The introduction of a sound reduction bundle in the intensive care unit and its impact on sound levels and patients.

BACKGROUND: ICU outcomes are continuing to improve. However, this has not been matched by similar improvements of the ICU bedspace environment, which can detrimentally impact on patient outcomes. Excessive sound and noise, especially, has been linked with adverse and potentially preventable patient outcomes and staff errors. There are many sources of sound in the ICU, with alarms from bedside equipment frequently listed as a main source. The number of alarms is increasing in parallel with the introduction of new and more sophisticated technologies to monitor and support patients. However, most alarms are not accurate or critical and are commonly ignored by staff. OBJECTIVE: The objective of this study was to evaluate the impact of a sound reduction bundle on sound levels, number of alarms, and patients' experience and perceived quality of sleep in the ICU. METHODS: This was a pre-post, quasi-experimental study investigating the impact of three study interventions implemented sequentially (staff education, visual warnings when sound levels exceeded the preset levels, and monitor alarm reconfigurations). Effects of staff education were evaluated using pre-education and post-education questionnaires, and the impact on patients was evaluated via self-report questionnaires. A sound-level monitor was used to evaluate changes in sound levels between interventions. Alarm audits were completed before and after alarm reconfiguration. RESULTS: Staff knowledge improved; however, sound levels did not change across interventions. The number of monthly monitor alarms reduced from 600,452 to 115,927. No significant differences were found in patients' subjective rating of their experience and sleep. CONCLUSION: The interventions did not lead to a sound-level reduction; however, there was a large reduction in ICU monitor alarms without any alarm-related adverse events. As the sources of sound are diverse, multidimensional interventions, including staff education, alarm management solutions, and environmental redesign, are likely to be required to achieve a relevant, lasting, and significant sound reduction.

Evaluation of the sensory environment in a large tertiary ICU.

BACKGROUND: ICU survival is improving. However, many patients leave ICU with ongoing cognitive, physical, and/or psychological impairments and reduced quality of life. Many of the reasons for these ongoing problems are unmodifiable; however, some are linked with the ICU environment. Suboptimal lighting and excessive noise contribute to a loss of circadian rhythms and sleep disruptions, leading to increased mortality and morbidity. Despite long-standing awareness of these problems, meaningful ICU redesign is yet to be realised, and the 'ideal' ICU design is likely to be unique to local context and patient cohorts. To inform the co-design of an improved ICU environment, this study completed a detailed evaluation of the ICU environment, focussing on acoustics, sound, and light. METHODS: This was an observational study of the lighting and acoustic environment using sensors and formal evaluations. Selected bedspaces, chosen to represent different types of bedspaces in the ICU, were monitored during prolonged study periods. Data were analysed descriptively using Microsoft Excel. RESULTS: Two of the three monitored bedspaces showed a limited difference in lighting levels across the day, with average daytime light intensity not exceeding 300 Lux. In bedspaces with a window, the spectral power distribution (but not intensity) of the light was similar to natural light when all ceiling lights were off. However, when the ceiling lights were on, the spectral power distribution was similar between bedspaces with and without windows. Average sound levels in the study bedspaces were 63.75, 56.80, and 59.71 dBA, with the single room being noisier than the two open-plan bedspaces. There were multiple occasions of peak sound levels > 80 dBA recorded, with the maximum sound level recorded being > 105 dBA. We recorded one new monitor or ventilator alarm commencing every 69 s in each bedspace, with only 5% of alarms actioned. Acoustic testing showed poor sound absorption and blocking. CONCLUSIONS: This study corroborates other studies confirming that the lighting and acoustic environments in the study ICU were suboptimal, potentially contributing to adverse patient outcomes. This manuscript discusses potential solutions to identified problems. Future studies are required to evaluate whether an optimised ICU environment positively impacts patient outcomes.

Creating the ICU of the future: patient-centred design to optimise recovery.

BACKGROUND: Intensive Care survival continues to improve, and the number of ICU services is increasing globally. However, there is a growing awareness of the detrimental impact of the ICU environment on patients, families, and staff. Excessive noise and suboptimal lighting especially have been shown to adversely impact physical and mental recovery during and after an ICU admission. Current ICU designs have not kept up with advances in medical technology and models of care, and there is no current 'gold-standard' ICU design. Improvements in ICU designs are needed to optimise care delivery and patient outcomes. METHODS: This manuscript describes a mixed-methods, multi-staged participatory design project aimed at redesigning and implementing two innovative ICU bedspaces. Guided by the action effect method and the consolidated framework for implementation research, the manuscript describes the processes taken to ensure the patient-centred problems were properly understood, the steps taken to develop and integrate solutions to identified problems, and the process of implementation planning and rebuilding in a live ICU. RESULTS: Two innovative ICU bedspaces were rebuilt and implemented. They feature solutions to address all identified problems, including noise reduction, optimisation of lighting, access to nature via digital solutions, and patient connectivity and engagement, with solutions developed from various specialty fields, including IT improvements, technological innovations, and design and architectural solutions. Early evaluation demonstrates an improved lighting and acoustic environment. CONCLUSIONS: Optimising the ICU bedspace environment and improving the lighting and acoustic environment is possible. The impact on patient outcomes needs to be evaluated.

Near-field fault slip of the 2016 Vettore Mw 6.6 earthquake (Central Italy) measured using low-cost GNSS.

The temporal evolution of slip on surface ruptures during an earthquake is important for assessing fault displacement, defining seismic hazard and for predicting ground motion. However, measurements of near-field surface displacement at high temporal resolution are elusive. We present a novel record of near-field co-seismic displacement, measured with 1-second temporal resolution during the 30th October 2016 Mw 6.6 Vettore earthquake (Central Italy), using low-cost Global Navigation Satellite System (GNSS) receivers located in the footwall and hangingwall of the Mt. Vettore - Mt. Bove fault system, close to new surface ruptures. We observe a clear temporal and spatial link between our near-field record and InSAR, far-field GPS data, regional measurements from the Italian Strong Motion and National Seismic networks, and field measurements of surface ruptures. Comparison of these datasets illustrates that the observed surface ruptures are the propagation of slip from depth on a surface rupturing (i.e. capable) fault array, as a direct and immediate response to the 30th October earthquake. Large near-field displacement ceased within 6-8 seconds of the origin time, implying that shaking induced gravitational processes were not the primary driving mechanism. We demonstrate that low-cost GNSS is an accurate monitoring tool when installed as custom-made, short-baseline networks.

Multispecies in situ monitoring of a static internal combustion engine by near-infrared diode laser sensors.

A multispecies near-infrared diode laser spectrometer has been constructed for measurements of carbon monoxide, carbon dioxide, and methane directly in the exhaust of a static internal combustion engine. A wavelength modulation-division multiplexing scheme was implemented for the two distributed feedback diode lasers. Gas concentration variations were observed for changes in operating conditions such as increasing and decreasing the throttle, adjusting the air-fuel ratio, and engine start-up.

Three-dimensional brittle shear fracturing by tensile crack interaction.

Faults in brittle rock are shear fractures formed through the interaction and coalescence of many tensile microcracks. The geometry of these microcracks and their surrounding elastic stress fields control the orientation of the final shear fracture surfaces. The classic Coulomb-Mohr failure criterion predicts the development of two conjugate (bimodal) shear planes that are inclined at an acute angle to the axis of maximum compressive stress. This criterion, however, is incapable of explaining the three-dimensional polymodal fault patterns that are widely observed in rocks. Here we show that the elastic stress around tensile microcracks in three dimensions promotes a mutual interaction that produces brittle shear planes oriented obliquely to the remote principal stresses, and can therefore account for observed polymodal fault patterns. Our microcrack interaction model is based on the three-dimensional solution of Eshelby, unlike previous models that employed two-dimensional approximations. Our model predicts that shear fractures formed by the coalescence of interacting mode I cracks will be inclined at a maximum of 26 degrees to the axes of remote maximum and intermediate compression. An improved understanding of brittle shear failure in three dimensions has important implications for earthquake seismology and rock-mass stability, as well as fluid migration in fractured rocks.