Biren Kamdar, MD, MBA, MHS & Dale Needham, MD, PhD

birenk@gmail.com 8/2013
Name of Nurse collecting this information:
Reference: Kamdar BB, King LM, Collop NA, Sakamuri S, Colantuoni E, Neufeld KJ, Bienvenu OJ, Rowden AM, Touradji P, Brower RG, Needham DM.
The effect of a quality improvement intervention on perceived sleep quality and cognition in a medical ICU. Critical Care Medicine. 2013:800-9.

ICU Sleep Checklist Individual Patient Interventions BED #: _____
MRN: __ __ __ __ __ __ __ __ Patient initials: __ __ Date when shift started: ___/___/ 20__
1. Day Shift Environmental Actions
a. No caffeine after 3pm: b. Encourage activities to prevent napping. % of day shift spent napping:
3NPO 1yes 0no 2unknown 6N/A:RASS -4/-5 0<5% 15-25% 226-50% 351-75% 476-100% 5unknown
2. Night Shift Environmental Actions
a. Appropriate pain control: 1yes 0no 2unknown
b. Optimize room temp: 1yes 0no 2unknown
c. Warm bath before 10pm: 1yes 0no 2unknown
d. TV off by 10pm: 1yes 0no 2unknown
3patient wants TV left on
e. Prevent unnecessary alarms after 10pm: 1yes 0no 2unknown
f. Close curtains to room by 10pm: 1yes 0no 2unknown
g. Dim room lights by 10pm: 1yes 0no 2unknown
h. Minimize RN interruptions after 10pm
# of interruptions after 10pm (Enter 0 if none): __ 2unknown
3. Night Shift Actions (*Select N/A only if patient is unable to respond to you when offering the intervention, eg, sedated)
a. Offer soft music: 4N/A* 0not offered 1offered & used 2offered & refused 3unknown
b. Offer eye mask: 4N/A* 0not offered 1offered & used 2offered & refused 3unknown
c. Offer ear plugs: 4N/A* 0not offered 1offered & used 2offered & refused 3unknown
4. Night Shift: Patient recd any of the medications below?
0
no
2
unknown
1
yes-check all that apply
Check box S if medication given specifically for Sleep.
Check box N if medication given, but Not for sleep (i.e. for sedation, anxiety, etc).
Zolpidem (Ambien): 1S 2N Haldol: 1S 2N Quetiapine (Seroquel): 1S 2N Trazodone (Desyrel): 1S 2N
Lorazepam (Ativan): 1S 2N Morphine: 1S 2N Clonazepam (Klonopin): 1S 2N Diphenhydramine (Benadryl): 1S 2N
Midazolam (Versed): 1S 2N Fentanyl: 1S 2N Olanzapine (Zyprexa): 1S 2N Other:______________ 1S 2N










Biren Kamdar, MD, MBA, MHS & Dale Needham, MD, PhD
birenk@gmail.com 8/2013



ICU Sleep Checklist ICU-wide interventions

1. Dim hallways lights at 10pm:

0
Not done
1
Done. Time ACTUALLY performed: ___:___

2. Avoid overhead pages AFTER 10pm.
Estimated # of pages after 10pm (goal is 0 pages):

0
no pages

1
1-3

2
4-7 Reason for frequent pages (multiple

3
8-14 admissions, code blue, etc.): ________________________

4
15+

Name of Clerk collecting this information:
Reference: Kamdar BB, King LM, Collop NA, Sakamuri S, Colantuoni E, Neufeld KJ, Bienvenu OJ, Rowden AM, Touradji P, Brower RG, Needham DM.
The effect of a quality improvement intervention on perceived sleep quality and cognition in a medical ICU. Critical Care Medicine. 2013:800-9.

}