Interview with Dr. Marc Achilles, Head of the Department of Anesthesiology and Intensive Care Medicine, Marien Hospital in Wesel, Germany
Delirium, also known as acute confusional state, occurs in 30 to 80 percent of patients in intensive care units. This cerebral impairment not only causes mental confusion and emotional disruption but also drastically increases the mortality risk of patients. A controlled circadian rhythm and sleep/wake cycle is the prerequisite for delirium prevention. This is where the new VitalMinds concept from Philips comes in.
In this MEDICA-tradefair.com interview, Dr. Marc Achilles explains how light technology can prevent delirium, details how the VitalSky system works, and reveals the role artificial intelligence could play in the future of delirium prevention.
Dr. Achilles, how is your intensive care unit set up?
Dr. Marc Achilles: Our state-of-the-art intensive care unit opened in 2017, features 18 ICU beds, and has 1,200 square meters of floor space. The unit treats over 1,800 patients per year. Apart from classic intensive care unit treatments – including sepsis, respiratory failure, cardiogenic shock, and severe injuries - we predominantly focus on delirium prevention using VitalMinds from Philips. Last year, we were the first hospital in the world to equip seven ICU beds with the VitalSky light therapy system.
How does this system work?
Achilles: The patient lies under an artificial sky that measures 4 meters in length and 2 meters in width. The ceiling installation has 13,000 LEDs. During the 24-hour cycle, the artificial light mimics the sunlight outside and replicates the rising sun in the morning, for example. The light intensity slowly increases and stays bright all day since the body needs to be exposed to lots of light during the day to suppress the production of the sleep hormone melatonin. This means that the patient – including those on ventilators – is awake during the day and sleeps well at night. The light is subsequently lowered at night, allowing just enough low light intensity in the room for physicians and nurses to monitor the patient. The patient is not disturbed by this light or any alarms. Heart rate or blood pressure alarms are directed away from the patient. Circadian-effective light therapy and sound management are the two basic components of the VitalSky system.
How does VitalSky improve ICU patient recovery?
Achilles: A continuous night's uninterrupted sleep is the prerequisite for delirium prevention. It is such an important aspect because people who develop delirium have a much higher 1-year mortality rate. Each day an ICU patient spends in delirium is associated with a 10 percent increased risk of death. Older patients with cognitive impairments are especially at risk. They may arrive in our ICU with an injury and undergo surgery. The surgery and recovery go well until the second day of their hospital stay when they suddenly remove all catheters and don't know who or where they are. They are delirious. The reason we invest in this type of expensive light therapy system is that we want to prevent delirium. While the patient's underlying medical condition may have been treated, delirium prolongs the recovery process and simultaneously drastically decreases the chance of survival.
What has been the system feedback so far?
Achilles: At first, people tend to be very skeptical when you implement a new technology in the intensive care unit. Everybody has a different relationship with light. For example, older adults have a harder time with this change because they are used to taking an afternoon nap. We have to communicate the system's immediate effect on the patient's recovery to both patients and their family members, especially to explain the afternoon boost phase of the light therapy system when the light is most intense.
We provide a variety of information sources such as flyers, posters, and multimedia displays to educate. An observational study by the Charité Hospital in Berlin has shown that the 24-hour light therapy with VitalSky reduces delirium incidences by over 50 percent. That is obviously an impressive number. We haven't had this much recovery success in any other area of intensive care medicine as with these simple atmospheric tools.
This is an interprofessional approach and facilitates the coordinated care of patients by a collaborative team of the relevant health care providers. It is only successful if everyone – chief physician, senior physician, chief nursing officer, and intensive care staff – embraces this paradigm shift. This also means that nurses don't wake up patients every night at 2 a.m. or 3 a.m. to wash them, and interrupt their sleep in the process. This was still a common practice about 15 years ago because it fit better into hospital work schedules.
Where do you see some areas of potential improvement?
Achilles: Right now, physicians and nurses record all relevant clinical information pertaining to the patient and assess other parameters such as heart rate, blood pressure, respiratory rate, and level of consciousness to determine if there are signs of delirium. We also have scoring systems to help us with this analysis. Another conceivable option – and there is ongoing research in this area – would be to install a camera in the VitalSky to monitor patient movements. This gives the physician additional information as he or she might be tied up with another patient. This is also where artificial intelligence could assist to link this information to other variables (heart rate, blood pressure, respiratory rate). I don't see AI as a substitute but as a complement, as it can provide vital information during times when the hospital is running at high capacity. You have to remember that even patients who have not moved for 10 hours may still have developed delirium. Yet these types of cases often go unnoticed if the staff is super busy and occupied elsewhere. As we have seen amid the COVID-19 crisis, Germany has some of the best intensive care units in the world, but there are always areas we can improve upon.