Improving sleep duration in NICU graduates: a quality improvement initiative

Background Protected sleep is a core component of developmental supportive care in neonates. However, the overstimulating neonatal intensive care unit (NICU) environment and procedures often disrupt neonatal sleep periods. With improving neonatal survival rates in low- and middle-income countries like India, focus must shift towards ensuring neurologically intact outcomes. We implemented a point of care quality improvement initiative using environmental modification to improve sleep duration in neonates admitted to the low dependency unit (LDU) of our NICU. Methods This prospective quality improvement study was conducted at a tertiary care teaching hospital in North India from May to August 2024. All stable neonates admitted to the LDU during the study period were enrolled. Four sequential plan-do-study-act (PDSA) cycles were implemented, targeting cyclic lighting, noise reduction through alarm management and equipment repair, staff sensitisation and caregiver involvement. The primary outcome was the proportion of neonates achieving adequate sleep duration of more than 16 hours/day. Results A total of 625 neonates were enrolled across three phases (baseline: n=115; implementation: n=312; post implementation: n=198). The proportion of neonates achieving adequate sleep increased from 15.7% at baseline to 62.2% during implementation and sustained at 58.1% post implementation. Mean sleep duration increased significantly from 12.95±3.22 to 16.38±3.12 hours/day (p<0.001). Environmental parameters also improved, with daytime mean light intensity reducing from 486±124 to 285±98 lux and mean noise levels decreasing from 62.4±8.3 to 52.8±6.5 dB. Conclusion Simple, low-cost environmental modifications implemented through sequential PDSA cycles can significantly improve sleep duration in NICU neonates.