When the sun goes down, the ICU patient experience changes. New shifts begin, sleep disturbances are common, and an end to visiting hours can all affect a patient’s overnight experience.

Hayley Gershengorn

This changing ICU environment can affect care delivery and patient response, too. Health care professionals who are mindful of these changes can improve the experience by using proven interventions, which are outlined during today’s session, where panelists will dissect the world of the ICU at night from multiple stakeholders’ perspectives, including those of physicians, nurses, patients, and their families.

“The ICU differs at night across many dimensions,” said Hayley B. Gershengorn, MD, ATSF, associate professor at the University of Miami Miller School of Medicine, and a co-chair for this session. “ICU staffing is quite different overnight than during the daytime in terms of number of clinicians and the need for them to cross-cover for patients in other locations.”

Resources outside the ICU differ substantially between daytime and nighttime. Traditional hospital/ICU policies limit visitation by family and friends overnight, which may impact patient comfort and delirium.”

Another consideration is the patient’s normal circadian rhythms. “To not destroy normal circadian rhythms, patients should be asleep overnight and awake during the daytime,” she said. “In the confines of a busy ICU and in a room without direct sunlight, keeping the distinction between day and night straight for our patients is challenging. It requires effort directed at creating the right time-specific climate.”

By its very nature, the ICU could be a busy place because of patient checks from hospital staff. And nighttime is no different.

“Overnight in the ICU, a good night’s sleep can be hard to come by,” she said. In those instances, she said certain pharmacologic and non-pharmacologic strategies may be effective in improving a patient’s overnight experience.

Jean Hsieh

“If we’re more mindful about sleep promotion, there are simple, common-sense aspects of patient care that we can easily improve upon, such as turning down the lights at night, reducing environmental noise, and being more flexible in the timing of non-urgent aspects of care (such as bathing),” said Jean Hsieh, MD, MS, associate professor at the Icahn School of Medicine in New York, and co-chair for this session.

The session will explore other strategies, as well. For example, Dr. Gershengorn said limited data suggests patients admitted to or discharged from the ICU at different times of the day (day versus overnight) may have different outcomes. Similarly, some evidence suggests that performing elective interventions, such as extubations overnight may be associated with harm versus during the day. See additional strategy topics in the box that accompanies this story or attend the session for a full discussion.

May Hua

As staff changes and family hours end, be mindful of the possibility of patient anxiety. There could be a small element of fear at play, according to May Hua, MD, MSc,assistant professor at Columbia University Medical College in New York, and co-chair of this session. While fear from being left alone at night is not a common occurrence, she said having the bedside nurse and monitoring equipment nearby provides some comfort.

“But, as fewer people are around in general (and family may not be around), some patients have anecdotally stated that they had concerns or feelings of being abandoned,” said Dr. Hua. “What is more prevalent is ‘sundowning,’ where delirium, particularly in an agitated form, may be more likely to occur for certain patients during the nighttime.”