Reply: Sleep in the Intensive Care Unit Is a Priority

From the Authors:

We appreciate the letter by Giusti and colleagues regarding our recent publication in AnnalsATS (1). The letter highlights both the importance of sleep in the intensive care unit (ICU) and the increasing recognition of this problem by ICU providers. In addition, Giusti and colleagues propose changes to multiple aspects of care and delineate micro, meso, and macro level modifications of ICU workflow and environmental design, along with a “multicomponent, multidisciplinary bundle of interventions” aimed at providing patients with the opportunity for undisturbed sleep.

As noted in our survey-based study, 81% of ICU physicians and nurses rate their patients’ sleep as “very” or “extremely” important, and 88% indicate that poor sleep affects the ICU recovery process. Moreover, the importance of sleep promotion as it relates to delirium prevention was included in the 2013 Society for Critical Care Medicine Pain, Agitation, and Delirium (PAD) Clinical Practice Guidelines (2). The need for improved patient sleep has also been highlighted in major news outlets (3, 4). Despite these indicators of growing awareness, adoption of multi-faceted ICU sleep improvement bundles has been slow; only 32% of our respondents indicated that their institutions have sleep-promoting protocols in place. This disconnect is the very issue we wished to emphasize in our manuscript.

We agree with Giusti and colleagues that micro- and meso-level changes to promote sleep in the ICU should involve protocols that leverage itemized checklists and bundled care to facilitate uninterrupted blocks of time to sleep (5). However, while designing such protocols may seem straightforward, it requires dedicated ICU champions, a multidisciplinary stakeholder team, effective implementation methods to achieve staff buy-in and alter practice, and mechanisms for regular auditing. Currently, such efforts require stronger supporting evidence to earn attention and garner resources from hospital leadership. Moreover, as an overarching barrier to these efforts, measurement of sleep in the ICU is a major challenge and continues to hinder research aimed at linking improvements in ICU outcomes with sleep promotion. Polysomnography can be infeasible and expensive for use in large studies (6); actigraphy, while feasible to implement, has variable reliability in sedated or restrained patients (7). Subjective sleep measures can significantly overestimate sleep (8). Limited high-quality evidence and difficulty in measuring ICU sleep are also barriers to motivating cost intensive macro-level changes (i.e., improving room layout and building noise).

In addition, providing patients an opportunity to sleep while ignoring the issue of ICU-related circadian disruption may cause sleep promotion interventions to fall short. Circadian rhythm disruption, defined as misalignment between the brain’s master clock and peripheral body clocks, is a distinct component of ICU sleep disruption. Circadian rhythms are core physiologic determinants and have broad implications for end organ function (9). Circadian alignment in the ICU could be promoted via increased exposure to daytime light and exercise, and via feeding schedules designed to mimic normal meals.

In summary, most ICU physicians and nurses agree that sleep is poor and is a problem for their patients. In light of the 2013 PAD guidelines, ICUs are likely in varying phases of implementing interventions to promote sleep. As with any ICU-wide intervention effort, promoting sleep is complex, and requires resources and meticulous planning to maximize success and sustainability. We need large, rigorous studies that include circadian alignment as part of an overall ICU sleep improvement strategy to validate and motivate these efforts.