Shhhh...Quiet Time in the ICU

[traumaRUs, MSN, APRN]

The American Association of Critical Care Nurses recently published a study regarding the noise level in an ICU and ways to decrease patient and staff noise stimulation. Noise stress is a concern for both patients and staff. "In one study, it was found that making a unit quieter increased patient and staff satisfaction by 60% to 80%. In a study conducted in a neurosurgical ICU (NSCU), 54% of patients experienced sleep disturbances and the most common sleep interruptions were at night to monitor vital signs, conduct neurologic examinations, and reposition patients."

According to patients in the ICU, the most bothersome noise is at shift change, particularly in the early am. The patients often hear things they should not hear: the patient next door to them is going for a procedure and "we aren't sure how its going to turn out", the other patient on the other side, "can be shipped out to the floor today." Taken out of context much confusion and stress can occur.

This study took place on a neuro-surgical ICU that is part of an "806-bed, level I teaching hospital. The NSCU is an active unit with an average daily census of 15 and approximately 1800 patient admissions annually. This translates into 3 to 4 patient transfers out of the unit and 4 to 5 patient admissions daily."

They collected data and decided on quiet times from 1500-1700 and 0300-0500. They designed signage, achieved buy-in from administrative and ancillary staff stake-holders and began to consider what steps needed to be in place in order to implement quiet time. One of the lists they developed was to be proactive with care BEFORE quiet time began. Here are some of their initiatives:

Quiet time checklist

• Routine medications administered
• Pain assessed
• Bedpan/urinal/commode offered
• Blood drawn/intravenous catheters placed
• Vital signs taken
• Neurological check performed
• Television off
• Lights off in patient room
• Family aware/involved
• Door closed
• Multidisciplinary rounds completed
• Lights dimmed in nurses' station
• Alarm parameters customized to patient
• Minimize conversations in common areas
• No overhead paging
• Respond promptly to alarms
• No physical/occupational therapy sessions during quiet time
• Move equipment quietly
• Cell phones/pagers on vibrate
• Remind colleagues "Shhhh"

There were some limitations to the study regarding the ability to rearrange infrastructure of the unit. Some beds were closer to doors which increased noise. In addition, as this was a teaching hospital, there was simply more talk among providers and interdisciplinary team members. The providers that came to the unit to see patients did observe a guest mentality where they talked quietly and decreased their ambient noise as much as possible. However, as one researcher pointed out that with 5-6 people in a group, even if they are talking quietly it can get quite loud. Although the staff verbalized feeling less stress and having quality time to reflect on patient care, they did not conduct qualitative data collection by surveying staff about their perceived stress levels before and after quiet time. Because of the high level of cognitive impairment of the patients, examining Confusion Assessment Method scores before and after quiet time may have yielded useful data.

In conclusion, the neurosurgical ICU nurses were successful in changing unit practice and enhancing awareness about excessive unit noise. Registered nurses, clerical support associates, patient care associates, and unit leadership viewed the quiet time initiative as important, leading to adherence and buy in across the multidisciplinary team

References:

Narvaez R. Quiet time project improves patient satisfaction.

Ugras GA, Babayigit S, Tosun K, Aksoy G, Turan Y. The effect of nocturnal patient care interventions on patient sleep and satisfaction with nursing care in neurosurgery intensive care unit. J Neurosci Nurs. 2015;47(2):104-112.

[LovingLife123]

I work in a trauma/neuro/surgical icu. I would love to do quiet time. The problem is there are too many family members that we cater to.

I may show my manager this study. I think, especially with brain injuries, quiet time is essential.

[FranEMTnurse, CNA, LPN, EMT-I]

A 9yo boy was admitted to the ER as the result of a head on collision with a motorcycle. He was patched up, hooked up to an IV prior to being admitted to the ICU around 11 PM. He was in very critical condition, and a charge nurse began hooking him up to a ventilator, hooked him up to IV fluids, and administered the necessary meds.

I have been in an ICU several times, but there was only one time that I remember that I decided to tell my doctor I wanted to be placed in Hospice care, and not go back to the hospital. At the time, I was in an assisted living place that was also a hospice care home, so my decision was easy to request. The reason was due to the very LOUDLY spoken head nurse who was caring for him. I was in a room several rooms down from the trauma room when she began,telling her staff the history of the incident, and I heard every single word she said.

She said; 'He had been thrown from a car that collided with a motorcycle. He was the only individual of the family of 7 that survived. None of the occupants was wearing a seatbelt.' Soon after she told her staff the story, she pronounced him dead, and asked her staff if they were alright. Then after they answered in the affirmative, she asked two of them to take him down to the morgue.

No matter how hard I tried, I could NOT get back to sleep, . I was way too traumatized from hearing the very LOUD nurse relate her story.

Thankfully, I survived the hospice incident, and have been living independently in a senior housing complex for 10 years so far. So you see, even a head nurse who speaks loudly can traumatize a patient and not even realize she has done it.

[Mini2544, ASN, RN]

I work in a trauma/neuro/surgical icu. I would love to do quiet time. The problem is there are too many family members that we cater to.

I may show my manager this study. I think, especially with brain injuries, quiet time is essential.

I am in the same boat as you. I am still going to fight for this though. It's so ridiculous how much we cater to people and it directly interferes with pt care

[smf0903]

We are pretty strict about quiet time. A majority of our lights go out at 20:30, and an over head announcement of quiet time is played. If family is being loud, we remind them once, anything beyond that they have to leave. Same for families ringing in and out of the unit...you come in you stay in. You aren't ringing the bell for us to let you in 37 times. I had a family get irritated with me when I told them the TV had to be turned off and the room darkened when their family member needed no stimulation. (I got a "Well what are WE suppose to do?!" Sorry, not sorry, you can watch your cop show at home.

The people we have to remind are the ones who pop down to the unit to check on patients, like RTs and such. By and large though, everyone is pretty observant of our quiet time (20:30-07:00).

[FranEMTnurse, CNA, LPN, EMT-I]

That's the way it should be in all ICU units. The patients are not in there because they chose to be, they're critically ill and need the rest. I was not going to go back to our local hospital at first, because I was so traumatized by her very LOUD and tragic story. I hope she got fired.

[Corrine459]

Fran I'm sorry that happened to you. I'm not excusing the nurse but maybe she was traumatized too. She may have been loud because she was stressed, she was trying to save a dying child.

I hope she didn't get fired, I hope she got sympathy. She deserves it too.

[MunoRN, RN]

I've taken part in a number of implementations of ICU "quite time" initiatives, I've yet to see these last for any amount of time, which is because the basic premise is not based on well reasoned criteria, stupidity in other words. That's certainly not to say that measures to decrease noise in the ICU aren't extremely important, it's that there is no reason to limit these measures to only certain portions of the day, which suggests that outside of specified "quiet time" that there should be "loud time".

The excessive noise reduction measures list above should not be limited to certain times of day. Ensuring alarm parameters are adjusted to avoid unnecessary alarms are always important, there shouldn't be any time of day where meaningless alarms are allowed to go off without appropriate adjustment. Care should always be planned to provide the largest blocks of stimuli reduction (rest) possible, this isn't something that should happen once a day. The biggest problem is that having set, scheduled times for noise reduction does not always coincide to when care can truly be limited (we're obviously not going to avoid care necessary to avoid harm or risk of harm because it's quiet time) and having designated quite time suggests that it's possible for the patient to miss that once-a-day opportunity for limited excess noise, when really this should be occurring 24/7 whenever appropriate.