Stimulus deprivation in windowless rooms

The Energy Saving Potential of Wide Windows in Hospital Patient Rooms, Optimizing the Type of Glazing and Lighting Control Strategy under Different Climatic Conditions

If not properly designed, the adoption of large windows can sometimes have a negative impact on building energy demand. For this reason, aggravated by the outdated building envelope of the healthcare building stock, large fenestration systems are usually avoided in hospitals, especially in old structures. However, with appropriate glazing specifications, the adoption of wider openings can result into significant energy savings, lower costs and strong positive effects on patients and staff well-being. The present study investigates how different window sizes and types of glazing affect heating, cooling and lighting energy demand in a hospital patient room. The objective is to evaluate the energy savings that may be obtained when installing larger windows and to identify the glazing properties allowing one to reach the maximum energy reductions. Simulations were carried out using nine diverse glazing systems, already available on the market, and their energy performance was evaluated in relation to two different window areas: a common size opening, characterized by a 25% Window-to-Wall Ratio (WWR), and a floor to ceiling window, with 77% WWR. The analysis was conducted taking into consideration four different orientations in four Italian cities, supposing two artificial lighting control strategies. The results highlighted how the adoption of wider windows with appropriate glazings and a daylight-linked dimming lighting control strategy may lower the primary energy demand up to 17%.

Two decades (1993-2012) of adult intensive care unit design: a comparative study of the physical design features of the best practice examples

In 2006, Critical Care Nursing Quarterly published a study of the physical design features of a set of best practice example adult intensive care units (ICUs). These adult ICUs were awarded between 1993 and 2003 by the Society of Critical Care Medicine (SCCM), the American Association of Critical-Care Nurses, and the American Institute of Architects/Academy of Architecture for Health for their efforts to promote the critical care unit environment through design. Since 2003, several more adult ICUs were awarded by the same organizations for similar efforts. This study includes these newer ICUs along with those of the previous study to cover a period of 2 decades from 1993 to 2012. Like the 2006 study, this study conducts a systematic content analysis of the materials submitted by the award-winning adult ICUs. On the basis of the analysis, the study compares the 1993-2002 and 2003-2012 adult ICUs in relation to construction type, unit specialty, unit layout, unit size, patient room size and design, support and service area layout, and family space design. The study also compares its findings with the 2010 Guidelines for Design and Construction of Health Care Facilities of the Facility Guidelines Institute and the 2012 Guidelines for Intensive Care Unit Design of the SCCM. The study indicates that the award-winning ICUs of both decades used several design features that were associated with positive outcomes in research studies. The study also indicates that the award-winning ICUs of the second decade used more evidence-based design features than those of the first decades. In most cases, these ICUs exceeded the requirements of the Facility Guidelines Institute Guidelines to meet those of the SCCM Guidelines. Yet, the award-winning ICUs of both decades also used several features that had very little or no supporting research evidence. Since they all were able to create an optimal critical care environment for which they were awarded, having knowledge of the physical design of these award-winning ICUs may help design better ICUs.

Changes in patient satisfaction related to hospital renovation: experience with a new clinical building

IMPORTANCE

There is an increasing trend toward designing hospitals with patient-centered features like reduced noise, improved natural light, visitor friendly facilities, well-decorated rooms, and hotel-like amenities. It has also been suggested that because patients cannot reliably distinguish positive experiences with the physical environment from positive experience with care, an improved hospital environment leads to higher satisfaction with physicians, nursing, food service, housekeeping, and higher overall satisfaction.

OBJECTIVE

To characterize changes in patient satisfaction that occurred when clinical services (comprised of stable nursing, physician, and unit teams) were relocated to a new clinical building with patient-centered features. We hypothesized that new building features would positively impact provider, ancillary staff, and overall satisfaction, as well as improved satisfaction with the facility.

DESIGN

Natural experiment utilizing a pre-post design with concurrent controls.

SETTING

Academic tertiary care hospital.

PARTICIPANTS

We included all patients discharged from 12 clinical units that relocated to the new clinical building who returned surveys in the 7.5-month period following the move. Premove baseline data were captured from the year prior to the move. Patients on unmoved clinical units who returned satisfaction surveys served as concurrent controls.

EXPOSURE

Patient-centered design features incorporated into the new clinical building. All patients during the baseline period and control patients during the study period were located in usual patient rooms with standard hospital amenities.

MAIN OUTCOMES AND MEASURES

The primary outcome was satisfaction scores on the Press Ganey and Hospital Consumer Assessment of Healthcare Providers and Systems survey, dichotomized at highest category versus lower categories. We performed logistic regression to identify predictors of "top-box" scores.

RESULTS

The move was associated with improved room- and visitor-related satisfaction without significant improvement in satisfaction with clinical providers, ancillary staff, and only 1 of 4 measures of overall satisfaction improved. The most prominent increase was with pleasantness of décor (33.6% vs 64.8%) and visitor accommodation and comfort (50.0% vs 70.3%).

CONCLUSION AND RELEVANCE

Patients responded positively to pleasing surroundings and comfort, but were able to discriminate their experiences with the hospital environment from those with physicians and nurses. The move to a new building had significant impact on only 1 of the 4 measures of overall patient satisfaction, as clinical care is likely to be the most important determinant of this outcome. Hospital administrators should not use outdated facilities as an excuse for suboptimal provider satisfaction scores.

Guidelines for intensive care unit design

OBJECTIVE

To develop a guideline to help guide healthcare professionals participate effectively in the design, construction, and occupancy of a new or renovated intensive care unit.

PARTICIPANTS

A group of multidisciplinary professionals, designers, and architects with expertise in critical care, under the direction of the American College of Critical Care Medicine, met over several years, reviewed the available literature, and collated their expert opinions on recommendations for the optimal design of an intensive care unit.

SCOPE

The design of a new or renovated intensive care unit is frequently a once- or twice-in-a-lifetime occurrence for most critical care professionals. Healthcare architects have experience in this process that most healthcare professionals do not. While there are regulatory documents, such as the Guidelines for the Design and Construction of Health Care Facilities, these represent minimal guidelines. The intent was to develop recommendations for a more optimal approach for a healing environment.

DATA SOURCES AND SYNTHESIS

Relevant literature was accessed and reviewed, and expert opinion was sought from the committee members and outside experts. Evidence-based architecture is just in its beginning, which made the grading of literature difficult, and so it was not attempted. The previous designs of the winners of the American Institute of Architects, American Association of Critical Care Nurses, and Society of Critical Care Medicine Intensive Care Unit Design Award were used as a reference. Collaboratively and meeting repeatedly, both in person and by teleconference, the task force met to construct these recommendations.

CONCLUSIONS

Recommendations for the design of intensive care units, expanding on regulatory guidelines and providing the best possible healing environment, and an efficient and cost-effective workplace.

The effect of window rooms on critically ill patients with subarachnoid hemorrhage admitted to intensive care

Introduction

Clinicians and specialty societies often emphasize the potential importance of natural light for quality care of critically ill patients, but few studies have examined patient outcomes associated with exposure to natural light. We hypothesized that receiving care in an intensive care unit (ICU) room with a window might improve outcomes for critically ill patients with acute brain injury.

Methods

This was a secondary analysis of a prospective cohort study. Seven ICU rooms had windows, and five ICU rooms did not. Admission to a room was based solely on availability.

We analyzed data from 789 patients with subarachnoid hemorrhage (SAH) admitted to the neurological ICU at our hospital from August 1997 to April 2006. Patient information was recorded prospectively at the time of admission, and patients were followed up to 1 year to assess mortality and functional status, stratified by whether care was received in an ICU room with a window.

Results

Of 789 SAH patients, 455 (57.7%) received care in a window room and 334 (42.3%) received care in a nonwindow room. The two groups were balanced with regard to all patient and clinical characteristics. There was no statistical difference in modified Rankin Scale (mRS) score at hospital discharge, 3 months or 1 year (44.8% with mRS scores of 0 to 3 with window rooms at hospital discharge versus 47.2% with the same scores in nonwindow rooms at hospital discharge; adjusted odds ratio (aOR) 1.01, 95% confidence interval (95% CI) 0.67 to 1.50, P = 0.98; 62.7% versus 63.8% at 3 months, aOR 0.85, 95% CI 0.58 to 1.26, P = 0.42; 73.6% versus 72.5% at 1 year, aOR 0.78, 95% CI 0.51 to 1.19, P = 0.25). There were also no differences in any secondary outcomes, including length of mechanical ventilation, time until the patient was able to follow commands in the ICU, need for percutaneous gastrostomy tube or tracheotomy, ICU and hospital length of stay, and hospital, 3-month and 1-year mortality.

Conclusions

The presence of a window in an ICU room did not improve outcomes for critically ill patients with SAH admitted to the ICU. Further studies are needed to determine whether other groups of critically ill patients, particularly those without acute brain injury, derive benefit from natural light.

Blue-blocking IOLs decrease photoreception without providing significant photoprotection

Violet and blue light are responsible for 45% of scotopic, 67% of melanopsin, 83% of human circadian (melatonin suppression) and 94% of S-cone photoreception in pseudophakic eyes (isoilluminance source). Yellow chromophores in blue-blocking intraocular lenses (IOLs) eliminate between 43 and 57% of violet and blue light between 400 and 500 nm, depending on their dioptric power. This restriction adversely affects pseudophakic photopic luminance contrast, photopic S-cone foveal threshold, mesopic contrast acuity, scotopic short-wavelength sensitivity and circadian photoreception. Yellow IOL chromophores provide no tangible clinical benefits in exchange for the photoreception losses they cause. They fail to decrease disability glare or improve contrast sensitivity. Most epidemiological evidence shows that environmental light exposure and cataract surgery are not significant risk factors for the progression of age-related macular degeneration (AMD). Thus, the use of blue-blocking IOLs is not evidence-based medicine. Most AMD occurs in phakic adults over 60 years of age, despite crystalline lens photoprotection far greater than that of blue-blocking IOLs. Therefore, if light does play some role in the pathogenesis of AMD, then 1) senescent crystalline lenses do not prevent it, so neither can blue-blocking IOLs that offer far less photoprotection, and 2) all pseudophakes should wear sunglasses in bright environments. Pseudophakes have the freedom to remove their sunglasses for optimal photoreception whenever they choose to do so, provided that they are not encumbered permanently by yellow IOL chromophores. In essence, yellow chromophores are placebos for prevention of AMD that permanently restrict a pseudophake's dim light and circadian photoreception at ages when they are needed most. If yellow IOLs had been the standard of care, then colorless UV-blocking IOLs could be advocated now as "premium" IOLs because they offer dim light and circadian photoreception roughly 15-20 years more youthful than blue-blocking IOLs.

A decade of adult intensive care unit design: a study of the physical design features of the best-practice examples

This article reports a study of the physical design characteristics of a set of adult intensive care units (ICUs), built between 1993 and 2003. These ICUs were recognized as the best-practice examples by the Society of Critical Care Medicine, the American Association of Critical Care Nurses, and the American Institute of Architects. This study is based on a systematic analysis of the materials found on these ICUs in the booklet and videos jointly published by the above organizations in 2005. The study finds that most of these examples of best-practice adult ICUs have the following negative characteristics: (1) they are built as renovation projects with more health and safety hazards during construction; (2) most of them are mixed-service units with more safety and staffing problems; (3) the overall layout and the layout of staff work areas in these ICUs do not have any common design solutions for improved patient and staff outcomes; and (4) in these ICUs, family space is often located outside the unit, and family access to the patient room is restricted, even though family presence at the bedside may be important for improved patient outcomes. Some of these negative characteristics are offset by the following positive characteristics in most ICUs: (1) they have only private patient rooms for improved patient care, safety, privacy, and comfort; (2) most patient beds are freestanding for easy access to patients from all sides; (3) they have handwashing sinks and waste disposal facilities in the patient room for improved safety; and (4) most patient rooms have natural light to help patients with circadian rhythms. The article discusses, in detail, the implications of its findings, and the role of the ICU design community in a very complicated design context.

A qualitative study of the experiences of patients following transfer from intensive care

In nursing literature much attention has been paid to patients' experiences while in intensive care. Extensive literature exists examining the longer-term effects of critical care [Jones C, Humphris GM, Griffiths RD. Psychological morbidity following critical illness - the rationale for care after intensive care. Clinical Intensive Care 1998;9:199-205; Griffiths RD, Jones C. ABC of intensive care. Recovery from intensive care. Br Med J 1999;319:417-429]. There is an apparent scarcity of data examining patients' experiences immediately following discharge to wards. A Husserlian phenomenological approach was utilised to gain some understanding of the experience of patients following transfer from intensive care. Ten patients selected purposively comprised the sample. Interviews were performed on the wards 3-5 days following transfer from intensive care. Data was analysed utilising () [Colaizzi PF. Psychological Research as the phenomenologist views it. In: Valle R, King M, editors. Alternatives for psychology. New York: Oxford University Press; 1978. p. 48-71] procedural approach to phenomenological interpretation and analysis. Three major themes emerged: physical response, psychological response and provision of care. These provide a possible framework for patient assessment. Implications for future practice and study are discussed.

Sensory deprivation and chronic pain: a review of the literature

AIMS AND OBJECTIVES

The aim of this paper is to explore the literature into the use of 'Snoezelen' (Sensory Stimulation) for the management of chronic pain. Within the literature there are a number of research studies which have investigated the concept of sensory deprivation and these are considered. The studies indicate the potential of sensory input as a field of research in particular relation to the care of patients within hospital settings where they are removed from their 'normal' level of sensory input and could subsequently experience sensory deprivation. The relationship between sensory restriction and chronic pain is emphasized. This links with investigations of sensory stimulation (Snoezelen) as a potential strategy for the management of chronic pain.

CONCLUSIONS

In conclusion, it is suggested that sensory deprivation cannot exist and the term 'sensory restriction' would be more appropriate. It is proposed that there is a need to develop a tool to assist carers in identifying the existence of sensory restriction in their specific client groups to provide a basis for intervention.

Snoezelen and chronic pain: developing a study to evaluate its use (Part I)

Chronic pain can be devastating, it impinges upon the life of the sufferer, causing psychological, physical, social and financial problems, leaving the individual searching for an explanation and a cure. Although there are no major epidemiological studies to date, it has been suggested that the impact of chronic pain, not only to the patient, but also to society and the NHS is phenomenal, with loss of production and costs of treatments (Fordyce 1995). Specialists within the field of chronic pain have advocated the use of the multidisciplinary approach to deal with the problems and thus suggest the use of the pain management programme, which is designed to teach the patient coping strategies. Recently, however, there has been a call within the literature to identify the effectiveness of singular strategies, which may be equally as effective and less expensive (Keefe et al 1992). The purpose of these papers is to introduce one such strategy, which has been evaluated over the past four years in order to investigate the use of the sensory environment (Snoezelen) for the management of chronic pain. In part II of this paper, an evaluation of Snoezelen and chronic pain will be presented, along with the findings of an investigation into its use.

Snoezelen: its potential for people with chronic pain

The purpose of this paper is to outline the application of a new form of chronic pain management which is currently under investigation by the writer as a PhD study with the University of Wales, Cardiff, UK. The study was initiated by the writer whilst working as a Senior Nurse Specialist in pain management. It is anticipated that the results of the study will be available by 1996. The concept of the Snoezelen will be discussed. Snoezelen has been used by many centres for the care of individuals with learning disabilities. The paper will also describe the Snoezelen centre based in Chesterfield, UK and some of the experiences that are available. Finally, the rationale behind the application of a strategy for the management of individuals experiencing chronic pain will be discussed relating to some of the appropriate literature. As a result of this study several pain clinics are interested in looking at the use of some of the concepts.

Sleep and intensive care

Human beings spend on average one third of their life sleep. Given that sleep places an individual and its species at a potential biological disadvantage it follows that this must be outweighed by the advantages which sleep has to offer. Why do people sleep? What are its functions? What happens to people during sleep and how can nurses help patients to a better night's sleep? These are just a few questions considered here in relation to patients needing intensive care.

Therapeutic progress--review XXXI. Therapeutic progress in intensive care sedation and analgesia. Part II--Drug selection

In part I of this review the principles governing the uses of analgesics and sedatives in the ITU were considered. In part II we shall review the drugs available considering first, symptomatic therapy and secondly, regional analgesia.

The effects of fatigue on physician performance--an underestimated cause of physician impairment and increased patient risk

Evidence is reviewed demonstrating the high level of drug and alcohol abuse and marital disharmony among physicians and the particularly high rate among anaesthetists. The relationship between these factors and the effects of fatigue is explored. The current evidence for reduction in physician performance and vigilance resulting from fatigue and sleep loss is reviewed. Supplementary indirect evidence is surveyed which suggests that increased experience may not compensate adequately for this reduced performance. Since hours of work can be controlled, it is essential that anaesthetists, their professional organizations and regulatory agencies ensure that pressure for efficiency does not result in fatigue and the consequent compromise of both patient and physician health and safety.

Replanning of an intensive therapy unit

Considerable effort is needed when replanning an intensive therapy unit to avoid repeating mistakes in design, such as lack of windows and an impractical working area. Early consultation with the nursing and medical staff primarily responsible for such a unit is essential. The considerable technological innovations in intensive care will require flexibility in the future if they are to be incorporated into existing facilities.

Windows in the intensive therapy unit

Retrospective surveys were carried out on two groups of patients who had survived a stay of at least 48 h in an Intensive Therapy Unit. One group had been kept in a unit without windows, and the other in a similar unit with translucent but not transparent windows. Survivors from the windowless unit had a less accurate memory of the length of their stay, and were less well orientated in time during their stay. The incidence of hallucinations and delusions was more than twice as high in the windowless unit. The phenomenon of depersonalisation in the face of life-threatening danger is described and discussed.