S7 EP 4: Dr. Ed Litton, Summer Series

 As a ICU Specialist Dr. Ed discusses the importance of designing for patients within an ICU to enhance patient outcomes. 

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Transcript

[00:00:00] David Cummins: G'day and welcome to the AHDC podcast series, Health Design on the Go. I'm your host David Cummins, and today we're speaking to Dr Ed Litton. He's an ICU specialist who works at the Fiona Stanley Hospital in Perth, Western Australia. Dr Ed has been an ICU specialist for over 15 years, and more recently has been discussing how to improve clinical outcomes through better design.

[00:00:34] We're excited to have Dr Ed to here today on our program as part of our ICU series. 

[00:00:39] Hi Dr Ed, how are you? 

[00:00:40] Dr Ed Litton: Hi, David. Good, thanks. Thanks for having me. 

[00:00:42] David Cummins: Thanks for your time. 

[00:00:43] I was really interested to find out the other day that there are differences in conscious states of people sleeping, whether it be in an coma, in an ICU or whether it be just normal sleep.

[00:00:56] Do you mind, just talking medically about those differences of consciousness and the benefit of sleep and how that improves clinical outcomes for patients? 

[00:01:05] Dr Ed Litton: Yeah, absolutely David. Yeah, so I mean, um, coma through medication we give, like for an anesthetic is not the same as sleep. It's not the same experience for patients. 

[00:01:15] They can feel the difference and it's not the same effect for patients either. Sleep that we all experience, we know it is really nurturing, both for our physical body, our mental state, our psychological wellbeing. And so if you think sleep is important when you're well... imagine how important it must be when you are critically unwell in an intensive care.

[00:01:35] The most important thing we can do for patients is optimise their sleep because most of what intensive care is, is just supporting the body while the body repairs. So what you want to do is give it the best possible state to repair in, and that really is sleep. 

[00:01:50] David Cummins: So how then do patients sleep if, what I would probably argue is the noisiest department of a hospital? It's generally vinyl, it's generally echoey, it's generally one-to-one nursing, if not two-to-one nursing. 

[00:02:04] There's generally a lot of beeps and noises. It's generally a stale place. How. Someone sleep and rest and recover when there's so much going on in the heart of a hospital?

[00:02:17] Dr Ed Litton: Yeah, that's a great question. And it's really important. 

[00:02:20] The first thing is that, as clinicians, we have to value it for our patients and see the importance of it. And historically that's been hard to do because it's difficult to measure sleep. 

[00:02:32] Appearance-wise someone who's in a coma might look this similar to someone who's sleeping, but actually when you measure it, and the gold standard will be something called polysomnography.

[00:02:41] The details are not important, but, measuring it, is very different but it can look to a nurse at the bedside, to doctors at the bedside very similar. So that's the first difficulty is.. Do we have the tools to measure sleep? And that's been an interest of mine. 

[00:02:56] And then the second part then really is, what are we doing in this space to actually promote sleep? Because our focus a lot of the time in intensive care is all the machines, the interventions, and we think that that's what makes people better, right? Going in hard with these interventions, but actually, most of the time in intensive care for most patients, you've done all those things and you're just waiting.

[00:03:21] So in that waiting time, you've gotta value that time just as much as those really intense periods where you're doing lots of stuff and it's those waiting periods where the healing happens. So the first thing we've gotta do is actually recognise that as important and value that time and think about what we do in that time to make things better for patients.

[00:03:42] It's a whole of system approach is what we need. We've got to value sleep behaviourally as clinicians, we've gotta set up our spaces so that we think about sleep, and then we've gotta intervene in a way that is helpful for our patients to optimise their sleep. 

[00:03:57] And there's many, many different ways you can look to do that.

[00:03:59] David Cummins: So is measuring sleep a standard practice now in ICU? Just like measuring blood levels and measuring heart rate and measuring blood pressure, is that a standard measure of ICU medicine these days? 

[00:04:13] Dr Ed Litton: For most intensive cares, it is not because the level of evidence of how we measure sleep is still not as high as we want, and the link between improving sleep and improving outcomes is hard to establish.

[00:04:28] Even though, we know really if you could have one medicine that you could inject into each of your patients to improve the outcome, it would be sleep because sleep improves your physical performance. It improves your cognition. So delirium is less of a problem. It improves your mood.

[00:04:46] So if we had that as a medicine, that's what we would use, we don't. 

[00:04:50] So it is still really not standard practice, but I think it's starting to become incorporated into clinical guidelines that we should consider sleep. So there's more and more awareness that this is an important thing. 

[00:05:03] Personally, I think part of the reason it's difficult to prioritise sleep is that, as clinicians as well, maybe it's something we don't prioritise in our own lives.

[00:05:10] So it's hard to prioritise it for our patients if we don't value it for ourselves. And so part of the challenge is really promoting its importance holistically as well for ourselves. 

[00:05:22] David Cummins: So if I remember years ago I had roommates, and they would often come home at midnight and have a party and turn on the music, and it completely disrupted my sleep.

[00:05:33] I assume it's very similar for people in an ICU where you've got so many bells and whistles and nurses checking in on you, pretty much 24/7. 

[00:05:42] So how do we find that balance of noise treatment or acoustic treatment? Allowing the patient to sleep, but also allowing their care to continue when they're so sick?

[00:05:53] Dr Ed Litton: Yeah, so that's a good question. 

[00:05:55] The first is that there will be some stages for many patients in intensive care where the priorities are elsewhere but it's not treating every patient the same and not treating the same throughout their journey. 

[00:06:06] Once we're through that initial rocky phase where there's a lot going on, maybe there's a later phase where the priority really is just on their recovery.

[00:06:15] And so the amount of intervention, the amount of checking can diminish in keeping with their improvement. But often that's not what we do. 

[00:06:25] We maintain the same level of vigilance because we think that's the priority, but that compromises recovery. So it's tailoring our individual approach to where the each individual patient is at, and also becoming part of our standard care.

[00:06:42] Things that we don't normally maybe consider being mindful at 2:00 AM when we're still doing a ward round that maybe we don't need to wake up the patient who's been checked three hours before and is completely fine. Just to say that we've completed our checks on their ward round, it's not talking at the bedside and loud voices.

[00:07:01] It's being aware that, this really is a priority, that we're quiet. When all the studies we've done, one of the noisiest components, the noisiest components is clinicians talking at the bed. That's what's waking people up. So it's awful to think that we're contributing to the problem.

[00:07:18] But often we are because we are just not thoughtful in that way. So yes, part of it is our own behavioural approach reducing the noise we make. Part of it is simple things like dialing down the alarms on the existing machines to the lowest level that we think is acceptable that we can hear and is safe, and taking away the machines that we don't need anymore. 

[00:07:39] Often we are sort still intervening at a level we don't need, and then getting people out of intensive care as soon as possible when they're better so that they can go to a more restful environment on the ward. 

[00:07:51] David Cummins: I'm just thinking as well, would this also include light intervention? So when I'm sleeping at home and someone turns on the light, I get disrupted because light is in my eyes even though my eyes are shut.

[00:08:03] Would you even say light would disrupt sleep as well? 

[00:08:06] Dr Ed Litton: Absolutely. The three most important environmental factors are sound, light and temperature. 

[00:08:12] So all three of those, if you think about a good night's sleep for yourself, you need it to be dark, quiet, and cool enough. And all three of those are problematic and intensive cares.

[00:08:21] It's too hot, it's too noisy, and it's too bright. 

[00:08:24] David Cummins: Yeah, and especially during Covid, it was quite overcrowded and a busy environment as well, so there would be a lot more background noise as well when people are being transferred and turned. So as designers, what can we do to try and help improve clinical outcomes?

[00:08:39] I think you pretty much nailed those three items there. So what can we do? The way I see ICU is I remember being as a student, I don't think it's changed that much. It's changed a little bit, but there were still very stale clinical environments because there's so many things happening for the patients.

[00:08:55] So how do we find that balance as designers to try and improve clinical outcomes, noting those three priorities? 

[00:09:01] Dr Ed Litton: Yeah. So good question. 

[00:09:03] And I think it's so important, and it's so critical to think of it at the design stage for two reasons. One is this specific design measures, and two is that if you can build into your design the idea that sleep is really important, you change the behaviour of the staff.

[00:09:21] You signal that this is something that's really important and you help to move the behaviour of the staff towards valuing sleep. And that's equally as important as the specific design measures themselves. So in terms of specific design measures, trying to maintain a diurnal variation so that natural light coming in, in the day so it's bright with natural light in the day, and then it can be made dark at night is really important. 

[00:09:46] The individual control over temperature can be hard to do, but I think is really important so that it does cool down at night and our bodies respond best for sleep when we get that cooling off. But we tend to keep our ICUs the same temperature day and night.

[00:10:01] So again, we are losing that dialogue variation and both of those things are really important when it comes in to reducing something we call delirium, which is like an acute confusional state that is very common in intensive care, which we think lack of sleep exacerbates. 

[00:10:17] So maintaining that diurnal variation for that.

[00:10:19] And then of course there's the size, structure, function of the individual rooms, making sure that we are considering noise, reducing the sound, using materials that are going to absorb sound using the soft materials visually that are going to help soothe things down. Making sure the spaces are big enough so that we have capacity to move patients around so that maybe they can be facing the window.

[00:10:42] And they can see and maintain that connection. All of those things I think are super important. Avoiding the blue lights from screens that also disrupt our vision.

[00:10:52] All of those components together with that focus, I think can really help. 

[00:10:57] David Cummins: So just to clarify, you are suggesting every bed in an ICU should have individual temperature controls, just like a normal room as opposed to a floor based temperature control?

[00:11:09] Dr Ed Litton: Absolutely. Ideally, that is far preferable. Yeah, I mean, we already are vigilant with some patient groups. Classically patients who experience major burns lose their temperature regulation. So there we have much finer individual control, but if you want to maximise the individual patient ability to tailor their focus on sleep, temperature control is a really important part of that.

[00:11:33] David Cummins: Wow. Okay, cool. That's very interesting. So I spoke to a few architects about this topic the other day, and they were even suggesting some form of acoustic treatment on the walls and the floors on the ceiling to try and dampen the sound inside the ICU itself, but actually expel that sound to the nurses station.

[00:11:52] Is that something you have considered and thought about as an actual local acoustic treatment, which can help the nurses, but reduce their noise for the patient? 

[00:12:00] Dr Ed Litton: Yeah, I mean we've been looking at that with architectural colleagues. I think anything we can do to reduce the experience of the noise for the patients, the two components really are reducing the background noise level and reducing the spikes. 

[00:12:14] Both are harmful so anything we can do to dampen them down, and it looks like at least in non- intensive care, if you're understanding the considerations to modifications of the materials, which would still be compliant with infection control standards, but more absorbent for sound aspossible.

[00:12:30] And I think ultimately it probably also requires protection of the patient themselves. We've done some studies looking at earplugs and those are well tolerated by the patients.

[00:12:41] Some patients had concerns that they would be too effective, like feel isolating because suddenly there's no sound and they'll feel sensory deprivation.

[00:12:49] But actually the ones we trialed, we measured and the decreased sound by about 10 decibels, that's a logarithmic scale. So halving it, but not eliminating it. So protecting the patients as well is important. So we want, ideally, the nurses to be able to hear the essential alarms and the doctors and the physios and the rest of the team, but obviously not for the patients.

[00:13:11] So whether that's earplugs themselves, whether that's Bluetooth Systems for the nurses to have, so that it's just an earpiece that they wear so that no one else need hear it for certain alarms that are common. Decreasing the sound levels on the individual alarms themselves, placing monitors away from the patients.

[00:13:29] All of these can help.

[00:13:30] David Cummins: That's fascinating.

[00:13:31] So you are telling me the technology exists for, let's say, a SaO2 machine to warn the nurse in the nurse's station from an earpiece, from an alarm, as opposed to on the screen or anything like that. 

[00:13:45] That technology exists?

[00:13:46] Dr Ed Litton: Yeah. There's no reason why you can't have that setup.

[00:13:48] It obviously it needs the right safeguards and, it would need to be a graded system, but there's no reason why you can't have that set up. I think sometimes we forget the effect on ourselves as clinicians as well. Being in a noisy work environment is bad for the patients because it directly affects them, but it's also bad for them because it fatigues the staff looking after them and you want your staff to be fresh. 

[00:14:11] And working in a noisy environment, we all know, fatigues you, and you can't be at your sharpest. So we want a quiet environment because it's far, far better for our staff to stay fresh 

[00:14:21] and focused in, there's a lot of research now with biophilic treatment where access to nature, natural ventilation, visibility over trees and stuff.. Would fresh air in an ICU be advantageous or way too complicated with infection control protocols? 

[00:14:39] No. We're part of the way there at Fiona Stanley, we have two outside areas within the intensive care unit that are fully plumbed and we can take more stable patients out to. 

[00:14:48] And again, it's something we forget is that this is our workplace, but this is where our patients are spending 24 hours a day and just the loss of the feeling of wind on your skin, fresh air on your body is huge. So that is part of the healing and recovery process and maintaining that connection to the world. 

[00:15:10] Your world isn't just the intensive care unit. There's something to look forward to after you get through this and remembering that and staying connected to that, I think is so important. So that feeling of fresh air we all know is super important and healing and restorative 

[00:15:24] David Cummins: Yeah, as a physio, I remember I was working in rehab and some patients were in there for weeks and months and all they wanted to do was go out and I'd take them for a walk outside and unfortunately for some of them it was the one time a week or the, one time a day.

[00:15:39] Cause they just were enclosed environment. So I'm a big, big believer and fan of natural ventilation and natural light for healing which is why so many new models of care I work in but I just didn't know about it for ICU so that was a good tip.

[00:15:50] What's your thoughts on the new models of care with ICUs now where they very much have single isolated room with a pendant glass fully enclosed?

[00:15:59] Not necessarily isolation bays, but just an actual bay as opposed to t he more older style, which is more curtain-based, more open where you can actually open it up a lot more. 

[00:16:07] I know quite a few hospitals have both, but the newer model seem to be going towards glass enclosures. 

[00:16:13] Dr Ed Litton: I think it's an inevitable consequence of what we've been dealing with from a pandemic point of view, that that is the going to be the way of the future.

[00:16:21] One of the things we have to recognise and must be considered early on is that it completely changes the workforce requirements if you have an open plan intensive care unit where you've got a team-based approach to keeping an eye on the other patients that's Safer with a lower number of staff.

[00:16:41] As soon as you start putting patients in individual cubicles, whether or not you've got glass interconnecting them it makes it much harder for the staff to cross cover and that has major implications to safety. And requires a resourcing response in terms of the workforce that you allocate and how you look after patients.

[00:17:00] I experienced that change moving from one hospital to another one, which was open planter one, if you understand that was then individual cubicles. And I think we underappreciated how much of a change it was in terms of the requirements needed, the additional requirements needed to look after patients.

[00:17:20] When you move to individual cubicles, it's much, much harder to maintain safety without increasing your staffing when in that single cubicle approach much. 

[00:17:30] David Cummins: Yeah, I was working in ICU in a redevelopment for a hospital and during Covid it was very much the curtains were up cause there were so many people who had Covid and so little staff, and that's the only way they could have done it.

[00:17:42] I imagine in a place where it was very much isolation bays or individual rooms, that would've been way more difficult, especially with how much pressure there were on the nursing staff and doctor staff.

[00:17:52] But I'm just thinking automatically, how do you do that mechanically to have single bays, how do you get around that?

[00:17:58] So there's always so many layers of complication when it comes to such a complicated area. 

[00:18:03] So what would you like to see happen to ICUs rolled out around Australia, if not the world, from your research? 

[00:18:09] Dr Ed Litton: We've touched on it, but I'd like every patient to have the opportunity for individualised environmental considerations. So the space that each patient is going to be cared for in should have capacity to absolutely optimise their sleep through considerations on noise. Temperature and lighting and built in a way that allows the staff to facilitate those things.

[00:18:36] So the cubicles need to be able to differentiate temperature, they should have natural light, they should have fresh air. 

[00:18:45] They should be big enough to be able to orientate the patients how they want and also big enough so that the alarm systems, whether it's the monitoring themselves, the infusion pumps can be positioned in a way that the sound isn't beamed in towards the patient, but out away from the patient at the very least.

[00:19:00] And of course, the considerations around how cross covering of patients occurs in a way that is best integrated with staffing pressures. 

[00:19:08] If that can be done so that each patient you know, at different stages of their journey can have this tailored approach to maximising their sleep, I think that would be a really big step forward.

[00:19:19] David Cummins: Yeah. That's very impressive. It sounds like a few big challenges for a few architects out there to try and hit all that criteria.

[00:19:25] I've found that very, very fascinating. I think it's people like you, doing your research and understanding the importance of sleep, that's really what's going to help improve patient care, especially in the ICU setting.

[00:19:34] So thank you so much for your work and continued research into this field. 

[00:19:38] Dr Ed Litton: Thanks, David. 

[00:19:40] David Cummins: Thank you for your time, Dr Ed. 

[00:19:41] You have been listening to the Australian Health Design Council podcast series, Health Design on the Go. 

[00:19:46] If you'd like to learn more about the AHDC, please connect with us on our website or LinkedIn.

[00:19:51] Thank you for listening.