The improvements in ICU care and survival over the last 20 years are gratifying, but we must now look for quality not just quantity of survival. Despite growing awareness of the detrimental impact of the environment on patient outcomes, limited investment has been made in environmental redesign. This manuscript describes the process undertaken to improve the environment of two ICU bedspaces utilising best available and novel design principles and technology to address patient-centred problems common to most ICUs. Early outcomes demonstrate an improved acoustic and lighting environment, with reverberation time more than halved (demonstrating improved sound absorption within the bedspaces) as well as improved sound blocking from externally created sound, and a circadian lighting solution that closely mimic natural daylight compared to traditional electrical lighting. A separate manuscript has described the detailed lighting evaluation of the bedspaces before the implementation of the upgraded bedspaces, including a comparison between bedspaces with/without windows in different lighting conditions [29]. A key finding of that study was that in a windowed bedspace, the light available to patients closely mimicked natural light, but only when the ceiling lights were off. As soon as the ceiling lights were turned on, the light available to patients mimicked that of a windowless bedspace [29]. As can be seen in Figs. 6 and 7, the circadian lighting solution implemented in this project was found to closely mimic natural daylight, both with regards to the SPD (the ‘colour’ of the light) as well as the timing of delivery, delivering light very similar to the natural light we have evolved around and are dependent on for circadian rhythm entrainment. Moving the monitor alarms away from the patient’s head reduced the loudness of the alarms (as experienced by the patient) by between 8 and 11 dBA. A 10 dBA decrease equals approximately a halving of the perceived loudness of the noise and is the equivalent to the mean sound abatement achieved by earplugs [34].
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Incorporating multiple partners and perspectives in a participatory design approach, especially the voices of the consumers, was essential for project success and enabled the project team to completely reconceptualise and future-proof the bedspaces, addressing real and identified problems experienced by ICU patients, family members, and staff locally and internationally. There has been a growing awareness of the importance of consumer involvement in various healthcare change management processes, but to date this does not seem to have translated into any meaningful involvement of the end-users when it comes to ICU bedspace design. Ensuring widespread collaboration and inclusion of all relevant stakeholders, rather than the traditional top-down approach, is essential for achieving effective healthcare innovation [35]. Although solutions were prioritised and chosen based on local needs of the study ICU, the problems addressed are universal and the process undertaken (and many of the solutions implemented) applicable and generalisable to ICUs (and other hospital wards) worldwide.
The negative impact of the environment on patient outcomes is likely to accelerate as new technology is introduced to sicker people. Noise levels are increasing, and there are more screens and other sources of nocturnal lights [36,37,38]. Sicker patients are admitted to ICU and surviving, but commonly requiring longer admissions, extending their time in contact with the environment [39]. And patients are more commonly managed with reduced sedation, providing them with opportunities to interact with the environment. However, the bland clinical environment provides nothing interesting or stimulating to interact with. Therefore, simple, unidimensional solutions aimed at masking the problems (such as ear plugs and eye masks) are not likely to be the optimal solutions, and efforts should be focussed on multicomponent solutions addressing the source of the problems. Similarly, current ICU design standards and guidelines are unlikely to meet the needs of ICU patients today and in the future and should be updated to reflect the importance of patient participation, ensuring that ICU bedspace designs considers the rapidly changing models of care and technologies available to create an efficient and safe working environment for staff and a healing environment for patients.
Recently, there have been several calls to ensure access to nature or green environments for patients in ICU [26]. Unfortunately, as this was a retrofit project with two windowless bedspaces, there was no feasible way of physically providing this. However, to address this important requirements, technological solutions were utilised to virtually provide this as best as possible. Virtual windows and skylights allow various dynamic sceneries with accompanying soundtracks to be displayed to patients. These can be individualised based on patients’ preferences. Similarly, nature videos and soundtracks/nature sounds were incorporated into the patient entertainment system, with the sounds delivered directly to the patients via wireless speakers built into the ICU beds. There is strong evidence linking contact with greenery to improved patient outcomes and staff health [26]. However, the effectiveness of digital solutions needs to be tested in future research.
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Reducing noise and optimising lighting are obviously important aims, and this project has demonstrated that this is achievable. However, the ability to personalise the environment is also important. Every patient will have different needs of the environment and individual preferences. The ability to individualise parts of the environment such as the lighting (as an example) provides an opportunity to move the environment from being a passive cause of negative outcomes to potentially an active part of the care, where a ‘dose’ of the right environment at the right time can be used to optimise care provision. This also provides an amount of control and autonomy to the patient, something that is commonly lacking in traditional ICU designs.
This project has shown that environmental improvements are possible, albeit challenging, even as a retrofit in a live ICU, and that an improved lighting and acoustic environment can be created. Challenges faced during the implementation of this project included patient factors, staff factors, organisational factors, the retrofit nature of the implementation, technological limitations, and the fact that a pandemic started around the same time as the planning for project implementation. Many of these challenges (such as resistance to change when introducing new technology into an existing ICU) were expected, allowing proactive planning to occur. However, others were unexpected and required agility and ongoing open communication and dialogue with a diverse and large group of stakeholders.
Importantly, there is limited information available to determine whether environmental improvements make any difference to patient outcomes. Studies have reported that features such as circadian lighting solutions and physical barriers to reduce noise reduces the incidence of delirium and ICU length of stay [40]. Sleep has been shown to be improved by sound masking [41]. And as earplugs have been shown to reduce the incidence of delirium [42], it is likely that removing the noise in the first place or preventing it from disrupting patients’ sleep is likely to have the same effect. However, the authors have been unable to find any current literature on the impact of large environmental upgrades at this scale on patient outcomes. The next phase of our project will be to comprehensively evaluate project outcomes, both on patient experiences and outcomes, as well as on family members and staff. This evaluation will include qualitative interviews of patients, families, and staff members, and quantitative studies on patients’ sleep, circadian rhythms, delirium incidence, ICU outcomes, and physical/cognitive/psychological recovery 6-months after ICU discharge.
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