August 16, 2018

EJRC Article Review

Sleep: How crucial is it in the ICU?



Sleeping is one of the most pleasant and essential activities that human do. However, when a patient is admitted to the hospital, and more importantly, to the ICU, sleeping falls to the bottom of the “priorities list” due to the acuity and severity of the situation. While the true relationship between lack of proper sleep in critically ill patients and long-term consequences is still unknown, some correlations have been found with Delirium incidence (1). Additionally, lack of sleep is known to be one of the biggest causes of stress for patients during their stay in the ICU (2).

A recently published paper by Hafhuis and colleagues evaluated sleeping promotion practices in ICUs across Europe and beyond (3). The objectives of the study were to 1) describe clinical practices used to promote sleep in the adult ICUs of ten countries and 2) evaluate roles and responsibilities of the ICU interprofessional team in relation to key sleep promotion decisions.

Eleven countries participated in the study (Poland, Denmark, Cyprus, Greece, Norway, Sweden, The Netherlands, UK, Italy, Canada and Germany). A self-administered survey was adapted for the study (4) and distributed to nursing managers from the participating countries. They received responses from 522 ICUs across the countries, representing from 32% up to 100% of ICUs in the participating countries.

Practices to check if patients were sleeping diverged across countries. The most common practices noted were: patient lying quietly with closed eyes (78%), decreased blood pressure (66%) and slow and regular respiratory rate (60%). With regards to estimated sleep quality, overall it was perceived as moderate, scoring highest in Cyprus and Greece and lowest in Germany.

Only 9% of participating ICUs had a sleeping protocol in the unit, while 72% noted that they would like to implement such a protocol in the future. Notably, only 1% of ICUs utilised a questionnaire to assess sleep.

One related topic that is being studied recently is the use of earplugs or other noise cancellation techniques. In this study, only 18% of the ICUs were using such techniques. Amongst non-pharmacological measures, the most frequently used were: 1) reducing noise generated by ICU staff, 2) turning room lights off, 3) reducing nurse interventions at night and 4) keeping patients awake during the day. Regarding pharmacological measures, 59% of ICUs used benzodiazepines to promote sleep (most commonly Lorazepam) and 18% used Melatonin.

Significant differences were observed between ICUs. With regards to drug selection, 49% of the ICUs reported that it was performed by physicians and nurses collaboratively, whereas 31% reported that physicians made decisions independently. On the other hand, 55% reported that the effect on sleep was assessed together by physicians and nurses.

Finally, participants perceived that nurses had moderate autonomy for managing sleep and they had considerable influence on decisions related to sleep. There was an association between asking about sleep preference and level of nursing influence.

The authors stress the need for sleep-related quality improvement initiatives to target strategies such as increased assessment of sleep preference, documentation of sleep (even if restricted to time spent lying with eyes closed), and adoption of sleep promotion protocols that emphasise adoption of inexpensive strategies to reduce noise and light at night. In the same line, another recent publication has just been released that evaluated the feasibility and acceptability of a “care bundle” for the prevention of Delirium in ICU (2).

This article review was prepared and submitted by Mireia Llauradó-Serra on behalf of the EJRC.


  1. Bannon L, McGaughey J, Clarke M, McAuley DF, Blackwood B. Designing a nurse-delivered delirium bundle: what intensive care unit staff, survivors and their families think? Australian Critical Care 2018 May;31(3):174-179. doi: 10.1016/j.aucc.2018.02.007.
  2. Little, A., Ethier, C., Ayas, N., Thanachayanont, T., Jiang, D., Mehta, S., 2012. A patient survey of sleep quality in the intensive care unit. Minerva Anestesiol. 78, 406–414.
  3. Hofhuis JGM, Rose L, Blackwood B, Akerman E, McGaughey J, Egerod I, et al. Clinical practices to promote sleep in the ICU: a multinational survey. International Journal of Nursing Studies 2018; 81: 107-114.
  4. Hofhuis, J.G., Langevoort, G., Rommes, J.H., Spronk, P.E., 2012. Sleep disturbances and sedation practices in the intensive care unit-A postal survey in the Netherlands. Intensive Crit. Care Nurs. 28, 141–149.



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