0.05). There were no
One hundred and sixty ICU patients completed the final section of
the questionnaire, which evaluated the relationship between
specific ICU noises and perceived sleep disruption. There were
significant differences (p < 0.0001) among the specific ICU noises in
terms of their perceived disruptive effect on sleep in the ICU.
Communication between staff members (talking) and telemetry
alarms were significantly more disruptive (p = 0.003) to sleep than
was the mean of the other factors. Noises from telephones,
television, and doctors' beepers were significantly less disruptive (p
= 0.0001) to sleep than was the mean of the other factors. Sounds
of pulse oximetry and intravenous pump alarms were perceived as
not significantly different (p > 0.05) than the mean of the other
disruptive factors (Figure 4). There were no significant associations
between patient age or duration of stay and sleep disruption by
specific noises. There were no significant differences between the
respective ICUs and perceived sleep disruption by specific noises (p
> 0.05).
Fig
Table 2
View Larger Version
ORTHOGONALLYROTATEDFACTORPATTERN.
Factor analysis confirmed several findings from the primary
analysis. None of the four factors showed significant (p> 0.05)
associations with patient age or gender. The duration of stay was
not (p > 0.05) associated with sleep disruptions caused by human
intervention (Factor 1), sleep quality (Factor 2), or daytime
sleepiness (Factor 3). A patient's ventilator status was not (p > 0.05)
associated with perceived sleep disruptions caused by human
intervention (Factor 1), noise/ light (Factor 4), or sleep quality
(Factor 2). Also, neither sleep quality nor daytime sleepiness was (p
> 0.05) associated with a patient's respective unit.
Factor analysis allowed the detection of specific associations with
respect to sleep quality, daytime sleepiness, and sleep disruption
caused by the ICU environment that were not evident in the primary
analysis. Daytime sleepiness (Factor 3) was significantly different in
ventilated and nonventilated patients (p = 0.008), with ventilated
patients experiencing more daytime sleepiness than nonventilated
patients. Sleep disruption caused by environmental light and noise
(Factor 4) showed a weak but significant positive correlation (r =
0.19; p= 0.006) with duration of ICU stay (i.e., patients who had
longer stays in the ICU were more likely to have their sleep
disturbed by environmental light and noise). Sleep disruptions
caused by human interventions/diagnostic tests and environmental
light/noise (Factors 1 and 4) were significantly different in the
different units (p = 0.0365 and p = 0.0028, respectively) (Table 3).
Table 3
View Larger Version
COMPARISONOFFACTORS1AND4ACROSSUNITS.
Table 3 shows that patients in the MICU perceived interruptions
caused by human interventions and diagnostic tests (Factor 1) to be
DISCUSSION
We subjectively evaluated sleep and the environmental factors
disrupting sleep in 203 patients discharged from medical, surgical,
and cardiac ICUs. Overall, perceived ICU sleep quality was poorer
than sleep quality at home. Sleep quality and daytime sleepiness
did not change over the course of the patients' ICU stays, and there
were no significant differences in these parameters among the
different units. Factor analysis showed that patients who had been
mechanically ventilated during their ICU stay were significantly
sleepier during the day than were nonventilated patients. Overall,
sleep quality, daytime sleepiness, and perceived disruptions in sleep
caused by environmental factors were not affected by the patients'
age or gender. Although the primary analyses did not show
significant differences between various environmental sources of
sleep disruption, factor analysis showed that MICU patients
perceived their sleep to be more disrupted by environmental factors
than did patients in other units.
Study Design and Limitations
Our study design had several limitations. Because the study
assessed sleep quality subjectively, we were unable to determine
the patients' true sleep architecture and degree of sleep disruption
caused by the various environmental stimuli. However, we believe
that this investigation was an essential first step in understanding
the factors perceived by ICU patients as disturbing sleep. We did not
control for patients' severity of illness or medication use, both of
which factors may have affected the results of the study. We also
did not have a control group of hospitalized non-ICU patients for
comparison, since our main objectives were to determine whether
sleep quality was disturbed in an ICU setting and to determine the
generalized to critically ill ICU patients who die before their ICU
discharge.
Sleep Quality and Daytime Sleepiness in the ICU
Our finding that patients perceive their sleep quality to be worse in
the ICU than at home is supported by previous investigations (1-8).
Studies of sleep in ICU patients indicate that their sleep is abnormal,
as demonstrated by a predominance of Stages 1 and 2 sleep,
decreased or absent Stages 3 and 4 and REM sleep, shortened
periods of REM sleep, frequent arousals, and sleep fragmentation
(1-8). Our results also demonstrate that perceived sleep quality and
daytime sleepiness did not improve over the course of our patients'
ICU stays. These results are consistent with those of previous
polysomnographic studies, which showed that 40% to 50% of the
total sleep time in an ICU occurred during the day, and that altered
sleep patterns may not improve over the course of a patient's ICU
stay, and may take several days to normalize after transfer of the
patient to a general hospital ward (2, 3, 6, 7).
Although daytime sleepiness appeared to be a problem common to
all of the types of ICUs investigated in our study, factor analysis
showed that patients who had been mechanically ventilated during
their ICU stay perceived that they were significantly more sleepy
during the day than were nonventilated patients. This finding may
be explained by the typically greater sedation of mechanically
ventilated than of nonventilated patients, and their greater severity
of illness than that of nonventilated patients. Further studies will be
necessary to determine whether sedation and severity of illness are
correlated with sleep disruption in the ICU.
Interestingly, there were no differences among any of the individual
ICUs in perceived sleep quality, nor were there any associations
between sleep quality and patient age, gender, duration of stay, or
ventilator status. This suggests that poor sleep quality and
disrupted sleep are problems common to all ICUs and to many ICU
patients. It also suggests that factors disturbing sleep are generic to
all ICUs.
Sleep Disruption and the ICU Environment
Our findings support the assertion that environmental causes of
sleep disruption in the ICU are multifactorial. Our data indicate that
human interventions and diagnostic testing appear to be as
important to disrupting sleep as is environmental noise. Our findings
do not support our primary hypothesis that ICU noise is the most
disruptive environmental stimulus to sleep for most ICU patients. In
fact, the effect of specific ICU noises on sleep disruption appears to
be low, as shown by the low mean sleep-disruptive scores in our
15.4 yr. We may not have sampled enough younger patients (age <
40 yr) to show a significant association between age, sleep quality,
and sleep disruptions. One would also assume that patients who
were mechanically ventilated and thus exposed to the additional
noise of ventilators and alarms would perceive the ICU environment,
and specifically noise, as more disruptive to their sleep than would
nonventilated patients. This was not the case in our study. Our
results suggest that all ICU patients, and not specific subgroups, are
at risk for sleep disturbances.
Our results support the assertion that sleep disruption in the ICU is
multifactorial, and suggest that other, nonenvironmental factors
may be responsible for causing sleep disruptions in the ICU patient
population. In general, the mean disruption scores for the
environmental factors and specific ICU noises causing sleep
disruption in our study were relatively low, although the perceived
sleep quality among the vast majority of patients was poorer than
that of sleep at home. It is clear that the ICU environment is not
solely responsible for disturbed sleepwake patterns. Several
nonenvironmental factors, such as medications (32), pain, fever
(9, 33), and a patient's underlying chronic disease may have
adverse effects on sleep quality (34, 35). Studies with surgical ICU
patients that have decreased the number of environmental
interruptions of sleep have not demonstrated improvement in the
patients' altered sleep patterns. Other studies have shown
continued alterations in sleep duration and other sleep parameters
when patients were transferred from the ICU to a hospital ward (3).
It is possible that the severity of illness or underlying disease states
contributed to the perceived differences in sleep quality in our
study. Future studies should examine the effects of relationships
between disease severity, age, medications, and time in the ICU on
disruptions of sleepwake patterns in the ICU, although this may
prove difficult, given the number of potentially confounding factors.
CONCLUSIONS
Our results show that good-quality sleep may be difficult to achieve
in patients under intensive care. Poor sleep quality and sleep
disruptions are problems common to many ICU patients, and
environmental factors disturbing sleep are generic to all types of
ICUs. Although environmental noise is an important contributor to
sleep disruption in ICU patients, it is only one of a series of
important factors. Among other environmental factors responsible
for sleep disruptions in ICU patients, interruptions caused by human
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