Ask an answerable question (PICO)：
Mr. Chen, a 57-year-old patient, was transferred to the intensive care unit after undergoing abdominal surgery. During the morning rehabilitation session, he rested with his eyes closed. When asked, he wrote, “I didn't sleep well last night. The alarms are very loud, and the sound of the oxygen is noisy. Every time someone enters or exits the room, I am awakened, which really disturbs my sleep.” Intensive care unit (ICU) patients need to undergo frequent vital sign measurement and treatment, and these interventions, which cause the presence of light and the noise of medical equipment, hindered them to fall asleep. Despite efforts by the night shift nurses to reduce the volume of medical devices and minimize the frequency of turning on lights, disturbances to the patients' sleep persisted. This prompted the author to consider whether providing eye masks and earplugs to intensive care unit patients during nighttime rest could improve their sleep quality compared to standard care.
The Method and Analysis of Literature Review：
We conducted a comprehensive search of PubMed, Embase, The Cochrane Library, and CEPS. The search strategy included the utilization of keywords, synonyms, MeSH Terms, and Emtree, focusing on systematic reviews, meta-analysis and randomized controlled trials published within the past five years. Forty-three studies were included, and among them, five duplicate studies were eliminated using EndNote bibliographic software. Subsequently, the abstracts of the remaining studies were manually reviewed. Those studies which did not meet the PICO criteria were excluded. The systematic review and meta-analysis study and the random control trial were selected for comprehensive review and evaluation.
Critical Appraisal：
We utilized the CASP Systematic Review Checklist (2018) to appraise the meta-analysis conducted by Fang et al. (2021), which indicated that the use of eye masks and earplugs, compared to standard care, significantly improves nighttime sleep quality (SMD: 2.08, 95% CI: 0.95-3.21, p = 0.0003, Level 1). We employed the CASP Randomized Controlled Trial Standard Checklist (2020) to appraise the randomized controlled trials. Akpinar et al. (2022) demonstrated that the experimental group, using eye masks and earplugs, exhibited higher sleep quality compared to the control group receiving routine care (72.07 ± 11.75 vs. 47.04 ± 11.53, U = 70, p < 0.001). Through the synthesis of the above literature, the use of eye masks and earplugs with a duration of 6-9 hours per night over a span of 2 days can improve the intensive care unit patients’ sleep quality.
Clinical Application of Evidence：
From May 15, 2023, to September 15, 2023, ICU patients underwent the initial assessment of sleep quality using the Richards-Campbell Sleep Questionnaire (RCSQ) after one night's stay. For patients with a sleep quality score below 75 points, eye masks and earplugs were provided during nighttime sleep hours. The second assessment of sleep quality was conducted the following morning, and the use of eye masks and earplugs continued until the patients were transferred to the general ward. The third RCSQ assessment was performed just before their transfer out of the ICU to evaluate the improvement in sleep quality.
Evaluation of Effectiveness：
A total of 13 cases were included into the study. As for the sleep quality scores measured using the Richards-Campbell Sleep Questionnaire (RCSQ), the baseline score was 41.60±20.77. After the implementation of the intervention, the second assessment of sleep quality score was 54.20±20.41 points. The score measured just before their transfer out of the intensive care unit (ICU) was 62.58±19.30. These results indicate that the intervention with eye masks and earplugs led to an improvement in sleep quality among ICU patients.
Conclusions and Recommendations：
The author applied the evidence based care to clinical practice, demonstrating that it indeed improves patients' sleep quality. Nevertheless, considering patients' values remains imperative in ensuring optimal benefits from these measures. It is recommended that, in the future, upon admission to the ICU, patients should receive education on sleep quality to raise awareness of its importance and provide strategies for improvement. Furthermore, the establishment of a bundled care approach for sleep quality within the ICU is suggested to further enhance sleep quality for ICU patients.
吳俊賢 蔡佩臻 吳昭燕*
