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Implementation of Quiet Time and its Effects on Delirium

Carla L. Fuentes

James Madison University

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Abstract

The chaotic, busy, and loud environment of the intensive care unit can be a leading factor

in patient’s sleep deprivation. Patients who lack the appropriate amount of sleep are more at risk

for developing delirium which can lead to negative patient outcomes including higher mortality,

increased length of stay, and cognitive impairment. In this evidence-based literature review the

benefits of implementing scheduled quiet time will be stated in correlation to enhancing sleep

and decreasing the incidence of delirium for patients in the intensive care unit. These benefits

include: maintaining patient’s level of sedation, decreasing incidence of delirium, increasing

patient’s quality of sleep, and maintaining patient’s satisfaction. The implementation of non-

pharmacological interventions along with scheduled quiet time promotes the best chance for

quality of sleep for patients.

Key words: quiet time, sleep, delirium, noise reduction

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Implementation of Quiet Time and its Effects on Delirium

Sleep is an essential biological function that is important for both physiologic rest and

emotional wellbeing. According to the National Sleep Foundation, the recommended hours of

sleep per night for an adult is 7-9 hours (National, 2015). Unfortunately, due to the intensive care

unit (ICU) setting, patients do not receive the recommended amount of sleep per night. In fact,

critically ill patients obtain 5 hours of sleep per 24-hour period (Kamdar, Martin, Needham, &

Ong, 2016). A typical night in the ICU can be described as constant beeping from the machines,

staff conversations, bright lights, medical interventions, and visits from health care providers.

Increased noise levels may lead to sleep deprivation, decreased healing, increased pain

perception, increased length of stay, and increased delirium (Goeren et al., 2018). Currently in

the ICU nurses administer medications such as Melatonin and Ramelteon to promote sleep for

their patients. This literature review will examine the benefits of implementing scheduled quiet

time to promote sleep and how it can decrease delirium for adult patients in the ICU.

Scheduled quiet time consists of a period of reduced controllable noise and light. The

time in which quiet time occurs is hospital preference, but majority implement a scheduled 2-

hour quiet time twice a day during day and night shift. During scheduled quiet time, patient’s

assessments are observational unless their condition indicates otherwise and no lab sampling and

radiology procedures are to be done unless it is needed for emergency situations.

           There are many factors in the ICU that contribute to patient’s sleep deprivation. Due to

the patient’s acuity level, it is required that nurses monitor their vital signs every hour and check

their blood sugar and temperature every four hours. Other factors include loud alarms from the

telemetry and cardiac monitors which are located inside and outside patient’s rooms, as well as

alarms from the machines like ventilators, continuous renal replacement dialysis (CRRT), and
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intravenous infusion pumps. On top of the noise from the machines, noise from the staff is

another major factor to the disruption and lack of sleep in patients. Unfortunately, nurses cannot

limit the noise from machines, but they can limit the noise from the staff by implementing

scheduled quiet time to promote sleep and ultimately decrease a patient’s risk of developing

delirium.

       Sleep deprivation is not exclusive to the ICU, but can be found on every unit in the hospital.

It’s an important topic for the nurses as they want to provide the best service and healthiest

environment for each patient under their care. The lack of sleep that patients receive increases

their risk for developing delirium. Per Maidl, Leske, and Garcia (2014), “Delirium develops in

20% to 50% of patients in the ICU and up to 80% in those requiring mechanical ventilation” (p.

546). With this evidence-based literature review, the nurse hopes to encourage a change in

nursing practice that will promote sleep in hospitalized patients and decrease their chance of

developing delirium.

Using electroencephalogram (EEG) and polysomnography sleep deprivation was

confirmed for patients in the ICU. The results from the continuous EEG showed that most

patients in the Neurological ICU spent an increased percentage of time in lighter sleep and time

spent in N3 and REM sleep was significantly decreased (Foreman, Westwood, Claassen, &

Bazil, 2015). The results from the EEG showed that total sleep time was normal but fragmented.

(Foreman et al., 2015). Another study used polysomnography to assess patient’s sleep and it

showed that 69.7% of the night was spent awake (Boyko et al., 2017). This study also showed

that patients had decreased time spent in N3 (10%) and REM (1%) (Boyko et al., 2017).

The Environmental Protection Agency (EPA) recommends that noise level within the

hospital to be between 30 to 40 dB when patients are sleeping (Goeren et al., 2018). According
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to Harrington and DeLeskey (2015), “The EPA recommends that hospital noise levels to not

exceed 45 decibels during the day and 35 decibels at night” (p. 22). After a 2-hour quiet time

twice a day (0300-0500 and 1500-1700) was implemented, peak noise levels decreased 10 to 15

decibels from the baseline data, but did not meet EPA recommendations (Goeren et al., 2018). In

another study where quiet time was scheduled from 1400 to 1600 noise levels during quiet time

remained below the recommended EPA decibel levels (Harrignton & DeLeskey, 2015). Results

from this study showed that decibel levels before quiet time were 51-61dB and during quiet time

decibel levels were 43 dB (Harrington & DeLeskey, 2015).

The impact of quiet time was studied on mechanically ventilated patients in the Medical

ICU. Quiet time had a significant impact on the patient’s Richmond Agitation and Sedation

Scale (RASS) score, which is used by ICU nurses to assess patient’s level of sedation. Patients

who were agitated prior to quiet time were more likely to be at goal sedation after quiet time

(McAndrew et al., 2016). Per McAndrew (2016), “Patients who were under-sedated at the start

of quiet time were more likely to reach targeted sedation levels and those who were already in

the desired sedation range stayed at that level” (p. 25). The effect of quiet time on the level of

sedation for patients may decrease the need for sedative medications in the ICU (McAndrew et

al., 2016).

The impact of quiet time was also evaluated on Confusion Assessment Method (CAM-

ICU) scores. CAM-ICU is an assessment tool used by nurses to evaluate the presence of delirium

in patients. Patients who were CAM-ICU negative at the start of quiet time remained negative

after quiet time. Of the patients who were CAM-ICU positive, 19% converted to CAM-ICU

negative after the implementation of quiet time (McAndrew et al., 2016). According to Pol,

Iterson, and Maaskant (2017), “The percentage of patients with delirium in the pre-intervention
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period ranged from 22 to 36% and in the post-intervention period of nocturnal sound reduction,

the percentage ranged from 12 to 43%” (p. 21). Another study implemented a bundle of non-

pharmacologic interventions consisting of environmental noise and light reduction that showed a

decrease in the incidence of delirium (Patel, Baldwin, Bunting, & Laha, 2014). Although Patel

did not implement scheduled quiet time, his study showed that a reduction in noise decreases the

incidence of delirium with 33% of patients having delirium prior to noise reduction intervention

and 14% of patients having delirium after intervention (Patel et al., 2014).

Most of the articles implemented other nursing interventions along with scheduled quiet

time to promote sleep. Nurses turned off lights, televisions, and personal devices in patient’s

rooms to create a peaceful environment (Harrington & DeLeskey, 2015). Nurses would close the

patient’s door when appropriate to reduce their chance of being able to hear outside noise from

the unit. On the unit lights were dimmed and quiet time signs were posted inside and outside the

unit as a cue to all employees and visitors that quiet time was occurring (Harrington &

DeLeskey, 2015). To decrease patient interaction nurses clustered care before and after quiet

time (McAndrew & DeLeskey, 2016). Per Maidl, Leske, and Garcia (2014), “Comfort and sleep

were promoted through repositioning, assistance with elimination, and pain relief prior to

implementation of quiet time” (p. 551). Fabric eye masks, passive noise cancelling headphones,

or soft foam earplugs were also given to patients to promote sleep during quiet time (Foreman et

al., 2015).

Quiet time was not only beneficial for the patients, but for the nursing staff as well.

According to Goeren et al. (2018), “Making a unit quieter has been shown to increase patient and

staff satisfaction by 60% to 80%” (p. 39). Nurse’s stress levels also remained lower after the 2-

hour period of quiet time (Goeren et al., 2018). Since patient interaction is limited to
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observational only it gives the staff a chance to catch up on charting, review patient’s medical

records, and find quiet in the chaotic ICU environment which increases staff satisfaction (Goeren

et al., 2018).

No ethical or legal issues were noted in all articles for the evidence-based literature

review. Majority of the authors obtained informed consent from the patient or family member for

their studies except for Goeren and Harrington which was most likely due to their study being a

unit based project. Other than Goeren and Harrington, all other studies were approved by ethical

committees of their choice. Nurse’s consent was obtained for participation during the study by

Maidl and McAndrew.

Any nurse, no matter their time of nursing or level education can implement this

intervention of scheduled quiet time. A nurse leader should do the initial teaching for the benefits

of scheduled quiet time for the patients and unit-specific pamphlets with an explanation of quiet

time can be created. Also, the progress of implementation of quiet time should be evaluated by a

nurse leader.

The studies showed that the implementation of quiet time was a positive experience for

patients. According to Goeren et al. (2018), “After implementing quiet time, patients reported

better noise level ratings on the unit, more patients reported “good” or “very good” ratings more

often than “poor” ratings when surveyed about noise” (p. 40). Patient’s anxiety and pain ratings

lowered after implementation of quiet time (Maidl et al., 2014). Unfortunately, due to the patient

population of the ICU it can be difficult to assess patient’s perception of their sleep. Patients who

could rate their sleep after implementation of quiet time or reduction of noise rated an increase in

sleep and reduction of daytime sleepiness (Patel et al., 2014). The study also showed that the
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median time before implementation was 6.6 hours and after implementation of noise reduction

patients received 8.6 hours of sleep, resulting in longer sleep periods (Patel et al., 2014).

The nurse recommends for hospitals to implement scheduled quiet time as it has been

proven to be beneficial for both patients and staff. Prior to implementing the scheduled quiet

time, intervention teaching should be done for the staff to inform them of the change and show

them why it is important to have this practice for their patients. A quiet time checklist can be

created to inform the nurses of tasks to be performed before the initiation of quiet time. The

nurse recommends for the hospital unit to start implementing scheduled quiet time for 2-hours

twice a day. To cue the start of quiet time, the lights on the unit will be dimmed, patient’s doors

will be closed if appropriate, and staff will be reminded to limit their conversations and lower

their voices. Signs will be posted inside and outside the unit informing staff and visitors that

quiet time is in session. Non-pharmacologic nursing interventions will be implemented along

with quiet time including turning off the lights in patient’s room and television, eye masks, and

ear plugs will be offered. To promote the best quality of sleep for patients, the nurse will

continue to administer medications to promote sleep like Melatonin and Ramelteon in

conjunction with scheduled quiet time.

This evidence-based literature review showed that implementing quiet time does decrease

the incidence of delirium for patients in the ICU and improved the patient’s quality of sleep.

Scheduled quiet time involves reduced controllable noise and light for a certain amount of time

with a goal of promoting sleep for patients and decreasing delirium. Studies have validated with

continuous EEG and polysomnography that patients in the ICU are sleep deprived. Scheduled

quiet time has also helped keep the unit noise level within EPA recommended level of 30 to 40

decibels. After the implementation of quiet time patients could reach their RASS score or
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maintain their current score, leading to a decreased need of sedatives. The studies showed a

correlating relationship between implementation of quiet time and incidence of delirium. Patients

were converted from CAM-ICU positive to CAM-ICU negative or remained CAM-ICU negative

after quiet time and there was a decreased incidence of delirium. The nurse concluded that it is

best to implement quiet time with other non-pharmacological measures like turning off lights,

shutting doors, providing eye masks, and ear plugs. The nurse recommends the implementation

of quiet time after education is given to the staff. Quiet time has been shown to be beneficial as it

improves patient’s quality of sleep and decreases their risk of developing delirium.
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References

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care unit: The role of environment. Journal of Critical Care, 37, 99-105.

doi:10.1016/j.jcrc.2016.09.005

Foreman, B., Westwood, A. J., Claassen, J., & Bazil, C. W. (2015). Sleep in the neurological

intensive care unit: feasibility of quantifying sleep after

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Clinical Neurophysiology, 32(1), 66–74. doi:10.1097/WNP.0000000000000110

Goeren, D., John, S., Meskill, K., Iacono, L., Wahl, S., & Scanlon, K. (2018). Quiet Time: A

noise reduction initiative in a neurosurgical intensive care unit. Critical Care

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