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Practice Problem: Delirium is a common, yet often preventable complication in hospitalized patients. It is often caused by fragmented sleep, medications, environmental stimuli, and treatment therapies. PICOT: The PICOT question that guided this evidence-based practice change project was: For patients in an adult Intensive Care Unit (ICU), does using a nurse-initiated, non-pharmacological sleep-enhancement protocol, versus no sleep-enhancement protocol, reduce the incidence of ICU-delirium over a period of 2 months? Evidence: The reviewed literature supported the evidence for effective use of a nurse-initiated protocol in reducing delirium in the ICU. Sixteen articles met the inclusion criteria for the review of literature that supported the DNP project. Intervention: A nurse-initiated sleep-enhancement protocol was implemented, which reduced interruptions during the hours between midnight and 0400. Outcome: While there was a 50% reduction in delirious patients after the protocol was initiated, the data pool was small and was not proven to be statistically significant. Due to the Covid-19 outbreak, there were far fewer eligible patients than originally anticipated. Conclusion: Although a clinically significant project outcome was not realized, staff felt that the protocol improved patient care and advocated for its use on all patients as a standard of care. Unit-based shared governance councils on other acute care floors have also adopted the sleep enhancement protocol PROTECTING SLEEP TO REDUCE DELIRIUM 4 Protecting Sleep to Reduce Delirium in an Adult Intensive Care Unit Sleep, a critical factor in health recovery, has been noted to be fragmented in critical care settings, resulting in a correlative effect between sleep deprivation and delirium (Faraklas et al., 2013). Delirium is defined as a temporary syndrome of cognitive disability characterized by disorganized thinking and accompanied by a decreased ability to maintain attention (American Psychiatric Association, 2013). Sometimes even fatal, delirium is the most frequent complication affecting hospitalized patients over 65 years of age (Inouye et al., 2014). Sleep deprivation in the intensive care unit (ICU) can be attributed to loud noises, bright lights, monitors, frequent assessments, mechanical ventilation, and sedative or analgesic medications (Patel et al., 2014). Delirium, while often preventable, is prevalent in the ICU and is detrimental to restoration of health (Pessoa et al., 2019). Some negative outcomes caused by ICU delirium are increased mortality, increased hospital length of stay (LOS), increased financial cost of care, and long-term cognitive impairment (Barr et al., 2013; Inouye et al., 2014). Researchers have found a correlation between the length of time a patient suffered delirium and the level of functional disability for up to a year after discharge (Altman et al., 2018). Reducing the incidence of delirium has even been found to decrease the number of patient falls (Ferguson et al., 2018). Involving willing family members of ICU patients in delirium-prevention measures and decreasing the frequency of neurological assessments have been offered as feasible interventions to reduce delirium in the ICU (McLaughlin et al., 2018; Smithburger et al., 2017). Guidelines and protocols supporting protected rest periods in ICUs are ideal (Li et al., 2011). Each of the aforementioned studies looked at different interventions regarding their effect on delirium, and all acknowledged that lack of sleep is known to exacerbate it. This evidence-based practice change project implemented guidelines that promote noise and light control, and the PROTECTING SLEEP TO REDUCE DELIRIUM 5 reduction of non-emergent interventions during “quiet time” to maintain circadian rhythm and reduce sleep deprivation and fragmentation, thereby reducing ICU-associated delirium. Significance of the Practice Problem The effects of protected sleep in the ICU may positively impact patients’ outcomes by reducing delirium, LOS, and overall mortality (Irwin et al., 2016). The impact on the healthcare system may be profound because shortened LOS reduces the financial cost of recovery to the patient and the healthcare system. Families may also be positively impacted because they may be able to avoid the distress of seeing their loved ones in a state of delirium and confusion. The financial burden of treating delirium in the United States is a staggering $164 billion per year (Ferguson et al., 2018). In 2010 the average daily cost of an ICU stay was $4,300 (Society of Critical Care Medicine, n.d.). More recent data suggested an initial-day ICU expense of $10,794, which levels out to $3,968 by day 3, depending on whether the patient requires mechanical ventilation (Cunningham et al., 2020). Longer ICU LOS increases morbidity and mortality (Altman et al., 2018). There is a reliable association between sleep fragmentation and delirium (Irwin et al., 2016; Patel et al., 2014). One study, conducted in a neurological ICU, suggested the de-escalation of neuro-status checks after a patient has been there for more than 48 hours. The authors acknowledge that although the frequency of neurological assessment is initially done to avoid missing a key finding, after a certain time, it causes more harm than good (McLaughlin et al., 2018). The strength of this recommended practice change comes from the algorithm wherein sleep hygiene is a key recommendation in the diagnosis of ICU delirium, based on patient-oriented evidence and not opinion, consensus, or usual practice (Ebell et al., 2004). PROTECTING SLEEP TO REDUCE DELIRIUM 6 The hospital where this project was implemented has not historically collected data specifically related to ICU delirium, but they do closely monitor LOS. Compared with national benchmarks, this facility has higher than expected LOS for several diagnoses. The Strategic Analytics for Improvement and Learning (SAIL) Value Model is a system used within the organization for data collection and quality improvement project analysis (SAIL, n.d.).