The Effect of a Quality Improvement Intervention on Sleep and Delirium in Critically Ill Patients in a Surgical ICU

Chest. 2021 Sep;160(3):899-908. doi: 10.1016/j.chest.2021.03.030. Epub 2021 Mar 24.


Background: Delirium is a deleterious condition affecting up to 60% of patients in the surgical ICU (SICU). Few SICU-focused delirium interventions have been implemented, including those addressing sleep-wake disruption, a modifiable delirium risk factor common in critically ill patients.

Research question: What is the effect on delirium and sleep quality of a multicomponent nonpharmacologic intervention aimed at improving sleep-wake disruption in patients in the SICU setting?

Study design and methods: Using a staggered pre-post design, we implemented a quality improvement intervention in two SICUs (general surgery or trauma and cardiovascular) in an academic medical center. After a preintervention (baseline) period, a multicomponent unit-wide nighttime (ie, efforts to minimize unnecessary sound and light, provision of earplugs and eye masks) and daytime (ie, raising blinds, promotion of physical activity) intervention bundle was implemented. A daily checklist was used to prompt staff to complete intervention bundle elements. Delirium was evaluated twice daily using the Confusion Assessment Method for the Intensive Care Unit. Patient sleep quality ratings were evaluated daily using the Richards-Campbell Sleep Questionnaire (RCSQ).

Results: Six hundred forty-six SICU admissions (332 baseline, 314 intervention) were analyzed. Median age was 61 years (interquartile range, 49-70 years); 35% of the cohort were women and 83% were White. During the intervention period, patients experienced fewer days of delirium (proportion ± SD of ICU days, 15 ± 27%) as compared with the preintervention period (20 ± 31%; P = .022), with an adjusted pre-post decrease of 4.9% (95% CI, 0.5%-9.2%; P = .03). Overall RCSQ-perceived sleep quality ratings did not change, but the RCSQ noise subscore increased (9.5% [95% CI, 1.1%-17.5%; P = .02).

Interpretation: Our multicomponent intervention was associated with a significant reduction in the proportion of days patients experienced delirium, reinforcing the feasibility and effectiveness of a nonpharmacologic sleep-wake bundle to reduce delirium in critically ill patients in the SICU.

Trial registry:; No.: NCT03313115; URL:

Keywords: critical care; delirium; sleep; sleep hygiene; wakefulness.

Publication types

  • Observational Study
  • Research Support, N.I.H., Extramural

MeSH terms

  • Cardiology Service, Hospital / organization & administration
  • Cardiology Service, Hospital / standards
  • Critical Care* / methods
  • Critical Care* / organization & administration
  • Critical Care* / standards
  • Critical Illness* / psychology
  • Critical Illness* / therapy
  • Delirium* / etiology
  • Delirium* / prevention & control
  • Delirium* / therapy
  • Dyssomnias* / etiology
  • Dyssomnias* / prevention & control
  • Dyssomnias* / therapy
  • Female
  • Humans
  • Intensive Care Units / organization & administration
  • Intensive Care Units / standards
  • Light Pollution / adverse effects
  • Light Pollution / prevention & control
  • Male
  • Middle Aged
  • Noise / adverse effects
  • Noise / prevention & control
  • Outcome and Process Assessment, Health Care
  • Patient Care Bundles* / instrumentation
  • Patient Care Bundles* / methods
  • Protective Devices
  • Quality Improvement
  • Sleep Quality
  • Sleep Wake Disorders* / etiology
  • Sleep Wake Disorders* / therapy

Associated data