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24-Hour intensive care: An observational study of an environment and events
Intensive and Critical Care Nursing (2010) 26, 246—253
available at www.sciencedirect.com
journal homepage: www.elsevier.com/iccn
ORIGINAL ARTICLE
24-Hour intensive care: An observational study of an environment and events Merja Meriläinen a,∗, Helvi Kyngäs b, Tero Ala-Kokko c a
ODL Health Ltd, PL 365, 90101 Oulu, Finland Department of Nursing and Health Administration, University of Oulu, PL 5000, 90014, Finland c Division of Intensive Care Medicine, Department of Anaesthesiology, Oulu University Hospital, PL 21, 90029, Finland b
Accepted 23 June 2010
KEYWORDS ICU; Environment; Critical care nursing; Nursing environment
Summary Background: In intensive care, patients are exposed to a strange and sometimes hostile environment, which can lead to post-traumatic psychological problems. The aim of this study was to describe an intensive care environment from a patient point of view and the events and social contacts during a patient’s day. Methods: The study had an observational qualitative design. The data were generated by recording on DVD four adult intensive care patients in an intensive care unit over one day (n = 96 hours). The DVD recording of two patients also included daylight (lx) and decibel (db) measurement. The material was analysed by inductive and deductive content analysis. Results: An intensive care patient environment is made up of physical, social and symbolic environments. The hospital, ward and patient room constitute an environment that is indirectly connected to the patient. The patient bed and all that is included in it are directly connected to the ICU patient’s physical environment. The social environment includes the people who are near the patient and in direct or indirect contact with them. ICU norms, regulations, values, expectations and knowledge make up the symbolic environment. Taken together, these factors constitute an intensive care unit’s way of action. The symbolic environment is connected to the social environment through people and the way of action. Conclusion: The patient is connected to the ICUs environment, but is usually not able to influence it. It is important to eliminate things that prevent recovery and to promote feeling safe. Besides the physical environment, things that prevent recovery and increase a feeling of being safe can be found in both the social and the symbolic environment. We also need to learn more about ICU patients’ subjective experiences in order to be able to describe the psychological environment. © 2010 Elsevier Ltd. All rights reserved.
∗
Corresponding author. Tel.: +358 013453480. E-mail addresses: merja.merilainen@odl.fi (M. Meriläinen), helvi.kyngas@oulu.fi (H. Kyngäs), tero.ala-kokko@ppshp.fi (T. Ala-Kokko). 0964-3397/$ — see front matter © 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.iccn.2010.06.003
24-Hour intensive care
Introduction During the intensive care unit period the patient is restricted to the bed, equipment and ward environment 24 hours a day. ICU care focuses on combating the life-threatening situation with drugs, monitoring and equipment supporting organ functions using the best available knowledge and evidence-based medicine. In an intensive care unit environment, efficacy and functionality is ensured with planning — vital functions must be easy to control and maintain. The rapid progress seen in technology and critical care medicine pose their own demands on the environment. Studies have shown that the intensive care unit environment can seem strange and hostile to patients, and it may even lead to posttraumatic psychological problems (Almerud et al., 2007; Dyson, 1999; Hweidi, 2007; Jones et al., 1994; Novaes et al., 1999; So and Chan, 2004). The problem of technology in health care lies in the choices made about what is humane and dignified care (Almerud et al., 2008). During the ICU period the patient is exposed to noise, lack of sleep and privacy, problems with communication and feelings of helplessness and frustration resulting from loss of control (Hupcey, 2000; Hweidi, 2007; McCuire et al., 2000; Russell, 1999). Some of the difficulties are found to be a consequence of medical treatment during ICU care. Previous studies have shown that survivors of critical care report physical and psychological disability after their ICU experience (Griffiths and Jones, 1999; Jones et al., 2000; Russell, 1999; Scragg et al., 2001; Strahan et al., 2003). There have not been any studies about the ICU environment from the patient’s perspective and from the viewpoint of what can we do during the ICU treatment to make the environment more comprehensible to the patient. It is important to identify the things that are not important in terms of ICU patient care and that contribute to patients’ problems.
The environment The term environment usually means the physical, social or symbolic environment (Kim, 2000). It can also be used to refer to the environment as a psychological environment (Gordon, 1998; Roper et al., 1990). The physical environment includes people’s general surroundings, the concrete environment in which they live as well as their immediate surroundings, such as home or hospital sickroom. The physical environment can be seen as a resource that makes people’s actions possible, but it can also be seen as a source of stress. Social environment refers to other people, attitudes, norms and institutions. It includes social networks, the challenges they pose and the support and control for people’s lives and activities. People are in interaction with their environment (Lauri and Elomaa, 1999). Social environment takes place in physical space and it causes us to be in interaction with the material environment (Horelli, 1983). According to Kim (2000), the symbolic environment can be divided into ideal, normative and institutional elements, all of which have their own history. The ideological aspects of the symbolic environment consist of values, ideas, beliefs and knowledge. The normative element includes written or unwritten rules, laws, expectations and sanc-
247 tions. The basis of the symbolic environment is made up by the social norms of culture, language, religion and community. It is also influenced by upbringing and education, the norms of behaviour set to individuals, role expectations as well as the ideas concerning health and sickness and taking care of patients that prevail in the community (Kim, 2000). The psychological environment is a private emotional environment that protects people from damage. It includes the feelings, experiences and thoughts that are closely connected to the individual’s own identity (Sarvimäki and Stenbock-Hult, 1996). Intelligence, personality, temper, self-confidence and stress level are things that interact with the safety of the psychological environment (Roper et al., 1990). The psychological environment could not be analysed in this research material.
Critical care unit as a nursing environment The equipment and devices intended for the care of critically ill patients make the intensive care unit the most technologically sophisticated environment in any hospital (Almerud et al., 2007). Being connected to various devices, exposure to noise, lighting, a room that is too hot or cold, various smells and being able to see other patients as care objects can cause both physical and mental stress to patients (Almerud et al., 2007; Jones et al., 1994; Novaes et al., 1999; So and Chan, 2004). It has been found that short-term exposure to noise can cause reactions such as vasoconstriction, changes in heart rate, elevated blood pressure, increased breath rate, increased adrenaline secretion and changes in sleep quality (Hweidi, 2007; Mussalo-Rauhamaa et al., 2007). Patients adapt to their environment. They trust in the skills of the staff and accept the ward environment and events taking place there as routines. Control over one’s own body and opportunity to impact one’s own situation disappears in daily routines (Almerud et al., 2007). Things that promote stress related to social situations include changing staff, communication difficulties, disorientation as to time, place and what has happened, and being away from loved ones (Almerud et al., 2007; Dyson, 1999; Hweidi, 2007; Wilkin and Slevin, 2004). Although patients are closely monitored they feel that they are invisible to the staff. Careful observation and monitoring are very important from a medical perspective, but they do not promote patients’ feeling of being safe (Almerud et al., 2007, 2008; Wilkin and Slevin, 2004). Dyson (1999) sees a direct relationship between sickness and environment: as sickness increases, the environment becomes more hostile and alien. The aim of this study was to describe an intensive care environment during treatment from a patient point of view and the events and social contacts taking place during the patient’s day.
Methods Study design and setting This study was an observational study with a qualitative design using digital versatile disc (DVD) recording.
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An observational study can be either participative or nonparticipative. It can take a place in real time or be carried out afterwards with the help of DVD recordings, for example. If the research material is gathered over a longer time period, it must be collected using non-participative observation (Polit and Beck, 2004). DVD recording was chosen because the researcher wanted to obtain a comprehensive picture of patients’ day in intensive care. The recording makes it possible to go back to events, making the study more reliable. This study was designed to be descriptive and observational. The data collection (hours of recording) was planned to continue until saturation. Saturation was considered to be attained when no new information related to the research questions came out. The total number of participants was four (one woman and three men). The study data were collected between 31 March and 21 June 2006 by recording four patients onto DVD for 24 hours.
(MODS). The participants represent a typical ICU patient case-mix in our adult general ICU. The aim of this study was to describe an intensive care environment from the patient perspective and the events and social contacts during a patient’s day in a single university level ICU. This may limit the generalisation of the results to other types of units and nursing culture. This study, however, describes a large and detailed sample of events in everyday nursing practice and gives valuable information for planning nursing from the patients point of view. There was a screen test before the material was collected. The researcher checked the test material and planned the study setting. The hospital’s televisual (TV) studio engineer placed the DVD camera in a patient room so that the camera was aimed at the patient and their environment. No other patients were seen in the recording. Each DVD had a six-hour capacity and the discs were changed by the patient’s own nurse.
Ethical approval
Analysis
The study was approved by the hospital ethics committee and carried out according to the guidelines of the Declaration of Helsinki of the World Medical Association (2000). After the university hospital’s ethics committee had approved the study protocol, the researcher informed the ICU personnel and asked for verbal consent. No personnel from the ICU refused to participate in the study. The researcher approached the patients’ relatives for written informed consent. Two relatives out of six refused to give consent. On the patients’ visit to the ICU follow-up clinic three months after their ICU stay the researcher told them about the study and informed them of voluntary participation, confidentiality, anonymity and privacy and asked them for a written consent. All of the four patients gave their consent. The researcher also offered them an opportunity to view the DVDs together with the researcher. One patient wished to see her DVD in part. None of the patients denied the use of the research material. The researcher is keeping the DVD material as required by Oulu University ethics committee and will destroy the material once the study is concluded.
In the first phase the data were analysed using an inductive approach, searching the DVDs for things that are included in the care of intensive patients. In accordance with Elo and Kyngäs (2008), the analysis advanced to inductive content analysis. This process includes open coding, creating categories and abstraction. The process consists of creating categories and abstraction of the upper categories action, doer, duration and patient reaction. The categorisation matrix was developed with these categories. Analysis continued as deductive content analysis and the data were coded according to the categories. In addition, furniture, equipment and nursing devices were analysed. The noise level was measured by the bed of two patients with a decibel meter and lighting with a lux meter. The data analysis was started after the collection of data from the first patient, and continued until saturation. Saturation was considered to be attained when no new information related to the research question came out. Total recording time of 96 hours with four patients was judged to be adequate to saturate the information needed (Table 1).
Results Generation of data and participants Physical environment Data were generated by DVD recording in a 12-bed mixedtype adult intensive care unit in a tertiary level university hospital. Convenience sampling was used to collect the sample, and participants were recruited with the assistance of ICU nurses. When everything was ready for data collection consecutive patients fulfilling the inclusion criterion were selected. Inclusion criteria for the patients were: 18—65 years old and mechanically ventilated; being sedated, had spent at least two days in intensive care before inclusion and were independent prior to their intensive care admission. Recruitment was stopped when saturation of data was achieved after four patients. The participants were aged 20—45 years and the mean length of stay in the ICU was 13.5 days. The ICU diagnoses were sepsis, pneumonia, cerebral haemorrhage and multiple organ dysfunction syndrome
The patients were treated in a 12-bed intensive care unit at a university hospital and they came from a 350 km radius. Two patients were in a double patient room and two were in a room with seven patient beds. The size of the bedspace was approximately 15 m2 in the double room and approximately 12.9 m2 in the room for seven patients. The bedspaces were separated from each other with curtains. The floor material was plastic, the walls were partially tiled and the ceiling was covered with gypsum board. The physical environment of intensive care patients can be divided into direct and non-direct environment. The direct physical environment of the patient included all the equipment and nursing instruments that were connected to the patient, such as patient monitors with wires, respirator, intravenous cannulas and infusion devices and the bed. In
24-Hour intensive care
249
Table 1
Analysis.
Table 2
Noise level and lighting. Mean db 7:00—22:00
Patient 159 Patient 257
Mean db 22:00—7:00
Lowest db
Highest db
Mean lx 7:00—22:00
Mean lx 22:00—7:00
Lowest lx
Highest lx
51 54
48 53
81 76
295 342
162 128
120 134
523 770
the patient were physical examinations of the patient, nursing, support, advice, encouragement and rehabilitation. The functions involving non-contact with the patient were conversations in the patient room and on the telephone, service operations related to supplies and the environment, patient observation, actions before and after nursing and functions in data transmission. The functions involving varied contacts with patients included service operations related to supplies and the environment, patient examination, observation, nursing and transmission. In these situations, making contact varied according to the situation and the people involved (Table 3).
addition, the direct patient physical environment included lighting, noise and temperature in the room. Light intensity was between 120 and 770 lx and noise volume between 48.0 and 81.0 db measured by the bed of two patients (Table 2). The indirect physical environment included the hospital, patient place and room where the patient was during the study.
Social environment The social environment of intensive care patients consists of intensive care unit personnel, supporting staff, other patients in the intensive care unit and relatives. Over 24 hours, the patients’ contacts with other people varied from 41 to 165 direct contacts. The duration of contacts varied from quick ones lasting only a few seconds to longer continuous contacts lasting several minutes. The longer contacts usually included interruptions, for example, during washing. During the interruptions the patients closed their eyes or followed what happened in their environment. Patients’ social environment includes functions that take place in contact or non-contact with the patient or functions with varied contacts. The functions involving contact with
Table 3
Symbolic environment In intensive care, actions were repeated in nursing that constituted the patient’s symbolic environment. These functions were routines based on norms, regulations and knowledge. Routine functions included staff working hours, physical examinations, taking blood samples and X-rays, washing the patients in the morning and in the evening. These functions were discontinued if there were changes in the patient’s state, if the patient needed drug administration or if the nurse had to wait for assisting staff. The
Patients’ contacts with nursing environment in one day.
Contacts
Patient 1
Patient 2
Patient 3
Patient 4
Direct contact with communication Direct contact, no communication Non-direct contact, patient reaction with movement 24-hour contacts in total
43 45 31 129
53 55 57 165
15 18 8 41
61 47 28 138
250 patient’s nurses took care of the planned treatment and transferred data to other professionals, the patient and the relatives. Nurses also took care of nursing devices and the orderliness of the patient place. Physicians checked measurements, planned treatment, performed procedures and transferred information to other professionals, the patient and the relatives. The patient’s relatives followed advice, received information from the staff, asked questions and were in contact with the patient. Other professionals performed occasional tasks, such as taking X-rays and blood samples or providing physiotherapy.
Discussion The physical environment The patients treated in intensive care had one severe vital organ function disorder or several organ failures. A physician specialising in intensive care is available 24 hours a day, seven days a week, and the intensive care nurse-to-patient ratio is set at 1:1. Patients’ care is based on multiprofessional teamwork to make sure that functions that are vital in the unit and from a patient perspective are taken into consideration (Fontaine et al., 2001). Structural planning in an intensive care unit should be expanded to involve a multiprofessional team to ensure that functions that are vital in the unit and from a patient perspective are taken into consideration (Fontaine et al., 2001). In this study, bedspaces were 12.9—15 m2 in size. An optimally functional patient place in intensive care should measure 22.83 m2 (Hignett and Lu, 2007). A physical turf is a space where people need to feel safe. Personal turf can be defined as a space that protects a person from insult. In physical turf, intimate distance is 0—45 cm (Klemi, 1988). During the patient’s day in intensive care there were many nursing functions that violated the patient’s intimate space. Trespassing into a person’s intimate space can cause stress, anxiety, fear and anger (Horelli, 1983). On the other hand, the feeling of being under close observation can increase patients’ feeling of safety (Hupcey, 2000). In this study, patients’ physical intimate space was violated on average 43 times per day. Patients’ capability to observe speech and situations poses a challenge in an intensive care unit (Wåhlin et al., 2006). Patients reacted on average 35 times per day to noises in the physical environment by opening their eyes, fidgeting in bed, moving their arms and legs, turning their head towards the noise, lifting their head, grimacing and cringing. The noise in intensive care unit has been estimated to be one of the most important reasons for delirium and poor quality of sleep during treatment in ICU and for slower pace of recovery (Fontaine et al., 2001; McCuire et al., 2000; Pun and Ely, 2007; Topf et al., 1996). During this study, the noise level varied between 48 and 81 db. According to the recommendation of the Finnish Ministry of Social Affairs and Health, the noise level in a patient room should be 35 db during the day (7:00 am—10:00 pm) and 30 db during the night (10:00 pm—7:00 am). In the United States, the Ministry of Environmental Protection (EPA) recommends that the noise level should be 45 db during the day and 35 db during the night (Khan et al., 1998; MSAH, 2003). Patients reacted to changes in noise level by opening their eyes and turning their
M. Meriläinen et al. head toward the noise. Even small changes, such as monitor reminder alarm, increased the noise level from 56 to 65 db. When the noise level rises 3 db, the noise effect increases twice as much (Antti-Poika and Vaheri, 1993). In this study, lighting intensity was measured during a season when there is a lot of natural light during the day and night in Finland (the measurements were performed between 15 May and 10 June). Lighting intensity in the unit varied from 120 to 770 lx. The patients reacted to variation in lighting by cringing, by opening their eyes and by turning their head towards the light. Together with noise, the bright lighting and the lack of day—night rhythm in intensive care units are significant reasons for delirium and poor quality of sleep among ICU patients. The intensity of lighting can be increased by extra light sources in the case of emergencies and during procedures (Fontaine et al., 2001; Hewitt, 2002; McCuire et al., 2000). Patients in critical condition have described the technical environment as being strange, hard to understand and frightening. Very few people have been treated in intensive care unit or even visited one. The environment is unfamiliar and difficult to understand, even more so for a patient in a critical condition. Patients may be unable to understand their surroundings, the treatment and the meanings of the events. In this study, one of the patients had been in the intensive care unit before. It is essential for patients to feel safe and comfortable in the nursing environment (Gordon, 1998; Sarvimäki and Stenbock-Hult, 1996). Patients may take the technology for granted, but at the same time they may feel guilty, for example, if they trigger a monitor alarm (Almerud et al., 2007). Factors contributing to a feeling of safety among patients are knowledge, maintenance of control, hope and trust. The staff can influence these factors in a positive or negative manner (Hupcey, 2000; Wåhlin et al., 2006).
The social environment According to Granberg et al. (1998), patients’ fear and stress is increased by poor interaction between patient and nursing staff, being subjected to observation by another patient and seeing other patients being treated, technical equipment as well as unfamiliar and terrifying experiences. In this study, the patients did not see other patients being cared for, but they did have a chance to hear voices and sounds from other patient places. During this study patients were intubated and lightly sedated, so they were not able to communicate with words, but they did react to their social environment by cringes, face movements, turning their head towards the noise, lifting their head or by moving their arms and legs. The patients did not always have time to react to the information given to them, and sometimes they did not get any information at all. Lack of information was seen in situations where the staff was telling the patient what they were about to do while actually doing it. In some situations nursing actions were interrupted and the patient fell asleep; when action was resumed, the staff did not give any information to patient, so the patient woke up in the middle of the procedure. It has been found that patients who are in ICU suffer from being isolated from their nearest and dearest. The
24-Hour intensive care feeling of being isolated may be due to different reasons, such as being physically isolated to avoid infections, being isolated from your loved ones and daily routines, limited capability to communicate or chemical isolation with drugs (Dyson, 1999). Patients’ experiences of weakness, lack of information and defence, being vulnerable and anxious can lead to disorientation or even delirium. A safe environment consists of people known to the patients, i.e. nurses or relatives who recognise the patients’ needs, hold their hands and show through their actions that they are taking care of the patients’ business (Hupcey, 2000; Wåhlin et al., 2006). During the DVD recording each patient had their own nurse in the day and evening shift, while in the night shift there was one nurse per two patients. Two patients had relatives visit them during the recording.
Symbolic environment The symbolic environment of intensive care unit patients consists of norms, rules, values and routines in the ICU. The norms, rules and routines are official guidelines and regulations that govern the work of professionals. In this study, these included professionals’ working hours, examinations performed by physicians, routine blood samples and X-rays and washing the patient in the morning and in the evening. Repeated tasks were carried out from a professional point of view. This was seen in several situations, e.g. when the patient finally fell asleep after a difficult night and was woken by the physician to ask how the night had gone, or when a nurse started to brush the patient’s teeth after the patient had been given pain medication and had fallen asleep. Operational environment values are based on official guidelines and ways of doing things that have been jointly accepted. The values are embedded in each person’s thoughts of what is the right and good way to treat a patient. Knowledge, maintaining control, hope and trust are factors that increase feeling of safety among patients (Hupcey, 2000). Obstacles to good treatment may include shortage of personnel or equipment, or personnel that is technologyorientated (Wilkin and Slevin, 2004). Unpleasant patient experiences can lead to lack of privacy and disrespectful behaviour and contribute to feelings of fear (Hupcey, 2000; Russell, 1999). Intensive care is orientated to treat patients round the clock during the critical phase of illness with specialist treatment and ICU equipment (Almerud et al., 2007; Orko, 1995). In definitions of ICU, the emphasis is on effectiveness, technology and intensiveness. These definitions describe a common way of operation in ICU. The treatment of ICU patients may require rapid actions and technical equipment; professionals can impact the actions with their own attitudes and comprehensive evaluation carried out every day in the ICU.
Reliability The qualitative method was selected because this phenomenon had not been studied earlier from this perspective (Burns and Grove, 2005; Polit and Beck, 2004). Reliability of quantitative research can be evaluated by the criteria of credibility, transferability, consistency and validity of results
251 (Lincoln and Cuba, 1985). These criteria refer to the reality of the research theme. The intensive care environment was familiar to the researcher, but in order to study this phenomenon from the patient’s point of view, round the clock, observation was required. Transferability of the criterion of reliability is related to how research can be applied into other contexts (Lincoln and Cuba, 1985). In qualitative research, results are linked to specific contexts and cannot be transferred to another research situation, as is the case in the present study. To enable evaluation of the results, the researcher has described the participants, collection of material and analysis in detail. In qualitative research the consistency of the criterion of reliability is connected to how the results are presented — is the reader able to follow the reasoning from material to conclusions? The reader can evaluate the consistency of the research process, the clarity of research questions and correlations between methodology and sampling. Confirmation of results refers to how results can be re-researched, to data collection and analysis, and whether the conclusions are derived from the data. In addition, the impact of the researcher on the research process can be explored (Lincoln and Cuba, 1985). One of the advantages of filming is the possibility to capture situations that could be missed on location. Observational findings can be re-examined from DVD recordings. The technical implementation was taken care of by the TV studio master at the hospital. The researcher chose the shooting angle together with the TV studio master, making sure that the shooting area was sufficiently wide. The personnel working in the ICU were informed about the research and the researcher gave instructions on shooting procedures. Based on a screen test, the researcher made decisions of data manageability in the analysis process, viewing angle and the use of DVD recorder. The research focus was captured closely, and when the analysis proceeded events could be rechecked. DVD recording can cause a change in staff behaviour, but earlier findings show (Halimaa, 2001) that research subjects adapt to the filming over time. Staff behaviour was not analysed in this study. Problems in recording may occur due to technical problems, which may be caused, for example, by poor lighting. If the subject being filmed remains still, shooting angles can cause a loop-perspective from situation or atmosphere (Latvala et al., 2000; Polit and Beck, 2004). The intensity of noise and lighting was measured close to the patients (1 m). The measurement point should not be less than one metre from room surfaces unless the measurement is carried out in a patient room (MSAH, 2003).
Conclusions Patients in an intensive care unit are in an environment which they cannot influence themselves, but which affects them in a comprehensive manner. There are features in an ICU patient’s environment that may be harmful to recovery. This study supports earlier research on intensive care unit noise, lack of day and night rhythm and emphasis on technology. The noise, lighting and equipment in the physical
252 environment can cause extra stress and difficulties for the patient. Noise can easily be reduced by avoiding unnecessary talking near the patient, by closing the door if possible, by avoiding unnecessary handling of wrappings and equipment near the patient and by turning down the sounds of monitors if possible. The noise level should be measured regularly by the bed. Problems caused by bright lighting can be reduced by following a day rhythm that is as normal as possible — by planning in advance which actions are necessary at night and which can wait until the morning or daytime, or whether they can be performed using an adjustable spotlight. It may be impossible to reduce the role of technology in an intensive care unit, but the patient must be seen behind all the equipment. The patients need to feel that they come first, not technical equipment. The intensive care unit patient’s social environment includes a lot of rapidly changing contacts with many different people, not all of whom are in direct contact with the patient. The patients do not have a chance to influence communication in their own space. They need time to adjust to the situation, time and place. The staff must be aware of which contacts are necessary and which can be reduced. The symbolic environment is associated with the social environment. The impact of the symbolic environment is seen in the way the staff members act in different nursing situations. Their thoughts of what is a good and correct way of treating patients is evident in routines. ICU personnel can easily influence the ICU patient’s environment. This can be done by taking into consideration the patient’s point of view: is the way we do things wellgrounded? In addition, structural matters that reduce noise and unnecessary movement in patient rooms and promote a day rhythm that is as normal as possible must be taken into consideration in ICU planning.
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ORIGINAL ARTICLE
24-Hour intensive care: An observational study of an environment and events Merja Meriläinen a,∗, Helvi Kyngäs b, Tero Ala-Kokko c a
ODL Health Ltd, PL 365, 90101 Oulu, Finland Department of Nursing and Health Administration, University of Oulu, PL 5000, 90014, Finland c Division of Intensive Care Medicine, Department of Anaesthesiology, Oulu University Hospital, PL 21, 90029, Finland b
Accepted 23 June 2010
KEYWORDS ICU; Environment; Critical care nursing; Nursing environment
Summary Background: In intensive care, patients are exposed to a strange and sometimes hostile environment, which can lead to post-traumatic psychological problems. The aim of this study was to describe an intensive care environment from a patient point of view and the events and social contacts during a patient’s day. Methods: The study had an observational qualitative design. The data were generated by recording on DVD four adult intensive care patients in an intensive care unit over one day (n = 96 hours). The DVD recording of two patients also included daylight (lx) and decibel (db) measurement. The material was analysed by inductive and deductive content analysis. Results: An intensive care patient environment is made up of physical, social and symbolic environments. The hospital, ward and patient room constitute an environment that is indirectly connected to the patient. The patient bed and all that is included in it are directly connected to the ICU patient’s physical environment. The social environment includes the people who are near the patient and in direct or indirect contact with them. ICU norms, regulations, values, expectations and knowledge make up the symbolic environment. Taken together, these factors constitute an intensive care unit’s way of action. The symbolic environment is connected to the social environment through people and the way of action. Conclusion: The patient is connected to the ICUs environment, but is usually not able to influence it. It is important to eliminate things that prevent recovery and to promote feeling safe. Besides the physical environment, things that prevent recovery and increase a feeling of being safe can be found in both the social and the symbolic environment. We also need to learn more about ICU patients’ subjective experiences in order to be able to describe the psychological environment. © 2010 Elsevier Ltd. All rights reserved.
∗
Corresponding author. Tel.: +358 013453480. E-mail addresses: merja.merilainen@odl.fi (M. Meriläinen), helvi.kyngas@oulu.fi (H. Kyngäs), tero.ala-kokko@ppshp.fi (T. Ala-Kokko). 0964-3397/$ — see front matter © 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.iccn.2010.06.003
24-Hour intensive care
Introduction During the intensive care unit period the patient is restricted to the bed, equipment and ward environment 24 hours a day. ICU care focuses on combating the life-threatening situation with drugs, monitoring and equipment supporting organ functions using the best available knowledge and evidence-based medicine. In an intensive care unit environment, efficacy and functionality is ensured with planning — vital functions must be easy to control and maintain. The rapid progress seen in technology and critical care medicine pose their own demands on the environment. Studies have shown that the intensive care unit environment can seem strange and hostile to patients, and it may even lead to posttraumatic psychological problems (Almerud et al., 2007; Dyson, 1999; Hweidi, 2007; Jones et al., 1994; Novaes et al., 1999; So and Chan, 2004). The problem of technology in health care lies in the choices made about what is humane and dignified care (Almerud et al., 2008). During the ICU period the patient is exposed to noise, lack of sleep and privacy, problems with communication and feelings of helplessness and frustration resulting from loss of control (Hupcey, 2000; Hweidi, 2007; McCuire et al., 2000; Russell, 1999). Some of the difficulties are found to be a consequence of medical treatment during ICU care. Previous studies have shown that survivors of critical care report physical and psychological disability after their ICU experience (Griffiths and Jones, 1999; Jones et al., 2000; Russell, 1999; Scragg et al., 2001; Strahan et al., 2003). There have not been any studies about the ICU environment from the patient’s perspective and from the viewpoint of what can we do during the ICU treatment to make the environment more comprehensible to the patient. It is important to identify the things that are not important in terms of ICU patient care and that contribute to patients’ problems.
The environment The term environment usually means the physical, social or symbolic environment (Kim, 2000). It can also be used to refer to the environment as a psychological environment (Gordon, 1998; Roper et al., 1990). The physical environment includes people’s general surroundings, the concrete environment in which they live as well as their immediate surroundings, such as home or hospital sickroom. The physical environment can be seen as a resource that makes people’s actions possible, but it can also be seen as a source of stress. Social environment refers to other people, attitudes, norms and institutions. It includes social networks, the challenges they pose and the support and control for people’s lives and activities. People are in interaction with their environment (Lauri and Elomaa, 1999). Social environment takes place in physical space and it causes us to be in interaction with the material environment (Horelli, 1983). According to Kim (2000), the symbolic environment can be divided into ideal, normative and institutional elements, all of which have their own history. The ideological aspects of the symbolic environment consist of values, ideas, beliefs and knowledge. The normative element includes written or unwritten rules, laws, expectations and sanc-
247 tions. The basis of the symbolic environment is made up by the social norms of culture, language, religion and community. It is also influenced by upbringing and education, the norms of behaviour set to individuals, role expectations as well as the ideas concerning health and sickness and taking care of patients that prevail in the community (Kim, 2000). The psychological environment is a private emotional environment that protects people from damage. It includes the feelings, experiences and thoughts that are closely connected to the individual’s own identity (Sarvimäki and Stenbock-Hult, 1996). Intelligence, personality, temper, self-confidence and stress level are things that interact with the safety of the psychological environment (Roper et al., 1990). The psychological environment could not be analysed in this research material.
Critical care unit as a nursing environment The equipment and devices intended for the care of critically ill patients make the intensive care unit the most technologically sophisticated environment in any hospital (Almerud et al., 2007). Being connected to various devices, exposure to noise, lighting, a room that is too hot or cold, various smells and being able to see other patients as care objects can cause both physical and mental stress to patients (Almerud et al., 2007; Jones et al., 1994; Novaes et al., 1999; So and Chan, 2004). It has been found that short-term exposure to noise can cause reactions such as vasoconstriction, changes in heart rate, elevated blood pressure, increased breath rate, increased adrenaline secretion and changes in sleep quality (Hweidi, 2007; Mussalo-Rauhamaa et al., 2007). Patients adapt to their environment. They trust in the skills of the staff and accept the ward environment and events taking place there as routines. Control over one’s own body and opportunity to impact one’s own situation disappears in daily routines (Almerud et al., 2007). Things that promote stress related to social situations include changing staff, communication difficulties, disorientation as to time, place and what has happened, and being away from loved ones (Almerud et al., 2007; Dyson, 1999; Hweidi, 2007; Wilkin and Slevin, 2004). Although patients are closely monitored they feel that they are invisible to the staff. Careful observation and monitoring are very important from a medical perspective, but they do not promote patients’ feeling of being safe (Almerud et al., 2007, 2008; Wilkin and Slevin, 2004). Dyson (1999) sees a direct relationship between sickness and environment: as sickness increases, the environment becomes more hostile and alien. The aim of this study was to describe an intensive care environment during treatment from a patient point of view and the events and social contacts taking place during the patient’s day.
Methods Study design and setting This study was an observational study with a qualitative design using digital versatile disc (DVD) recording.
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M. Meriläinen et al.
An observational study can be either participative or nonparticipative. It can take a place in real time or be carried out afterwards with the help of DVD recordings, for example. If the research material is gathered over a longer time period, it must be collected using non-participative observation (Polit and Beck, 2004). DVD recording was chosen because the researcher wanted to obtain a comprehensive picture of patients’ day in intensive care. The recording makes it possible to go back to events, making the study more reliable. This study was designed to be descriptive and observational. The data collection (hours of recording) was planned to continue until saturation. Saturation was considered to be attained when no new information related to the research questions came out. The total number of participants was four (one woman and three men). The study data were collected between 31 March and 21 June 2006 by recording four patients onto DVD for 24 hours.
(MODS). The participants represent a typical ICU patient case-mix in our adult general ICU. The aim of this study was to describe an intensive care environment from the patient perspective and the events and social contacts during a patient’s day in a single university level ICU. This may limit the generalisation of the results to other types of units and nursing culture. This study, however, describes a large and detailed sample of events in everyday nursing practice and gives valuable information for planning nursing from the patients point of view. There was a screen test before the material was collected. The researcher checked the test material and planned the study setting. The hospital’s televisual (TV) studio engineer placed the DVD camera in a patient room so that the camera was aimed at the patient and their environment. No other patients were seen in the recording. Each DVD had a six-hour capacity and the discs were changed by the patient’s own nurse.
Ethical approval
Analysis
The study was approved by the hospital ethics committee and carried out according to the guidelines of the Declaration of Helsinki of the World Medical Association (2000). After the university hospital’s ethics committee had approved the study protocol, the researcher informed the ICU personnel and asked for verbal consent. No personnel from the ICU refused to participate in the study. The researcher approached the patients’ relatives for written informed consent. Two relatives out of six refused to give consent. On the patients’ visit to the ICU follow-up clinic three months after their ICU stay the researcher told them about the study and informed them of voluntary participation, confidentiality, anonymity and privacy and asked them for a written consent. All of the four patients gave their consent. The researcher also offered them an opportunity to view the DVDs together with the researcher. One patient wished to see her DVD in part. None of the patients denied the use of the research material. The researcher is keeping the DVD material as required by Oulu University ethics committee and will destroy the material once the study is concluded.
In the first phase the data were analysed using an inductive approach, searching the DVDs for things that are included in the care of intensive patients. In accordance with Elo and Kyngäs (2008), the analysis advanced to inductive content analysis. This process includes open coding, creating categories and abstraction. The process consists of creating categories and abstraction of the upper categories action, doer, duration and patient reaction. The categorisation matrix was developed with these categories. Analysis continued as deductive content analysis and the data were coded according to the categories. In addition, furniture, equipment and nursing devices were analysed. The noise level was measured by the bed of two patients with a decibel meter and lighting with a lux meter. The data analysis was started after the collection of data from the first patient, and continued until saturation. Saturation was considered to be attained when no new information related to the research question came out. Total recording time of 96 hours with four patients was judged to be adequate to saturate the information needed (Table 1).
Results Generation of data and participants Physical environment Data were generated by DVD recording in a 12-bed mixedtype adult intensive care unit in a tertiary level university hospital. Convenience sampling was used to collect the sample, and participants were recruited with the assistance of ICU nurses. When everything was ready for data collection consecutive patients fulfilling the inclusion criterion were selected. Inclusion criteria for the patients were: 18—65 years old and mechanically ventilated; being sedated, had spent at least two days in intensive care before inclusion and were independent prior to their intensive care admission. Recruitment was stopped when saturation of data was achieved after four patients. The participants were aged 20—45 years and the mean length of stay in the ICU was 13.5 days. The ICU diagnoses were sepsis, pneumonia, cerebral haemorrhage and multiple organ dysfunction syndrome
The patients were treated in a 12-bed intensive care unit at a university hospital and they came from a 350 km radius. Two patients were in a double patient room and two were in a room with seven patient beds. The size of the bedspace was approximately 15 m2 in the double room and approximately 12.9 m2 in the room for seven patients. The bedspaces were separated from each other with curtains. The floor material was plastic, the walls were partially tiled and the ceiling was covered with gypsum board. The physical environment of intensive care patients can be divided into direct and non-direct environment. The direct physical environment of the patient included all the equipment and nursing instruments that were connected to the patient, such as patient monitors with wires, respirator, intravenous cannulas and infusion devices and the bed. In
24-Hour intensive care
249
Table 1
Analysis.
Table 2
Noise level and lighting. Mean db 7:00—22:00
Patient 159 Patient 257
Mean db 22:00—7:00
Lowest db
Highest db
Mean lx 7:00—22:00
Mean lx 22:00—7:00
Lowest lx
Highest lx
51 54
48 53
81 76
295 342
162 128
120 134
523 770
the patient were physical examinations of the patient, nursing, support, advice, encouragement and rehabilitation. The functions involving non-contact with the patient were conversations in the patient room and on the telephone, service operations related to supplies and the environment, patient observation, actions before and after nursing and functions in data transmission. The functions involving varied contacts with patients included service operations related to supplies and the environment, patient examination, observation, nursing and transmission. In these situations, making contact varied according to the situation and the people involved (Table 3).
addition, the direct patient physical environment included lighting, noise and temperature in the room. Light intensity was between 120 and 770 lx and noise volume between 48.0 and 81.0 db measured by the bed of two patients (Table 2). The indirect physical environment included the hospital, patient place and room where the patient was during the study.
Social environment The social environment of intensive care patients consists of intensive care unit personnel, supporting staff, other patients in the intensive care unit and relatives. Over 24 hours, the patients’ contacts with other people varied from 41 to 165 direct contacts. The duration of contacts varied from quick ones lasting only a few seconds to longer continuous contacts lasting several minutes. The longer contacts usually included interruptions, for example, during washing. During the interruptions the patients closed their eyes or followed what happened in their environment. Patients’ social environment includes functions that take place in contact or non-contact with the patient or functions with varied contacts. The functions involving contact with
Table 3
Symbolic environment In intensive care, actions were repeated in nursing that constituted the patient’s symbolic environment. These functions were routines based on norms, regulations and knowledge. Routine functions included staff working hours, physical examinations, taking blood samples and X-rays, washing the patients in the morning and in the evening. These functions were discontinued if there were changes in the patient’s state, if the patient needed drug administration or if the nurse had to wait for assisting staff. The
Patients’ contacts with nursing environment in one day.
Contacts
Patient 1
Patient 2
Patient 3
Patient 4
Direct contact with communication Direct contact, no communication Non-direct contact, patient reaction with movement 24-hour contacts in total
43 45 31 129
53 55 57 165
15 18 8 41
61 47 28 138
250 patient’s nurses took care of the planned treatment and transferred data to other professionals, the patient and the relatives. Nurses also took care of nursing devices and the orderliness of the patient place. Physicians checked measurements, planned treatment, performed procedures and transferred information to other professionals, the patient and the relatives. The patient’s relatives followed advice, received information from the staff, asked questions and were in contact with the patient. Other professionals performed occasional tasks, such as taking X-rays and blood samples or providing physiotherapy.
Discussion The physical environment The patients treated in intensive care had one severe vital organ function disorder or several organ failures. A physician specialising in intensive care is available 24 hours a day, seven days a week, and the intensive care nurse-to-patient ratio is set at 1:1. Patients’ care is based on multiprofessional teamwork to make sure that functions that are vital in the unit and from a patient perspective are taken into consideration (Fontaine et al., 2001). Structural planning in an intensive care unit should be expanded to involve a multiprofessional team to ensure that functions that are vital in the unit and from a patient perspective are taken into consideration (Fontaine et al., 2001). In this study, bedspaces were 12.9—15 m2 in size. An optimally functional patient place in intensive care should measure 22.83 m2 (Hignett and Lu, 2007). A physical turf is a space where people need to feel safe. Personal turf can be defined as a space that protects a person from insult. In physical turf, intimate distance is 0—45 cm (Klemi, 1988). During the patient’s day in intensive care there were many nursing functions that violated the patient’s intimate space. Trespassing into a person’s intimate space can cause stress, anxiety, fear and anger (Horelli, 1983). On the other hand, the feeling of being under close observation can increase patients’ feeling of safety (Hupcey, 2000). In this study, patients’ physical intimate space was violated on average 43 times per day. Patients’ capability to observe speech and situations poses a challenge in an intensive care unit (Wåhlin et al., 2006). Patients reacted on average 35 times per day to noises in the physical environment by opening their eyes, fidgeting in bed, moving their arms and legs, turning their head towards the noise, lifting their head, grimacing and cringing. The noise in intensive care unit has been estimated to be one of the most important reasons for delirium and poor quality of sleep during treatment in ICU and for slower pace of recovery (Fontaine et al., 2001; McCuire et al., 2000; Pun and Ely, 2007; Topf et al., 1996). During this study, the noise level varied between 48 and 81 db. According to the recommendation of the Finnish Ministry of Social Affairs and Health, the noise level in a patient room should be 35 db during the day (7:00 am—10:00 pm) and 30 db during the night (10:00 pm—7:00 am). In the United States, the Ministry of Environmental Protection (EPA) recommends that the noise level should be 45 db during the day and 35 db during the night (Khan et al., 1998; MSAH, 2003). Patients reacted to changes in noise level by opening their eyes and turning their
M. Meriläinen et al. head toward the noise. Even small changes, such as monitor reminder alarm, increased the noise level from 56 to 65 db. When the noise level rises 3 db, the noise effect increases twice as much (Antti-Poika and Vaheri, 1993). In this study, lighting intensity was measured during a season when there is a lot of natural light during the day and night in Finland (the measurements were performed between 15 May and 10 June). Lighting intensity in the unit varied from 120 to 770 lx. The patients reacted to variation in lighting by cringing, by opening their eyes and by turning their head towards the light. Together with noise, the bright lighting and the lack of day—night rhythm in intensive care units are significant reasons for delirium and poor quality of sleep among ICU patients. The intensity of lighting can be increased by extra light sources in the case of emergencies and during procedures (Fontaine et al., 2001; Hewitt, 2002; McCuire et al., 2000). Patients in critical condition have described the technical environment as being strange, hard to understand and frightening. Very few people have been treated in intensive care unit or even visited one. The environment is unfamiliar and difficult to understand, even more so for a patient in a critical condition. Patients may be unable to understand their surroundings, the treatment and the meanings of the events. In this study, one of the patients had been in the intensive care unit before. It is essential for patients to feel safe and comfortable in the nursing environment (Gordon, 1998; Sarvimäki and Stenbock-Hult, 1996). Patients may take the technology for granted, but at the same time they may feel guilty, for example, if they trigger a monitor alarm (Almerud et al., 2007). Factors contributing to a feeling of safety among patients are knowledge, maintenance of control, hope and trust. The staff can influence these factors in a positive or negative manner (Hupcey, 2000; Wåhlin et al., 2006).
The social environment According to Granberg et al. (1998), patients’ fear and stress is increased by poor interaction between patient and nursing staff, being subjected to observation by another patient and seeing other patients being treated, technical equipment as well as unfamiliar and terrifying experiences. In this study, the patients did not see other patients being cared for, but they did have a chance to hear voices and sounds from other patient places. During this study patients were intubated and lightly sedated, so they were not able to communicate with words, but they did react to their social environment by cringes, face movements, turning their head towards the noise, lifting their head or by moving their arms and legs. The patients did not always have time to react to the information given to them, and sometimes they did not get any information at all. Lack of information was seen in situations where the staff was telling the patient what they were about to do while actually doing it. In some situations nursing actions were interrupted and the patient fell asleep; when action was resumed, the staff did not give any information to patient, so the patient woke up in the middle of the procedure. It has been found that patients who are in ICU suffer from being isolated from their nearest and dearest. The
24-Hour intensive care feeling of being isolated may be due to different reasons, such as being physically isolated to avoid infections, being isolated from your loved ones and daily routines, limited capability to communicate or chemical isolation with drugs (Dyson, 1999). Patients’ experiences of weakness, lack of information and defence, being vulnerable and anxious can lead to disorientation or even delirium. A safe environment consists of people known to the patients, i.e. nurses or relatives who recognise the patients’ needs, hold their hands and show through their actions that they are taking care of the patients’ business (Hupcey, 2000; Wåhlin et al., 2006). During the DVD recording each patient had their own nurse in the day and evening shift, while in the night shift there was one nurse per two patients. Two patients had relatives visit them during the recording.
Symbolic environment The symbolic environment of intensive care unit patients consists of norms, rules, values and routines in the ICU. The norms, rules and routines are official guidelines and regulations that govern the work of professionals. In this study, these included professionals’ working hours, examinations performed by physicians, routine blood samples and X-rays and washing the patient in the morning and in the evening. Repeated tasks were carried out from a professional point of view. This was seen in several situations, e.g. when the patient finally fell asleep after a difficult night and was woken by the physician to ask how the night had gone, or when a nurse started to brush the patient’s teeth after the patient had been given pain medication and had fallen asleep. Operational environment values are based on official guidelines and ways of doing things that have been jointly accepted. The values are embedded in each person’s thoughts of what is the right and good way to treat a patient. Knowledge, maintaining control, hope and trust are factors that increase feeling of safety among patients (Hupcey, 2000). Obstacles to good treatment may include shortage of personnel or equipment, or personnel that is technologyorientated (Wilkin and Slevin, 2004). Unpleasant patient experiences can lead to lack of privacy and disrespectful behaviour and contribute to feelings of fear (Hupcey, 2000; Russell, 1999). Intensive care is orientated to treat patients round the clock during the critical phase of illness with specialist treatment and ICU equipment (Almerud et al., 2007; Orko, 1995). In definitions of ICU, the emphasis is on effectiveness, technology and intensiveness. These definitions describe a common way of operation in ICU. The treatment of ICU patients may require rapid actions and technical equipment; professionals can impact the actions with their own attitudes and comprehensive evaluation carried out every day in the ICU.
Reliability The qualitative method was selected because this phenomenon had not been studied earlier from this perspective (Burns and Grove, 2005; Polit and Beck, 2004). Reliability of quantitative research can be evaluated by the criteria of credibility, transferability, consistency and validity of results
251 (Lincoln and Cuba, 1985). These criteria refer to the reality of the research theme. The intensive care environment was familiar to the researcher, but in order to study this phenomenon from the patient’s point of view, round the clock, observation was required. Transferability of the criterion of reliability is related to how research can be applied into other contexts (Lincoln and Cuba, 1985). In qualitative research, results are linked to specific contexts and cannot be transferred to another research situation, as is the case in the present study. To enable evaluation of the results, the researcher has described the participants, collection of material and analysis in detail. In qualitative research the consistency of the criterion of reliability is connected to how the results are presented — is the reader able to follow the reasoning from material to conclusions? The reader can evaluate the consistency of the research process, the clarity of research questions and correlations between methodology and sampling. Confirmation of results refers to how results can be re-researched, to data collection and analysis, and whether the conclusions are derived from the data. In addition, the impact of the researcher on the research process can be explored (Lincoln and Cuba, 1985). One of the advantages of filming is the possibility to capture situations that could be missed on location. Observational findings can be re-examined from DVD recordings. The technical implementation was taken care of by the TV studio master at the hospital. The researcher chose the shooting angle together with the TV studio master, making sure that the shooting area was sufficiently wide. The personnel working in the ICU were informed about the research and the researcher gave instructions on shooting procedures. Based on a screen test, the researcher made decisions of data manageability in the analysis process, viewing angle and the use of DVD recorder. The research focus was captured closely, and when the analysis proceeded events could be rechecked. DVD recording can cause a change in staff behaviour, but earlier findings show (Halimaa, 2001) that research subjects adapt to the filming over time. Staff behaviour was not analysed in this study. Problems in recording may occur due to technical problems, which may be caused, for example, by poor lighting. If the subject being filmed remains still, shooting angles can cause a loop-perspective from situation or atmosphere (Latvala et al., 2000; Polit and Beck, 2004). The intensity of noise and lighting was measured close to the patients (1 m). The measurement point should not be less than one metre from room surfaces unless the measurement is carried out in a patient room (MSAH, 2003).
Conclusions Patients in an intensive care unit are in an environment which they cannot influence themselves, but which affects them in a comprehensive manner. There are features in an ICU patient’s environment that may be harmful to recovery. This study supports earlier research on intensive care unit noise, lack of day and night rhythm and emphasis on technology. The noise, lighting and equipment in the physical
252 environment can cause extra stress and difficulties for the patient. Noise can easily be reduced by avoiding unnecessary talking near the patient, by closing the door if possible, by avoiding unnecessary handling of wrappings and equipment near the patient and by turning down the sounds of monitors if possible. The noise level should be measured regularly by the bed. Problems caused by bright lighting can be reduced by following a day rhythm that is as normal as possible — by planning in advance which actions are necessary at night and which can wait until the morning or daytime, or whether they can be performed using an adjustable spotlight. It may be impossible to reduce the role of technology in an intensive care unit, but the patient must be seen behind all the equipment. The patients need to feel that they come first, not technical equipment. The intensive care unit patient’s social environment includes a lot of rapidly changing contacts with many different people, not all of whom are in direct contact with the patient. The patients do not have a chance to influence communication in their own space. They need time to adjust to the situation, time and place. The staff must be aware of which contacts are necessary and which can be reduced. The symbolic environment is associated with the social environment. The impact of the symbolic environment is seen in the way the staff members act in different nursing situations. Their thoughts of what is a good and correct way of treating patients is evident in routines. ICU personnel can easily influence the ICU patient’s environment. This can be done by taking into consideration the patient’s point of view: is the way we do things wellgrounded? In addition, structural matters that reduce noise and unnecessary movement in patient rooms and promote a day rhythm that is as normal as possible must be taken into consideration in ICU planning.
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