The impact of daylight and window views on length of stay among patients with heart disease: A retrospective study in a cardiac intensive care unit

Daylighting and Patients' Access to View Assessment in the Palestinian Hospitals' ICUs

Daylight and access to a view out are vital factors in improving patients' wellness, side by side healthcare providers' satisfaction and productivity in intensive care units (ICUs). Unfortunately, insufficient attention was paid to this issue in Palestine resulting in many ICU designs lacking the required daylight and access to view, which, in turn, negatively affects patients' wellness, increasing delirium incidence and sleep disorders. This study aims to assess the Palestinian hospitals' ICUs in terms of daylight and patients' access to view by conducting daylight measurements and field observations. The results show that the available ICU designs in Palestine do not provide adequate daylight and access to view for patients.

Investigating the Impact of Window Features and Room Layout on Anxiety, Depression, and Analgesic Medication Intake Among Patients: A Pilot Study in a Cardiac Intensive Care Unit

ObjectivesThis observational, pilot study investigated the impact of room layout (orientation of patient bed toward windows) and window features (blind positions) on patients' perceived anxiety and depression levels as well as analgesic medication intake in a cardiac intensive care unit (CICU).BackgroundWhile room layout and window features in patient rooms can impact the effectiveness of windows, there is a paucity of research on how these features can alleviate coexisting symptoms of anxiety, depression, and pain among hospitalized CICU patients with heart disease.MethodologyBlind positions, light, and temperature levels were recorded hourly in south-facing, windowed patient rooms of the same size with parallel or perpendicular patient bed placement to the window in a CICU. Anxiety scores, depression scores, and analgesic medication intake (mg) were obtained daily for 11 patients (22 observation days). Generalized linear models were employed to investigate the relationships between variables.ResultsBlind positions (open, semiopen, closed) varied throughout patients' CICU stay across the rooms. Linear models indicated that patients in rooms with predominantly open blinds (hourly frequency ≥ 50% per day) had significantly lower average anxiety (p = .004) and depression scores (p = .015), as well as reduced analgesic medication intake (p < .001) compared to those in rooms with closed blinds. The study found no significant relationships between different room layouts and the measured outcomes.ConclusionFindings underscore the importance of considering environmental factors, such as window features and room layout in CICUs, as nonmedical interventions to enhance patient health during hospitalization.

The Impact of Dynamic Lighting on Sleep Timing and Duration for Hospitalised Patients

Poor sleep is common in hospitalised patients due to multiple factors, including disruption of the circadian rhythm. Few studies have examined programmable artificial lighting systems in hospital patient rooms, and few have achieved meaningful improvement in sleep. We sought to determine how novel dynamic lighting affects sleep timing and duration compared to standard hospital lighting. Patients were admitted to rooms on a cardiology unit with customised intervention or standard lighting. The lighting system delivered blue-enriched light during the day, a melanopic stimulus twice daily and blue-depleted light in the evening. Sleep/wake probability was measured in 30-s epochs using mattress sensors to capture sleep timing and nocturnal sleep duration. Subjective sleep duration and alertness were assessed with sleep diaries and the Karolinska Sleepiness Scale (KSS), respectively. A total of 87 patients were enrolled. Subjects experiencing customised lighting demonstrated significantly advanced rest/wake activity phase by 160 min and overall greater sleep probability. Overnight sleep duration (11 p.m.-7 a.m.) was 66 min greater in the lighting condition (266 vs. 200 min, p < 0.05). Patients in the intervention group reported higher levels of alertness during the morning (KSS score 3.8 vs. 4.9, p = 0.01) and evening (5.4 vs. 7.1, p = 0.01). A lighting system programmed to entrain the circadian rhythm and provide a daytime melanopic stimulus on a hospital unit was associated with advanced circadian phase, increased nocturnal sleep duration and increased perceived morning and evening alertness. These results suggest that dynamic lighting systems have the potential to improve sleep for hospitalised patients.

Windows in the ICU and Postoperative Delirium: A Retrospective Cohort Study

OBJECTIVES

The ICU built environment-including the presence of windows-has long been thought to play a role in delirium. This study investigated the association between the presence or absence of windows in patient rooms and ICU delirium.

DESIGN

Retrospective single institution cohort study. Delirium was assessed with the Confusion Assessment Method for the ICU.

SETTING AND PATIENTS

ICU patients between January 1, 2020, and September 1, 2023, were categorized into windowed or nonwindowed groups based on their ICU room design. The primary outcome was the presence or absence of delirium at any time during the patient's ICU stay. Secondary outcomes included the presence of delirium during the first 7 days of the ICU stay, hospital length of stay, ICU length of stay, in-hospital mortality, pain scores, and Richmond Agitation-Sedation Scale scores.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 3527 patient encounters were included in the final analysis, of which 1292 distinct patient encounters were admitted to a room without windows (37%). Delirium was observed in 21% of patients (460/2235) in windowed rooms and 16% of patients (206/1292) in nonwindowed rooms. In adjusted analyses, patients in windowed rooms were associated with an increase in the odds of the presence of delirium (odds ratio, 1.29; 95% CI, 1.07-1.56; p = 0.008). Patients in windowed rooms were found to have longer hospital (adjusted hazard ratio [aHR], 0.94; 95% CI, 0.87-1.00) and ICU length of stay (aHR, 0.93; 95% CI, 0.87-1.00) compared with patients in the nonwindowed rooms, although this was not statistically significant in adjusted analyses ( p = 0.06 and 0.05, respectively). No statistically significant difference was observed in other secondary outcomes.

CONCLUSIONS

The current study provides insightful information regarding associations between a component of the ICU built environment, specifically the presence or absence of windows, and the frequency of delirium.

Society of Critical Care Medicine 2024 Guidelines on Adult ICU Design

RATIONALE

Advances in technology, infection control challenges-as with the COVID-19 pandemic-and evolutions in patient- and family-centered care highlight ideal aspects of ICU design and opportunities for enhancement.

OBJECTIVES

To provide evidence-based recommendations for clinicians, administrators, and healthcare architects to optimize design strategies in new or renovation projects.

PANEL DESIGN

A guidelines panel of 27 members with experience in ICU design met virtually from the panel's inception in 2019 to 2024. The panel represented clinical professionals, architects, engineers, and clinician methodologists with expertise in developing evidence-based clinical practice guidelines. A formal conflict of interest policy was followed throughout the guidelines-development process.

METHODS

Embase, Medline, CINAHL, Central, and Proquest were searched from database inception to September 2023. The Grading of Recommendations Assessment, Development, and Evaluation approach was used to determine certainty in the evidence and to formulate recommendations, suggestions, and practice statements for each Population, Intervention, Control, and Outcomes (PICO) question based on quality of evidence and panel consensus. Recommendations were provided when evidence was actionable; suggestions, when evidence was equivocal; and practice statements when the benefits of the intervention appeared to outweigh the risks, but direct evidence to support the intervention did not exist.

RESULTS

The ICU Guidelines panel issued 17 recommendations based on 15 PICO questions relating to ICU architecture and design. The panel strongly recommends high-visibility ICU layouts, windows and natural lighting in all patient rooms to enhance sleep and recovery. The panel suggests integrated staff break/respite spaces, advanced infection prevention features, and flexible surge capacity. Because of insufficient evidence, the panel could not make a recommendation around in-room supplies, decentralized charting, and advanced heating, ventilation, and air conditioning systems.

CONCLUSIONS

This ICU design guidelines is intended to provide expert guidance for clinicians, administrators, and healthcare architects considering erecting a new ICU or revising an existing structure.

Impact of new lighting technology versus traditional fluorescent bulbs on sedation and delirium in the ICU

BACKGROUND

Critically ill patients frequently encounter disruptions in their circadian rhythms in the intensive care unit (ICU) environment. New lighting systems have been developed to enhance daytime light levels and to promote circadian alignment.

OBJECTIVES

To investigate the impact of implementing an innovative lighting technology that mimics natural light and reproduce the colour of the sky.

DESIGN

Prospective, observational, non-randomized comparative trial. ICU patients were exposed to either a cutting-edge lighting system based on new technology (intervention group) or a conventional lighting system using fluorescent bulbs (control group).

SETTING

An Italian intensive care unit with ten beds and five windowless rooms, thereby denying access to natural light. Three rooms had new lighting technology.

MAIN OUTCOME MEASURES

The two groups were compared to assess the prevalence or absence of delirium and the need for sedatives during ICU stay. The secondary aim was to assess the presence of anxiety, depression, and post-traumatic stress disorder in patients at 3, 6, and 12 months after ICU discharge.

RESULTS

86 patients were included: 52 (60 %) in the intervention group and 34 (40 %) in the control group. Seventy-nine patients (82 %) were alive at ICU discharge. Fourteen patients (16 %) developed delirium (intervention group: n = 8 [15 %] vs. control group: n = 6 [18 %] in the control group, (P=0.781). The use of sedative drugs and neuromuscular blocking agents was similar in both the groups. No differences in the incidence of anxiety, depression, or post-traumatic stress disorders were observed among patients who underwent follow-up visits.

CONCLUSIONS

Compared to traditional fluorescent tube lighting, the innovative lighting system did not provide any significant benefit in reducing the frequency of delirium or the necessity for sedative medications.

IMPLICATIONS FOR CLINICAL PRACTICE

A single intervention, the use of lights that mimic sunny light and the sky, did not result in a statistically significant reduction in the incidence of delirium. Delirium has a multifactorial aetiology, necessitating interventions that are multifaceted and address different domains.

Innovate and renovate: Environmental intensive care unit design

This article describes the reallocation of space and construction of a new adult shock trauma intensive care unit implementing methods to mitigate the environmental impact. The environmental burden was reduced through innovative reallocation of space and diversity of lighting sources. Circular economy principles were implemented which enabled much of the infrastructure materials to be reused. Collaboration among interdisciplinary health care teams, such as described in this article, helped to ensure expertise was shared so that the environmental impact was lessened. This article provides insight into innovative methods to mitigate the carbon footprint of a critical care renovation project.

Light, sleep and circadian rhythm in critical illness

PURPOSE OF REVIEW

Sleep and circadian disruption (SCD) are associated with worse outcomes in the ICU population. We discuss sleep, circadian physiology, the role of light in circadian entrainment and its possible role in treating SCD, with special attention to the use of light therapies and ICU design.

RECENT FINDINGS

The American Thoracic Society recently published an official research statement highlighting key areas required to define and treat ICU SCD. Recent literature has been predominantly observational, describing how both critical illness and the ICU environment might impair normal sleep and impact circadian rhythm. Emerging consensus guidance outlines the need for standardized light metrics in clinical trials investigating effects of light therapies. A recent proof-of-concept randomized controlled trial (RCT) showed improvement in delirium incidence and circadian alignment from ICU room redesign that included a dynamic lighting system (DLS).

SUMMARY

Further investigation is needed to define the optimal physical properties of light therapy in the ICU environment as well as timing and duration of light treatments. Work in this area will inform future circadian-promoting design, as well as multicomponent nonpharmacological protocols, to mitigate ICU SCD with the objective of improving patient outcomes.

Modification in ICU Design May Affect Delirium and Circadian Melatonin: A Proof of Concept Pilot Study

OBJECTIVES

Nonpharmacologic delirium management is recommended by current guidelines, but studies on the impact of ICU design are still limited. The study's primary purpose was to determine if a multicomponent change in room design prevents ICU delirium. Second, the influence of lighting conditions on serum melatonin was assessed.

DESIGN

Prospective observational cohort pilot study.

SETTING

The new design concept was established in two two-bed ICU rooms of a university hospital. Besides modifications aimed at stress relief, it includes a new dynamic lighting system.

PATIENTS

Seventy-four adult critically ill patients on mechanical ventilation with an expected ICU length of stay of at least 48 hours, treated in modified or standard rooms.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The clinical examination included a prospective assessment for depth of sedation, delirium, and pain every 8 hours using validated scores. Blood samples for serum melatonin profiles were collected every 4 hours for a maximum of three 24-hour periods. Seventy-four patients were included in the analysis. Seventy-six percent ( n = 28) of patients in the standard rooms developed delirium compared with 46% of patients ( n = 17) in the modified rooms ( p = 0.017). Patients in standard rooms (vs. modified rooms) had a 2.3-fold higher delirium severity (odds ratio = 2.292; 95% CI, 1.582-3.321; p < 0.0001). Light intensity, calculated using the measure of circadian effective irradiance, significantly influenced the course of serum melatonin ( p < 0.0001). Significant interactions ( p < 0.001) revealed that differences in serum melatonin between patients in standard and modified rooms were not the same over time but varied in specific periods of time.

CONCLUSIONS

Modifications in ICU room design may influence the incidence and severity of delirium. Dedicated light therapy could potentially influence delirium outcomes by modulating circadian melatonin levels.

A systematic literature review: building window's influence on indoor circadian health

Light has been shown to have a non-visual impact on the biological aspects of human health, particularly on circadian rhythms. Building windows are a potential means of regulating daylight conditions for circadian health and well-being. As a result of advancements in window and glazing technologies and variations in outdoor solar/sky conditions, understanding daylight's spectral characteristics, which pass through building window systems, is complex. Therefore, a systematic review and summary of the knowledge and evidence available regarding windows' impact on human circadian health is necessary. This study provides an overview of research in this domain, compares approaches and evaluation metrics, and underscores the importance of window parameters' influence on circadian health. Published studies available on various online databases since 2012 were evaluated. The findings of this study define a holistic approach to the melanopic performance of windows and provide an overview of current knowledge regarding the effect of windows on circadian health. Additionally, this work identifies future research directions based on the studies reviewed. This research contributes to the growing body of knowledge on the impact of windows on circadian health, which has implications for the design and construction of buildings in ways that support indoor human health and well-being from the circadian light adequacy perspective.