Abstract
Study Objectives:
Sleep is crucial for healing but often impaired in the pediatric intensive care unit due to environmental disruptions. Caregivers and bedside nursing staff are often most aware of these factors and the impact on patient sleep, but studies have not yet compared their perceptions.
Methods:
Caregivers and bedside nursing staff of pediatric patients staying a second night in the pediatric intensive care unit were asked to complete a survey regarding environmental factors (ie, temperature, light, sound, nursing staff room entries), sleep quality, and sleep quantity (ie, sleep duration, number of naps) of the pediatric patient. Caregivers were asked similar questions about their child’s sleep at home.
Results:
The caregivers and nursing staff of 31 pediatric patients participated in this pilot study. There was no significant difference between caregiver and nursing staff ratings of sleep quality, sleep duration, number of naps, room temperature, sound, or light (P > .05 for all). Nursing staff did report significantly more room entries than caregivers (P = .01). Compared to sleep at home, caregivers reported sleep in the hospital to be of lower quality (P = .009) with more frequent room entries (P = .01).
Conclusions:
Caregivers rate their child’s sleep in the pediatric intensive care unit as lower quality than sleep at home. Caregivers and bedside nursing staff largely agree about pediatric patient sleep quality and quantity as well as environmental factors. This agreement may facilitate further research and interventions at improving sleep in the pediatric intensive care unit.
Citation:
Witte MA, Lloyd RM, McGree M, Kawai Y. Sleep quantity and quality of critically ill children perceived by caregivers and bedside nursing staff: a pilot study. J Clin Sleep Med. 2023;19(12):2027–2033.
Keywords: sleep quality, sleep duration, pediatrics, critical care
BRIEF SUMMARY
Current Knowledge/Study Rationale: Despite medical team reliance on caregiver and nursing reports of patient sleep, no studies have compared the perceptions of nursing staff and caregivers regarding sleep quality and quantity in the pediatric intensive care unit. Understanding the correlation of these perceptions is important, as the medical team often relies on their reports when making clinical decisions and these reports may help foster future discoveries and improvements to the pediatric intensive care unit sleeping environment.
Study Impact: This pilot study demonstrates that caregivers and nursing staff have similar perceptions of pediatric patient sleep quality and quantity as well as environmental factors. This finding may help facilitate future research and interventions aimed at promoting sleep in the pediatric intensive care unit using their perceptions.
INTRODUCTION
Sleep is a crucial part of the healing process, especially for patients in the critical care setting.1 Unfortunately, environmental disruptions, such as noise, light, and caregiver interactions, can greatly impair sleep, leading to potentially poorer health outcomes and decreased patient/family satisfaction with the hospital stay.2–5 This is especially true in the pediatric intensive care unit (PICU), where, in addition to exposure to a suboptimal sleeping environment, patients are exposed to medications and interventions that also impair sleep.6
Sleep promotes numerous aspects of health and development. Sufficient sleep is crucial for immune function.1,7–10 Additionally, sleep deprivation may lead to increased inflammation and impaired glucose metabolism and growth hormone secretion, impairing healing.1,7,11–16 Furthermore, sleep promotes emotional modulation and mitigates pain perception, which are particularly important in the PICU.11,17–20
Unfortunately, most PICU patients are not acquiring the recommended hours of sleep.2,21–23 The PICU environment contributes to sleep disruptions. Specifically, prior studies have found that noise level, light luminance, and caregiver contact were predictive of whether the PICU patient was awake or asleep as rated by a researcher.2,22,23 Early morning and late evening rounding by physicians and trainees also contribute to sleep disruption. PICUs are loud, with average noise levels ranging from 48 to 55 dB, much higher than the Environmental Protection Agency’s recommendation of less than 45 dB, which is roughly the level of a quiet conversation.22,24,25 Most of this noise is attributed to equipment alarms.26 A systematic review of 21 studies conducted in the PICU found that poor sleep quality was associated with delirium, a disorder characterized by agitation, disorientation, inattention, and hallucinations, with another study finding that louder environments were correlated with higher delirium scores.27,28
Unfortunately, examining sleep in the PICU has proven to be complex. Not only does sleep duration and composition vary greatly with age and between individuals, but no reliable and economically feasible measure of sleep quality and quantity currently exists for the pediatric population.21,29,30 Polysomnography (PSG) is the gold standard for monitoring sleep, but it is invasive, costly, and work intensive.31,32 Alternatives, such as having researchers monitor for signs of sleep and actigraphy, have proven ineffective. Specifically, one study comparing actigraphy to PSG found that actigraphy had low specificity of 28% and low accuracy of 70%.32
To our knowledge, no study has compared caregiver and nursing staff perceptions of sleep quality and quantity in the PICU. These individuals, who are more familiar with the PICU patient, may have more reliable assessments of sleep state while also helping to offset the cost and invasiveness of PSG, fostering future discoveries and improvements to the PICU sleeping environment. The medical team relies on caregiver and nursing reports of patient sleep quantity and quality when making clinical decisions, especially as delirium and other conditions receive more focus and nursing-driven bundles to promote sleep become more utilized.25,33 The present study aimed to assess the relationship between various PICU environmental factors (ie, luminance, noise level, temperature) and sleep duration and quality, as rated by caregivers and nursing staff.
METHODS
Participants
Overall, 31 PICU patients were recruited to participate in this pilot study between March 2021 and March 2022 (22 male, 9 female). Patients between the ages of 0 and 18 years old who had spent one night in the PICU and were expected to stay another night were asked to participate in the study by study coordinators on weekdays. Participants who were non-English speaking were excluded from the study. Caregivers who agreed to participate in this study provided written informed consent.
The median age of recruited participants was 6.5 years (2.0, 13.6). The majority identified as White (n = 28, 90.3%) with the rest being Asian (n = 3, 9.7%). Patients were admitted for a median of 7 days (5, 13) with 48.4% (n = 15) being admitted for a medical condition and 51.6% (n = 16) being admitted for a surgical condition. The median Pediatric Index of Mortality 3 Probability of Death (PIM3 PoD) on admission was 0.14% (0.06, 0.70).34 On the day of recruitment, 25% met criteria for delirium (n = 7) with 80.6% (n = 25) being nonintubated, nonsedated, and nonparalyzed.
For the 31 recruited PICU patients, survey completion rates were as follows: 20 had a caregiver, day nurse, and night nurse surveys; 3 had only caregiver and day nurse surveys; 2 had only day nurse and night nurse surveys; 3 had only caregiver surveys; 2 had only day nurse surveys; and 1 had only a night nurse survey.
Procedure
Caregivers of pediatric patients admitted to the PICU were approached by research staff after their child’s first night in the PICU. Patients who were planning to discharge that day (ie, were not planning to stay a second night) were not included in the study. If caregivers consented to participate in the study, the nurse caring for the patient during the second hospital night from 7:00 pm–7:00 am (“night nurse”) was provided with a tablet and asked to complete the survey following their shift on the second hospital night. On the subsequent day, the nurse caring for the patient from 7:00 am–7:00 pm (“day nurse”) was provided with a tablet and asked to complete the survey regarding their shift on the day following the second hospital night. The caregiver was then provided with a tablet and asked to complete the survey regarding their observations over the second hospital night and the day after the second hospital night. They were also asked to provide information about their child’s sleep at home including sleep timing, nap frequency, and nighttime routines.
Researchers later extracted demographic data including age, race, ethnicity, and sex from the patient charts as well as information regarding admission diagnosis, length of stay, interventions (ie, intubation, sedation, paralytics), and Cornell Assessment of Pediatric Delirium (CAPD) score. PIM3 PoD was provided by Virtual Pediatric Systems, LLC, which is an internal patient database with demographic information on all patients admitted to the PICU.35
No endorsement or editorial restriction of the interpretation of these data or opinions of the authors has been implied or stated. The study protocol was approved by the Institutional Review Board at the Mayo Clinic in Rochester, Minnesota (approval number 18-011409).
Research instruments
Surveys created by our team were used to assess caregiver and nursing staff’s perceptions of the recruited patients’ sleep and environmental factors. Specifically, to assess sleep quantity, both caregivers and nursing staff were asked to record the time the recruited patient fell asleep and woke up during the second hospital night. They were also asked to record the number of naps that the recruited patient took during the day following the second hospital night. To assess sleep quality, both caregivers and nursing staff were asked to rate the recruited patient’s quality of sleep on a scale of 1 to 5 with 1 being “not at all well” and 5 being “very well.” To assess environmental factors, both caregivers and nursing staff were asked to rate the temperature, sound, and light of the room on a scale of 1 to 5 with 1 being “very cold/quiet/dark” and 5 being “very warm/loud/light” during the second hospital night. They were also asked to record the number of room entries by caregivers or staff during the second hospital night. The caregivers were similarly asked to record the bedtime, wake time, number of naps, and number of room entries typical at home as well as rate the quality of sleep typical at home and identify their child’s home nighttime routines.
CAPD scores to identify delirium and PIM3 PoD to quantify illness severity were extracted from the recruited patients’ charts on the day following the second hospital night.
Statistics
Ratings of sleep in the hospital by the caregiver vs the nursing team were compared using the Wilcoxon signed rank test. Similarly, ratings by the caregiver of sleep in the hospital vs at home were compared using the Wilcoxon signed rank test. The correlation between ratings of sleep in the hospital and environmental factors were quantified using the Spearman rank correlation coefficient separately using the ratings of the caregiver and nursing team. Lastly, the correlation of ratings of sleep and environmental factors with the CAPD and PIM3 scores, respectively, were quantified using the Spearman rank correlation coefficient. All calculated P values were two-sided, and P values less than .05 were considered statistically significant.
RESULTS
Caregiver and nursing staff perceptions
Participant demographic data is presented in Table 1. Caregiver and nursing staff ratings of sleep quality (median difference 0 (–1,1), P = .62) and sleep quantity in terms of nighttime sleep duration (median difference –0.3 (–1.8,2.0), P = 1.00) and naps (median difference 0 (0,0), P = .83) were not significantly different.
Table 1.
Demographic and patient characteristics.
| Characteristic | Total (n = 31) |
|---|---|
| Median age in years (IQR) | 6.5 (2.0, 13.6) |
| Age distribution (years) (%) | |
| ≤ 2 | 12 (38.7) |
| 3–5 | 3 (9.7) |
| 6–12 | 8 (25.8) |
| 13–18 | 8 (25.8) |
| Sex (%) | |
| Male | 22 (71.0) |
| Female | 9 (29.0) |
| Race (%) | |
| Asian | 3 (9.7) |
| White | 28 (90.3) |
| Ethnicity (%) | |
| Hispanic or Latino | 1 (3.2) |
| Not Hispanic or Latino | 30 (96.8) |
| CAPD score | |
| Median (IQR) | 5 (2, 9) |
| No delirium (CAPD score < 9) (%) | 21 (75.0) |
| Delirium (CAPD score ≥ 9) (%) | 7 (25.0) |
| Hospital diagnosis organ system (%) | |
| Cardiac | 2 (6.5) |
| Gastrointestinal | 2 (6.5) |
| Infectious disease | 1 (3.2) |
| Musculoskeletal | 1 (3.2) |
| Neurological | 10 (32.3) |
| Renal | 5 (16.1) |
| Respiratory | 10 (32.3) |
| Hospital diagnosis category (%) | |
| Medicine | 15 (48.4) |
| Surgery | 16 (51.6) |
| Median length of hospital stay in days (IQR) | 7 (5, 13) |
| Interventions on day of survey (%) | |
| No intubation, sedation, or paralytic | 25 (80.6) |
| Intubation, sedation, and paralytic | 2 (6.5) |
| Intubation and sedation | 2 (6.5) |
| Sedation only | 2 (6.5) |
| Median PIM3 PoD (IQR) | 0.14 (0.06, 0.70) |
CAPD = Cornell Assessment of Pediatric Delirium, IQR = interquartile range, PIM3 PoD = Pediatric Index of Mortality 3 based probability of death percentage, SD = standard deviation.
For environmental factors, nursing staff reported significantly more room entries during the night than did caregivers (median difference –1 (–3,0), P = .01). There was no statistically significant difference in ratings of temperature (median difference 0 (0,0), P = .75), sound (median difference 0 (–1,0.5), P = 1.00), or light (median difference 0 (0,1), P = .34). Caregiver and nursing staff ratings are compared in Table 2.
Table 2.
Comparison of self-reported sleep quality/quantity and environmental factors between caregivers and nursing staff.
| Measure | Number with Responses from Both Caregiver and Nurse | Agreement n (%) | Median (Interquartile Range) | P † | ||
|---|---|---|---|---|---|---|
| Caregiver | Nurse | Difference (Caregiver− Nurse) | ||||
| Night sleep quality (5-point scale: 1 = not at all well, 5 = very well) | 20 | 6/20 (30) | 3 (3, 4) | 3 (2.5, 4) | 0 (−1, 1) | 0.62 |
| Duration of sleep at night (hours) | 8 | 1/8 (13) | 8.8 (6.8, 10.0) | 8.0 (7.0, 10.0) | −0.3 (−1.8, 2.0) | 1.00 |
| Number of naps | 21 | 14/21 (67) | 1 (0, 3) | 1 (0, 2) | 0 (0, 0) | 0.83 |
| Hospital temperature (5-point scale: 1 = very cold, 5 = very warm) | 20 | 15/20 (75) | 3 (3, 3) | 3 (3, 3) | 0 (0, 0) | 0.75 |
| Hospital sound (5-point scale: 1 = very quiet, 5 = very loud) | 20 | 9/20 (45) | 2 (2, 3) | 2 (2, 3) | 0 (−1, 0.5) | 1.00 |
| Hospital light (5-point scale: 1 = very dark, 5 = very light) | 20 | 9/20 (45) | 2.5 (2, 3) | 2 (2, 2) | 0 (0, 1) | 0.34 |
| Hospital number of nightly room entries (range 1–16) | 19 | 5/19 (26) | 3 (2, 5) | 5 (4, 10) | −1 (−3, 0) | 0.01 |
Wilcoxon signed rank test.
Both caregivers and nursing staff rated room entries as the environmental factor that most influenced sleep (44.4% caregivers, 62.5% day nurses, 50.0% night nurses). Similarly, both caregivers and nursing staff reported temperature least influenced sleep (44.4% caregivers, 87.5% day nurses, 62.5% night nurses).
Caregiver perceptions of sleep at home and in the hospital
Compared to patients’ sleep in the hospital, caregivers rated sleep at home as significantly higher quality (median difference 1 (0,1), P = .009). While not statistically significant, there was also a trend toward caregivers rating nighttime sleep duration as longer at home (median difference 1 (–0.5,3), P = .09) and their children having fewer naps at home (median difference 0 (–2,0), P = .07) compared with in the hospital.
For environmental factors, caregivers reported significantly fewer room entries at home compared with in the hospital (median difference –3.5 (–5,–1), P = .01). Caregiver ratings for home and hospital sleep are compared in Table 3.
Table 3.
Comparison of caregiver self-reported sleep quality, sleep quantity, and room entries at home vs in the hospital.
| Measure | Number with Responses from Home and Hospital | Agreement n (%) | Median (Interquartile Range) | P † | ||
|---|---|---|---|---|---|---|
| Home | Hospital | Difference (Home− Hospital) | ||||
| Sleep quality during the night (5-point scale: 1 = not at all well, 5 = very well) | 26 | 8/26 (31) | 4 (4, 5) | 3.5 (3, 4) | 1 (0, 1) | 0.009 |
| Duration of sleep during the night (hours) | 23 | 2/23 (9) | 10 (9, 11) | 9.5 (7, 10.5) | 1 (−0.5, 3.0) | 0.09 |
| Number of naps during the day | 25 | 9/25 (36) | 0 (0, 1) | 1 (0, 3) | 0 (−2, 0) | 0.07 |
| Number of room entries per night | 10 | 0/10 (0) | 1.5 (1, 3) | 5 (2, 8) | −3.5 (−5.0, −1.0) | 0.01 |
Wilcoxon signed rank test.
Correlations between sleep perceptions and environmental factor perceptions
For caregivers, worse nighttime sleep quality was associated with louder environments (r = –.47, P = .02). There was also a trend toward worse nighttime sleep quality being associated with more frequent room entries (r = –.40, P = .05). Ratings of sleep quality were not significantly associated with temperature or light. Similarly, ratings of sleep quantity in terms of sleep duration and number of naps were not significantly associated with ratings of any environmental factors.
For nursing staff, there was a trend toward worse nighttime sleep quality being associated with brighter environments (r = –.39, P = .07). All other ratings of sleep quality were not associated with ratings of other environmental factors. More room entries were associated with shorter duration of sleep (r = –.72, P = .02) and more naps (r = .65, P = .002). All other ratings of sleep quantity in terms of sleep duration and number of naps were not significantly associated with ratings of other environmental factors. Correlations between caregiver and nursing ratings of environmental factors and ratings of sleep are presented in Table 4.
Table 4.
Correlation between self-reported sleep quantity/quality and environmental factors by caregivers and nursing staff.
| Sleep Quantity/Sleep Quality | |||
|---|---|---|---|
| Environmental Factor | Hospital Sleep Quality (5-Point Scale: 1 = Not At All Well, 5 = Very Well) | Duration of Sleep | Number of Naps |
| Caregivers | |||
| Hospital temperature (5-point scale: 1 = very cold, 5 = very warm) | r = .22, p† = 0.28 (n = 26) | r = –.01, P = .96 (n = 24) | r = –.04, P = .86 (n = 25) |
| Hospital sound (5-point scale: 1 = very quiet, 5 = very loud) | r = –.47, P = .02 (n = 26) | r = –.21, P = .33 (n = 24) | r = –.13, P = .52 (n = 25) |
| Hospital light (5-point scale: 1 = very dark, 5 = very bright) | r = –.28, P = .17 (n = 26) | r = –.16, P = .46 (n = 24) | r = .005, P = .98 (n = 25) |
| Hospital number of room entries per night (range: 1–16) | r = –.40, P = .05 (n = 24) | r = –.20, P = .35 (n = 23) | r = –.14, P = .51 (n = 24) |
| Nursing Staff | |||
| Hospital temperature (5-point scale: 1 = very cold, 5 = very warm) | r = .00, P = 1.00 (n = 23) | r = –.53, P = .12 (n = 10) | r = –.13, P = .59 (n = 20) |
| Hospital sound (5-point scale: 1 = very quiet, 5 = very loud) | r = –.35, P = .10 (n = 23) | r = –.47, P = .17 (n = 10) | r = .25, P = .28 (n = 20) |
| Hospital light (5-point scale: 1 = very dark, 5 = very bright) | r = –.39, P = .07 (n = 23) | r = .08, P = .82 (n = 10) | r = .02, P = .93 (n = 20) |
| Hospital number of room entries per night (range: 1–16) | r = –.21, P = .35 (n = 22) | r = –.72, P = .02 (n = 10) | r = .65, P = .002 (n = 20) |
Spearman rank correlation.
Other analysis
CAPD scores were not significantly associated with ratings of sleep quality and quantity as rated by caregivers and nursing staff (see Table S1 (18KB, pdf) in the supplemental material). Similarly, CAPD scores were not significantly associated with ratings of environmental factors as rated by caregivers and nursing staff (see Table S2 (18KB, pdf) ).
PIM3 PoD scores were also not significantly associated with ratings of sleep quality and quantity as rated by caregivers and nursing staff (see Table S3 (18KB, pdf) ).
DISCUSSION
This pilot study found no difference in caregiver and nursing staff ratings of pediatric patients’ sleep quality and quantity. While it is still unclear how these ratings correlate with the gold standard of PSG, it is possible that both caregiver and nursing staff reports of sleep may prove useful for future pediatric sleep research. Practically, caregiver and nursing reports of patient sleep are already utilized to prioritize interventions and sleep promotion strategies in the PICU. The lack of measurable difference between their reports provides added validity to nursing interpretations when caregivers are unable to be present.
Caregivers reported that their child’s sleep was worse in the PICU compared to sleep at home, as expected. There were also trends toward more frequent naps and decreased sleep duration in the hospital. This worsened sleep quality and quantity did not appear to be associated with illness severity as measured by PIM3 PoD score, suggesting that all admitted patients experienced impaired sleep.
Prior research has found similar sleep disruptions. For example, several studies have found that patients in the PICU have reduced total sleep time compared to their typical sleep duration at home with patients in one study averaging only 4.7 hours per night.2,22,23 These patients also have more fragmented sleep with average number of awakenings per night varying between 9 and 40.2,22,24 Some studies have even found that PICU patients lose diurnal rhythms with some patients sleeping more during the day compared to the night.24,36,37 Furthermore, PICU patients have alterations in sleep architecture. They have significant reductions in rapid eye movement sleep, which typically accounts for 50% of total sleep time in neonates and subsequently declines to roughly 25% by age 10.38 Specifically, in PICU patients, rapid eye movement sleep accounted for only 3% of patients’ total sleep time with another study finding that 19% of patients did not experience any rapid eye movement sleep at all.2,24,39,40 Slow-wave sleep is also reduced with one study finding that 40% of patients did not experience any slow-wave sleep and another finding significant reductions in delta waves, a measure of slow-wave sleep depth and intensity.36,37,39
Some of the worsened sleep may be explained by PICU environmental factors in addition to medications, pain, limited physical activity, and the child’s underlying medical conditions. For caregivers, their child’s sleep quality was negatively associated with louder environments with a similar trend for more frequent room entries. Caregivers also noted that room entries occurred more frequently in the PICU when compared to home, which they may have actually underestimated, as nursing staff reported significantly more room entries than caregivers. For nursing staff, more frequent room entries at night were associated with self-reported reduction in nighttime sleep duration and more frequent naps the following day. There was also a trend toward brighter environments being associated with worse self-reported sleep quality. Alterations from the child’s home sleep routine may also have played a role, as 31% of caregivers (n = 8) stated that their child had a specific sleep routine at home and 27% (n = 7) stated that their child coslept with another person.
The disruption of caregiver contact, light, and sound on sleep in the PICU has been reported in several other studies.2,22,23 Specifically, more frequent caregiver interactions in the PICU promote sleep fragmentations. One study found that hospital staff interacted with PICU patients an average of 240 minutes per day with the amount of interaction not varying between day and night, resulting in an average duration of 99 minutes between interactions and an average of 17 interactions between 7:00 am and 7:00 pm.24 Caregivers were found to interact with their children 13% of the time between 7:00 pm and 6:00 am.22 High levels of luminance may also disrupt the diurnal cycle, as PICUs have significant light pollution with one study finding an average luminance of 23 ft-c, only slightly dimmer than a well-lit office.22,45 Finally, as mentioned previously, PICUs are loud, with average noise levels ranging from 48 to 55 dB, higher than the Environmental Protection Agency’s recommendation.22,24,25 These environmental factors may be an area of intervention with prior research showing significant noise reductions after implementation of a delirium bundle.25 Further investigation into strategies like this will be crucial for determining whether addressing environmental factors and nursing entries can promote better sleep in the PICU as well as improve nursing and caregiver satisfaction.
Although our study did not find a significant association between sleep quality and quantity and delirium scores, it is notable that 25% of enrolled patients screened positive for delirium, suggesting that both sleep impairment and delirium were prevalent in this cohort of patients. Similar prevalence of both sleep impairment and delirium have been found in the adult literature with mixed results regarding their relationship.41–43 Specifically, several studies have found reductions in delirium scores following sleep promotion strategies, but this effect has not been found in all studies.44 It is known, however, that similar risk factors, such as pain, sedation, intubation, infection, and hypoxia, can foster both delirium and sleep impairment. Similarly, strategies aimed at minimizing low-priority interactions and fostering diurnal cycles can help manage both conditions.45
This study has several limitations. As PSG data was not collected, we were unable to compare survey responses to the gold standard of sleep quality and quantity determination. While we attempted to limit the subjectivity of a survey by surveying both caregivers and nursing staff who were regularly in contact with the patients, it is possible that both groups were inaccurate. Similarly, environmental data was not objectively measured, limiting the validity of these data. Another limitation was the small number of patients enrolled, which may have contributed to insufficient power to detect associations between factors or differences between groups. Furthermore, the small number of patients impaired our ability to correct for age, time of year, diagnosis, and presence of interventions like sedation, intubation, and other medications, which may have influenced our results as well as sleep architecture. By using paired analysis (ie, linking nursing staff surveys and caregiver surveys for a particular patient), we minimized some of these confounding factors. Furthermore, as the first study of its kind, we were unable to use a validated survey, limiting result interpretation. Finally, our patient population was largely Caucasian and recruited from a single Midwest tertiary center, which may limit the generalizability.
Sleep in the PICU is often impaired, impeding healing and promoting poor health outcomes. This research along with other studies suggests that environmental factors, such as noise, light, and room entries, may facilitate poor sleep in the PICU. Caregiver and nursing staff perceptions of sleep may facilitate future research and interventions aimed at promoting sleep in the PICU, but additional research into the validity of their perceptions is needed.
DISCLOSURE STATEMENT
All authors have seen and approved this manuscript. Research was performed at the Mayo Clinic in Rochester, MN. This work was supported by the Mayo Clinic Center of Clinical and Translational Science [Grant Number UL1TR002377] and T. Denny Sanford Pediatric Collaborative Research Fund. The authors report no conflicts of interest.
ACKNOWLEDGMENTS
The authors acknowledge Andrea Errthum and Tricia Cox, who helped recruit participants, and Travis Kirkpatrick, who obtained PIM3 data through the Virtual PICU System.
ABBREVIATIONS
- CAPD
Cornell Assessment of Pediatric Delirium
- PICU
pediatric intensive care unit
- PIM3
PoD Pediatric Index of Mortality 3 Probability of Death
- PSG
polysomnography
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