Trauma Surgical ICU Quiet Time Group

This letter is to nominate a group of nurses who have implemented a “Quiet Time” (QT) period in the Trauma Surgical Intensive Care Unit (TSICU) at Harborview Medical Center (HMC). The primary types of patients admitted to the unit are those who have suffered major penetrating, blunt, vascular traumatic injuries and patients undergoing major abdominal and vascular surgeries. Studies show elevated noise levels are a constant issue for Intensive Care Units, including the TSICU. Sources of noise include frequent alarms, equipment, pagers, phones, and the need for multiple interventions and procedures. This constant stimulation leads to increased stress levels for both patients and their families. Literature documents that these noise related stressors negatively impact the patients’ ability to sleep, their immune function and therefore their recovery from injury.

The goal of implementing a QT period was to lower noise levels in our ICU during designated times on both the day and night shifts in order to provide patients and families with uninterrupted periods of rest during their stay. Indeed, sleep helps maintain a normal biological equilibrium and function, and disruption of normal sleep stages can affect neurologic function, the immune system, hormonal function, metabolism, and cardiac function. Furthermore, sleep deprivation has demonstrated side effects such as delirium and increased narcotic requirements, and leads to longer recovery times. Nelson et al. (2001) reported that sleep deprivation and disruption was the second most stressful factor reported by ICU patients. In addition, (Simini, 1999) found that 61% of patients reported sleep deprivation as their worst experience in the ICU. Based on the evidence that sleep deprivation negatively affects patients’ outcomes, a committee consisting of 5 nurses (Karin Huster, Holly Broadbent, Joann Rodgers, Jodie Prescott and Patty McElveny) proposed to implement a QT period in our ICU.

The committee of the above named nurses and a physician champion (Dr. Eileen Bulger) developed a process to implement a “QT” in the TSICU. Literature on the topic of hospital noise and its effects on patients was reviewed, presented and discussed among staff. Baseline noise level data were collected using a decibel monitor and compared with the levels recommended by the Environmental Protection Agency, the Joint Commission and the Department of Health. Those agencies recommend noise levels of 35 to 45 decibels during the day and 30 decibels at night. The TSICU registered an average of 68 to 78 decibels on both day and night shifts.

After review of the literature and decibel data, the committee recommended two blocks of QT: 1400-1600 for the day shift and 2200-0200 for the night shift. The team reviewed contributing factors of noise for our unit and met with other departments to solicit ideas and options for noise reduction.

The following measures were initiated:

• Patients, visitors, and ancillary staff were educated on the process and benefits of QT.
• Quiet Time Signage was developed and placed at the TSICU entrance.
• Facilities engineers modified the lighting system to be able to dim lighting in the hallways.
• Telephone ring tones were turned down and with only half of the phones having an audible ring and the rest having only a flash signal.
• The internal intercom was changed to “night mode” which is a quieter setting.
• The electronic door push button was changed to a touch soft button
• Before the start of QT, nursing staff position the patient for comfort, adjusts the lighting and temperature, pre-medicates the patient for pain and take steps to avoid unnecessary alarms during the QT.
• Patient care packs were created which include earplugs and eye-masks.
• An internal announcement was made at the start of the QT.
• A request to change a noisy double door was approved by facilities engineering.
• A family education poster outlining the purpose and the outcome of the QT was posted in the family lounge to inform families about the new process.

The QT process was implemented on December 1, 2010. Decibel monitoring pre and post intervention documented a large decrease in noise levels during QT. Our QT periods now average 35-50 decibels as compared to 68-78 decibels before implementation. Nursing staff completed a post implementation survey on the perceived benefit and satisfaction levels with QT. The survey showed that 100% of the respondents (n=39) perceived a clear benefit to patients as it provided uninterrupted sleep. In addition, nurses reported an unexpected benefit to them as this time provided a calmer environment, the ability to catch up on charting, and attend educational meetings such as morbidity and mortality reviews, trauma club, and standards and policy discussions. In addition, a survey of all the Intensive Care Units asked patients’ families about their perception of noise in the intensive care unit. We compared their responses before and after the implementation of the QT, and results showed a 20% increase in satisfaction with noise levels in the TSICU.

Upon interviewing families regarding the QT process, much positive feedback was received. Family members feel a sense of relief and ability to leave the bedside knowing their loved one is resting quietly and comfortably and will have a period designated for rest. Patients also report positive feedback concerning QT. They appreciate the consideration for their need to sleep, especially during the night.

The implementation of a QT period in our unit has shown clear benefits to our patients, their families and our staff. The positive outcomes from this process have become apparent to the other intensive care units at HMC, who have adopted and implemented QT in their own units.

References

Surani S, Subramanian S, Babbar H, Murphy J, Aguillar R. Sleepiness in critical care nurses: results of a pilot study. J Hosp Med. 2008 May;3(3):200-5. PubMed PMID: 18571776.

Nelson JE, Meier DE, Oei EJ, Nierman DM, Senzel RS, Manfredi PL, Davis SM, Morrison RS. Self-reported symptom experience of critically ill cancer patients receiving intensive care. Crit Care Med. 2001 Feb;29(2):277-82. PubMed PMID: 11246306.