So I was chair of the PAD guidelines. We started our effort in 2015, and a huge focus of the guidelines was sleep. And this was one of the most interesting areas, at least me personally, being involved in the guidelines, because there was a lot of evolving literature about sleep being a problem, and things that we could do at the bedside, things that maybe we shouldn't do. And so it led to a lot of recommendations. What I'm gonna do today is just go through some of the recommendations and some of the data, but more importantly, the ICU Liberation Committee has worked on a good sleep hygiene sort of new bundle element. It's been submitted, it's almost finalized, it's been submitted to SCM Council. There's a lot of review that's gone on, so it's almost ready for prime time. How many people in the last couple of years have found in their ICU that they've talked a lot more about the quality of their patient's sleep, and they're thinking about sleep, and how the patient is sleeping, and maybe doing some non-pharmacologic things? Yeah, I think it's really sort of taking off. And so we'll hopefully at the end of this talk, just talk about some of the things that you could try in your institution. Some are better evidence-based than others, and we'll go from there. So obviously, sorry, I'll get used to this. Obviously, we know sleep is really a common complaint, and a source of distress for many ICU patients. You know, 10 years ago, when everybody was, we were maintaining patients at RAS as a minus four, minus three, I think the natural thing would be to observe the patient, say, well, this patient looks like they're sleeping just fine, and of course now, in an era of much greater wakefulness, I think this is where we're seeing a lot more awareness of sleep, both at nighttime, and then, you know, patients are tired during the day. You know, it can be quite severe. It's characterized by sleep fragmentation and normal circadian rhythms, where we're seeing increased light sleep, so stage one and two, and then decreased sleep state, which is stage three, or slow-wave sleep, and REM sleep. You know, it's a potentially modifiable risk factor that definitely can affect recoverability in the ICU, and we know in, you know, a lot of the research that people are doing in post-ICU outcomes, that sleep is a persistent problem for many survivors of critical illness, and it's a complex milieu, right? You know, there's lots of questions that we don't know about sleep in the outpatient setting, nevermind starting to try to investigate this in the ICU. It's really complex, because we have medications, critical illness, inflammation, delirium, perfusion. We often have a lot of patients that are older with a lot of chronic conditions, so they might not have been particularly great sleepers or have a lot of sleep abnormalities before they became critically ill, so it's a big area of research. The one thing that we, sorry about that. The one question we asked is risk factors, and so we did a thorough systematic review. There's a number of studies where patients either were asked to characterize either during or shortly after their ICU stay, their perceptions of sleep, or some of these studies are also PSG-driven, so there's kind of two types of literature. Basically, when we look at, you know, how sleep in the ICU differs from normal sleep, total sleep time and sleep efficiency are normal. Sleep fragmentation is higher, and subjective sleep quality, which is frequently used, I think, in many ICUs, asking the patients how they slept is reduced. During the ICU admission, looking at the risk factors, it's really, pain's a big one, all different types of environmental stimuli, healthcare-related interruptions at night, various psychologic factors, respiratory factors of medications each affect sleep, and there's extensive tables and supplemental material in the PAD guidelines regarding this. The list is really quite long, and I don't think that's a surprise to anybody. Sleep assessment, we asked the question, should physiologic monitoring, which could be PSG, could be actigraphy, basically, it's something that's trying to look at the sleep waves or patterns, be used in the ICU, and we made the recommendation not to routinely use these agents. It doesn't mean that actigraphy doesn't have a role in some ICUs, if you have the equipment, but it's expensive, and it might not be able to be routinely used in all patients. Certainly, polysomnography is a great research tool, but not something that most patients are gonna put, you know, their ICU patients in normal care on a sleep survey, and I think, more likely than not, we're looking at things, you know, like the Richard Campbell Sleep Scaler, just asking the patient, you know, a bedside nurse or clinician, asking the patient how they slept and what their perception was of sleep, and trying to put some documentation down. But when we rigorously looked at this, and the evidence, looking at our outcomes, there's just nothing that suggests that. So, and you can imagine, I mean, this is someone with an ambulatory PSG, and when you bring that into the ICU, it's fraught. You know, I've done some research in this area, and it's really hard to do a sleep study in the ICU. So, we looked at non-pharmacological interventions to improve sleep at night. The ones we chose, and these are, there's other things that we probably could have asked, but these are the ones that we're addressing the guidelines. Switching to an assist control of mechanical ventilation at night from a pressure support mode, acupressure, music, noise reduction, light reduction, and NIV-specific ventilator or aromatherapy. And then we basically compared studies. Ideally, randomized control studies, obviously, are the strongest evidence versus no use of the intervention. And the things we looked at were measures of sleep quality, sleep duration, circadian rhythm, delirium, duration of mechanical ventilation, ICU mortality, and then the patient experience. Those are the key outcomes that we were looking for. So, some of the stronger data actually comes with the studies that have compared assist control versus pressure support ventilator mode at night. And it decreased sleep efficiency by about 18%. There's three randomized studies that all show the same signal. When we meta-analyzed them, that's where we got this significant reduction. The percent of time in REM sleep, one study was significant, one was almost, was not. So, there's some heterogeneity here. But we do suggest using assist control mechanical ventilation at night versus pressure support to improve sleep. It's very much a patient-dependent decision because if you're switching someone to assist control, they might not tolerate that mode as well. And you certainly wouldn't want to be giving more sedation just to put them on a volume-controlled mode to try to improve their sleep. So, I think this could be a consideration at the bedside, but it doesn't mean you should just be switching the vent modes on all patients. Noise and light reduction strategies. There was two randomized studies and two observational studies that looked at the use of earplugs with or without eye shades in non-sedated ICU patients. So, a lot of these patients where we're doing the sleep studies are generally healthier patients that certainly aren't as critically ill. So, their severity of illness is much lower. Improvements in patient-reported sleep quality was seen, reduced delirium. Pooled analysis from two of the observational studies with earplugs found a 20% increased chance of achieving four hours of sleep, but lots of limitations. The studies weren't blighted. Some of the patients, and I'm sure many of you might have experienced this, patients, you really have to ask the patients if they want earplugs. Some patients just don't want them. And if you give the earplugs, you gotta make sure you take them out the next morning. But certainly, it's a fairly safe, low-cost intervention. So, we do make a conditional recommendation, which means it's like a weak recommendation. It's not a strong recommendation to potentially consider noise and light reduction strategies. And there's, of course, other things regarding noise and light that we could do that actually haven't been as well-evaluated in these studies. And I'm gonna talk more about some of these other things that we could do in our ICUs in this domain. Use of aromatherapy, acupressure, or music. Two small, unblinded, randomized studies with aromatherapy found no difference in any outcome. One small, randomized study looked at acupressure. And it did increase the duration of sleep. Daytime sleep decreased, but it's low-risk. A lot of patients' ICUs, obviously, aren't gonna have this modality in their ICU. Interesting enough, there's a lot of interest in music, but when it comes to sleep, there was only one small, randomized study of 28 patients. And small improvements in sleep quality and efficiency. The evidence isn't there. It doesn't mean it doesn't work, but you need to start seeing some evidence that it's worth it because there is resources, whether it's an iPod or having a piano in the hallway of the lobby or a harpist. When you're in the guideline business, you really have to be careful that you're not suggesting something that every ICU feels that they need to have when the data's not there to do it, even though, obviously, these things are fairly low-risk. So we don't suggest routinely using aromatherapy, acupressure, and music at night. Sleep-promoting protocol. One of these was randomized control studies. The other two were before or after. There's three that were published at the time. There's been some other ones that have come out since, but generally, they're showing a consistent pattern where delirium prevalence is decreased. However, when you look at any of these sleep protocols, really not showing a big signal on improving sleep, but most of these studies aren't using polysynagraphy or tigraphy, and it's really hard to measure sleep in such a dynamic environment and show change. So it doesn't mean that they're not doing anything to improve sleep. It's just, it's really hard for these studies to show it. But we did suggest using a sleep-promoting multi-component protocol, and I'll talk more in just a minute about what could be the components of this protocol. Dexmedetomidine to improve sleep. There's two randomized studies, both very small. One was mechanically ventilated adults requiring sedation, one non-mechanically ventilated. Overall, when we meta-analyzed these, significant increase in stage two sleep, significant, which is good, significant decrease in stage one sleep, which is good, but no real difference in sleep fragmentation or time spent with REM sleep, and neither delirium duration mechanical ventilation or patient preference evaluated in either RCT. So there is a concern. We made a recommendation. We actually made no recommendation for Dex. There's just, you know, the risk benefit is just not quite there to suggest that everybody should be on a Dexmedetomidine infusion. And there's costs, hemodynamic effects. Of course, if someone's already on Dexmedetomidine for sedation on a 24-7 basis, potentially you could argue that maybe, because there is some PSG data suggesting, you know, there could be some benefits with sleep, but not really, really strongly evaluated. So you could argue that maybe Dex, if you need a set of it's better than say Propofol, but again, starting a Dex infusion based on the evidence used in the guidelines to initiate it over the nighttime period hasn't been shown to improve outcomes. There is a study that I worked on with you on a scrobic that we published in the Blue Journal. It's been over a year and a half, and this is a double-blind rasmized control study of low-dose Dexmedetomidine 0.4 to 0.8 mics per kilogram per hour at bedtime between 10 and 6 a.m. Patients were managed with the sleep protocol. All of these patients, and what we found when we evaluated these patients in 100 patients that were all delirium-free, we found the prevalence of delirium. So time to first episode of delirium was lower in the Dex treated patients. So it definitely has a pretty strong preventative effect on preventing delirium. However, a lot of these patients were quite sick. Our APACHE-2 scores were well into the 20s. They were most, I think 95% of them were mechanically ventilated. A lot of them were getting sedatives, including propofol and benzodiazepines. So it's kind of hard to know, is it just maybe we're using less propofol and midazolam in this study that helped reduce the delirium, or is it truly a Dex treatment effect? We used something like the Richard Campbell called the LEAD Sleep Score and found virtually no difference between the groups. This is kind of hypothesis generating, but it's certainly, even if we were doing the guidelines again today, it doesn't mean that everybody in the ICU should be on a Dex strip at night to improve sleep. But if you have an agitated patient at night, maybe that has delirium that's hard to control, Dex could be an option to initiate it at night to help calm the patient. Melatonin, three very small randomized control studies looking at different nightly doses, three to 10 milligrams. All patients in these three very small studies were low acuity with chronic respiratory failure. There was no really clear improvements in sleep or reduced delirium. This is the forest plot for delirium. Relatively safe, low costs. You don't even need a prescription. And this was one, we actually, when our whole guidelines group got together, about three congresses ago to talk, sort of come to consensus with the recommendations. We spent three hours on this recommendation because there's a fair number of people like, melatonin probably works, it's cheap, it's low risk. And then other ones were, there's not the data, there's not the randomized studies. And you just have to be careful about saying, people should be on melatonin to improve sleep because everybody's gonna argue that the sleep is bad in the ICU. Get everybody on melatonin. I know this melatonin use is quite prevalent in many people's ICUs, but just, it's important to realize that the data really isn't there for its routine use. I think Romelteon, which is a melatonin analog is an interesting story. There's three randomized control studies. The first one by Hada and colleagues was looking at delirium-free older patients, about a third of which were in the, two thirds, sorry, one third were in the ICU, found a very low prevalence of delirium, but it was a trend for reduction. This Nishimura study was ICU only, but not particularly sick. And they found a significant reduction in delirium. But then there's a much more recent Romelteon randomized study from UCSD that actually found virtually no difference in delirium incidence and even no difference in other secondary outcomes. There's not data right now to really suggest that patients should be routinely even put on Romelteon for sleep. Lots of gaps, which I think I've kind of talked about in terms of measurement. You know, if you're looking at a medication intervention, you got to make sure you're also sort of applying what I think are increasingly becoming standard non-pharmacologic things in terms of noise and light, and likewise, and also other delirium prevention efforts. And we're not really sure exactly the sort of mix of interventions, particularly non-pharmacologic that we should be mixing in our protocols. So this is, I'm going to talk now about the good sleep hygiene bundle that again, our ICU liberation group has put a lot of effort over the last year developing. It's draft, I think this is pretty much the way it's going to be, because we've had lots of communication over the last three months with council. So the first thing is, is just thinking about what are the main goals that you might be thinking about as an ICU clinician or leader, and to promote good sleep in the ICU. And we're suggesting that a, you know, developing a process to routinely inquire about sleep quality in support of good sleep hygiene. So asking the question, and I'm not sure this is done routinely. It might be done routinely, but it's certainly not documented in most, you know, electronic medical records. Developing and implementing a plan to support sleep hygiene that can include both pharmacologic and non-pharmacologic methods. Constructing a locally supportable method to evaluate the efficacy of the approaches used to achieve good sleep in their patients. And obviously we're not going to be putting an etigraphy or PSG on these patients, but thinking about what are the outcomes? How do you know this might be making a difference? So maybe by doing some sort of before, after analyses. You know, the way these goals are reached, we've kept this kind of general, because it kind of depends on the ICU patient population that you have, right? And it could depend on the patient that might be quickly transitioning through a surgical ICU or a neurologic injured patient or a surgical ICU patient that may, or a medical ICU patient that's there for two weeks. It really depends. I think, you know, these approaches also should be maybe institutional nature instead of ICU specific. So rather than each ICU, if you're part of a health system, think about some general ways that things could be improved. And then there could be some individualization in certain ICUs or in certain subgroups of patients. Basically there's sort of, to reach these three good sleep goals, there's four potential strategies we've come up with that again are fairly general, but I think are important. Trying to obtain some kind of pre-ICU sleep history, because how the patient sleeps at home, what medication sleep aids they might take, how they prefer to sleep can really help drive what we're trying to achieve in the ICU. Evaluate patient's sleep during the ICU stay, employing non-pharmacologic strategies, focus on improving sleep, and judicially use sleep aid medications, particularly if a patient's not taking a sleep aid medication before they come to hospital. Really it's important to ask the question, what are we trying to achieve here by giving these drugs? So the pre-ICU sleep history, there's nothing out there. This whole area is so, if you're a researcher and interested in pursuing these, there's so much room with sleep in the ICU. It's kind of where we were with delirium like 15, 20 years ago, to be thinking about some of these things. So there's no validated screening tool or method to get a sleep history, but some of the things, and family members could play a big role in someone who's really critically ill, especially a spouse. Do they feel rested when the patient awakes in the morning at home? How many hours do they sleep at night? Some people, we're trying to get them to have six to eight hours in the ICU, but maybe they're more nappers during the day and they sleep at night. What time do they normally go to bed and wake up? What's their sleep position? So this is interesting, obviously mechanically ventilated patients, we're a little bit less inflexible in how we can position patients, but there's ways we can do it. We can change things. But if you're not sure if they're a back sleeper, side sleeper, stomach sleeper, sometimes if the question's not asked, you're not gonna know. Do patients have normal sleep disorders, insomnia? Do they use BiPAP at home, narcolepsy? Again, medical equipment. Do they need to do anything to get to sleep? One of my trainees, we shared a hotel room recently at a research meeting, and he could only fall asleep with ESPN going full blast. And I sleep with earplugs. So obviously I wouldn't, because he works for me. But I mean, it's amazing how the variability and how patients fall asleep and what they do and what they need to do. It's amazing. Do they use things like a temperature fan, white noise, what's the temperature? And do they take any over-the-counter prescription medications to help them sleep or sleep aids? It's amazing the high prevalence of this, and it's underreported. And a lot of people, especially older adults, they take a lot of benzos, right? Probably older adults, probably like 15, 18%, maybe. And they've been kind of trained not to talk about their benzo use, not talk to their family, because they kind of know maybe they shouldn't be on them, but they're on them. And so this can be an important part of what we're trying to do. So sleep assessment during the ICU stay is another important domain to be thinking about. The method and frequency by which we evaluate this and the benefits of doing this, we're not really sure. But we know we need to probably do something. Simply asking the patient if they're wakeful enough, and they probably don't have delirium, how did they sleep the prior night? This could help guide potential non-pharmacologic and medication-based improvement efforts. You can use a, there's a new, it's pretty simple, sleep assessment tool. And basically this was validated by a large Dutch group against Richard Campbell. And they found that patients, so zero is simple as sort of a pain visual analytic scale. So worst sleep, zero, best sleep, 10. Six or less suggests that the sleep isn't that great. And they validated this in over, I think about 500 patients against Richard Campbell. So I encourage you to look at this tool. It's a simple way to at least get some numbers down, realizing this will be hard to evaluate in some patients. If patients have a score of less than six, thinking about, well, what are the reasons why this score is they're not sleeping well? Is it pain, discomfort? Are they anxious, noise, light? Is it staff, staff interruptions, family interruptions? There could be lots of other things here. Non-pharmacologic strategies. This is kind of the meat and potatoes here. So we made gut recommendations as I already ran through for some of this, but there's some other things here that I think could be really useful. We're not really sure when we should apply these. A common time is sort of 2200 to 6 a.m., but this could be really based on, obviously, on the stability of patients, their patients' preferences, clinician judgment, institutional practice, and availability. So there's lots of things that could drive this. Trying to optimize daytime routines that help promote good sleep at night. So this could be overhead lights and natural sunlight as much as possible during the day, making it darker at night. Trying to discourage napping daytime. Obviously, maximizing mobility and patient-stimulated activities as appropriate. That's a huge driver of sleep, and for many other reasons. In stable patients, defining an area-protected time for tailored sleep promotion. This could be as short as four hours. Six hours is probably ideal. So this would include clustering nursing interventions, thinking about, look at the stability of the patient. Do you absolutely have to do a RAS or a CPOD or a pain assessment at three in the morning? Some patients, if they have unstable pain, maybe, maybe not. For medication administration, someone's on a drip, there's not a lot of changes, but if you're giving a crushed tablet down an NG tube, that could be enough to wake the patient up. So maybe you can move some of the medications around by a couple hours. Reducing light, obviously simple things, turning down lights, general room lighting, use red lights, flashlights if possible when entering rooms or troubleshooting equipment, and to potentially offer an eye mask if it's available. Reducing noise. So this is really, you know, the room and hallway noise. Lots of people have, you know, shown how noisy, you know, it's almost, you know, people have done, you know, decibel type studies where they found, you know, their ICU hallways are as loud as a construction site. And just thinking about alarm settings to reduce unnecessary frequent alarms and, you know, the technology of whether they can go off in the unit versus the patient's room. Ensure appropriate noise tailored to patient preferences. So potentially offering earplugs if available, avoid if a silicone allergy, potentially providing white noise if the hospital has the equipment and it's been approved. So you can kind of see, this is, council had a huge effect on this because we just don't want to be in a situation where saying everybody should have a white noise machine in their ICU, everybody should have this, everybody should do that. There's some variability and, but these are things to consider in the context of the resources and practices in your own ICU. Optimizing temperature of the room. And there's a lot of variability between people, how they like to sleep. Some people like it colder, some people hotter. If potentially offering a fan, if it's available, some people might prefer to have warm blankets. So just sort of, you know, cocooning and making the environment a little temperature. Not a lot of risks here. Patient positioning, we kind of talked about this. Patient comfort. So obviously pain, we all know the A and the A to F bundle should be assessed, treated. You know, there is some level of discomfort. Patient's just lying in the ICU bed. You know, thinking about the comfort related potential barriers to sleep. And this could include things that based on what you found out from the patient and their family that helps them sleep. So maybe it's family presence or not having family presence, right? It depends. Maybe music could help. We make a recommendation about not using in every patient, but it could easily help. Just turning on a radio, weighted special blankets, pillows, massage, a book, music. You know, and obviously it depends how critically ill the patient is and whether at what stage of their ICU stay they're at. You know, for medication strategies, again, just to emphasize, you should be really used to judiciously, again, if patients are taking a sleep aid medication, be really thinking about, do you need to initiate something? The non-pharmacologic strategy should be optimized first. And certainly there's going to be patients as we kind of already talked about. You might have a patient has delirium where they, you know, their circadian rhythm is off and they're, you know, they become agitated at night. They have to be given something. So probably a benzodiazepine is not the best drug for that, but they might, if they can't be calmed down, they probably need to receive something if it's not pain. So this is just, you know, hopefully we can create a better environment with mainly non-pharmacologic things that are low risk in our patient and help this patient's lying on their side. And, you know, hopefully we'll help improve outcomes, reduce delirium and quality of care in our patients by thinking of some of these things. So without any further ado, any questions or comments or experiences that you guys have in your ICUs, I'd love to hear them. Yes. Can you use the mic, sorry. Is that alarm that doesn't go off in the patient's room commercially available? I, Kathleen Volvin, you can answer that. I'm a pharmacist, so I'm not sure. I think there's ways of minimizing alarms in rooms. There are, I mean, they can put them on the outside of the door. However, I've seen that in intermediate units, but I've not really seen it in intensive care units. You can address that noise from creating a different sound environment. So there, I don't know if any of you guys have ever heard of the Healing Channel. It actually comes through the TV and it has pictures, as well as specifically designed music. So not Muzak, but literally beginning, middle, end music that addresses a different sound level for the patient. So it becomes the white noise of the environment versus the beeps and the blips. So that's one strategy I know people have utilized to try and create a better sound environment. And I think, you know, as this whole area becomes more prevalent and important, I think, you know, device manufacturers are listening and maybe there will be changes in technology or ways that things can be done just as safely, but not have those things. And so we're kind of in, as I said, the infancy in making these changes. Go ahead. One of our nursing teams at one of our facilities decided that they were noisy night staff and they wanted to make a difference in their unit. So they were the loudest people. So they surveyed all the other team members and they told them that they were the loudest people. So then they proceeded to try and fix their environment. They put the little noise monitors that you just talked about. Not only did it make them change their level of noise when x-ray and lab and everybody else came in, they're like, oh, what's that monitor? So they changed that. They had looked at these guidelines. They made sleep kits for their patients. They did diffusers. They had the alarm levels changed in the room, but not outside the room. So they got permission to decrease it to 25% in the room, which is the lowest it would go. But all of those things, they changed their HCaTS scores significantly through all of the different interventions. They did other stuff. They had walls painted and all kinds of crazy things to be all of these things, the white noise, but that was all driven by just the nurses looking at those exact guidelines and just saying, oh, we could do that. So it wasn't really a study per se. There's a lot of that. You know, there's a lot of qualitative kind of feedback from it, but it clearly made a difference to the patients and not particularly me. One of the things that we were talking about this earlier is a simple flip, is put the lights above the head of the bed, blue light, natural blue light, instead of the fluorescent and just have a fluorescent light for exam. And the cost is no difference. And it creates quite a different milieu feeling in the environment, which then addresses people's behavior because it feels different. And there's a lot of companies like Philips is investing a tremendous amount of money in these very expensive lighting systems that cost a lot to try to improve sleep or reduce delirium. And I think, as you guys suggested, there's probably ways we could do some of that much cheaper and change it. John, can I add a quick thing? Yes, please. I was just gonna talk about circadian rhythms and homeless people, because I get to see a lot. I live in San Francisco and we have a large homeless population and a lot of the homeless people that we have end up in the ICU at some point. And one thing to keep in mind about this population is they tend to have completely reversed sleep cycles because they want to be vigilant at night. That's when they get attacked and they like to sleep during the day. So when they come into our unit, they are crazy at night and they are sedate in the day almost by just that is their new system. They become nocturnal human beings. And what you actually have to do is wean them back to a daytime schedule. So what you don't wanna do is sedate them at night when they're getting wild, if you possibly can. What you do wanna do is try to make them be awake late in the afternoon and don't worry about them before 4 p.m. And then try to tire them out in the early evening and then gradually dial that back because if you sedate them at night and try to enforce the normal circadian rhythm upon them, you end up with an overly agitated person over and over again who bounces back and forth between overly agitated and sedated. So there's a whole process of weaning people who are reversed in their sleep cycles back into a daytime schedule, but it has to be a weaning. Are you a night-time person or a day-time person? Mm-hmm. That's right. And it's okay to let people be awake at night. I think the only time is medication is when patients are really complaining about anxiety or they really want to fall asleep and they just can't because they're so on edge or people that are obviously agitated, dangerously agitated. That could be a lot of people with delirium. I was just going to say the clustering. I think we talked about this earlier. Clustering care interventions is really important. And so what this little group of nurses did was they actually traded off jobs. So instead of doing night baths, you didn't do night baths anymore. They got to do some other job. I can't remember what it was. But that's a huge culture change. Like that is massive. And to get for them to be able to, because it's a night, it's the night day thing, right? So, but to trade that off and to have x-ray and all these other people are used to rolling in at three o'clock in the morning to do all their work, to come in at six, that's massive. Now I'll tell you the trade off to that though is that if you have high acuity patients that need to be monitored, you have to be very careful not to make it all or none. Because we put in delirium precautions for our hip fracture patients. I would say you might want to be monitored after you had a massive hip surgery, right? So you have to kind of trade off the who did. So as you said, you don't want to make it blanket and you've got to have enough evidence to support it. But I think there's opportunities both ways. Yeah, no, absolutely. Those are valuable points.

sleep in the ICU

sleep quality

ICU patients

non-pharmacologic interventions

sleep aid medications

pre-ICU sleep history

Sleep Assessment Tool