Sleep Fragmentation in the ICU: Exploring the Relationship Between Bundled Care, Environment and Patient Outcomes

Tuesday, 23 July 2013: 4:10 PM

Lucy Megginson, PhD, RN
Clinical Education, Floyd Medical Center, Rome, GA

Learning Objective 1: Discuss the ways in which nurse-driven research and interventions such as environmental change and bundled care can impact patient outcomes.

Learning Objective 2: Describe the theoretical basis of critical care architecture and design and how it relates to physiological and neurocognitive consequences.


The architecture of an ICU is designed to provide care to critically ill patients. An equal and opposing force in the design of critical care is the intersection of environment with frequent care. Noise, light, mechanical ventilation, assessment, phlebotomy, tests, medications, and nursing care create a cacophony of stimuli leading to sleep fragmentation with 40-60 interruptions each night. Sleep fragmentation contributes to physiological consequences such as hypoxia, impaired tissue repair and weakened immunity as well as neurocognitive consequences such as delirium. Duration of delirium is one of the strongest independent predictors of risk for death, LOS, cost of care, and long-term cognitive impairment. Thus, the purpose of this research is to explore the relationship between environment, care delivery and patient outcomes. The research question is: In adult ICU patients, does the use of bundled care, noise reduction, and visual reduction, in comparison to standard care, affect delirium (CAM-ICU scores), LOS, and falls?


A quasi-experimental design guides evaluation of the impact of interventions on patient outcomes. Power analysis based on intervention and control groups with expected replication of groups produced a sample size of 64. IRB approval was obtained. Upon patient consent, adult ICU participants were randomized into intervention and control groups. Collaboration with invested specialties including respiratory, phlebotomy, radiology, and medicine created a solid plan for bundling care. Conceptual and operational definitions of bundled care, noise reduction, visual reduction, delirium, LOS, and falls created valid and reliable measurements for variables. Inter-rater reliability was established through intensive education for all clinical staff including RNs, RRTs, and MDs.


The research study is currently in progress. Data will be analyzed via full factorial analysis to look at individual impact of interventions as well as combinations of interventions on selected patient outcomes.


Conclusions will be reported upon data analysis.