ERK1/2 Inhibition via the Oral Administration of Tizaterkib Alleviates Noise-Induced Hearing Loss While Tempering down the Immune Response.

Noise-induced hearing loss (NIHL) is a major cause of hearing impairment and is linked to dementia and mental health conditions, yet no FDA-approved drugs exist to prevent it. Downregulating the mitogen-activated protein kinase (MAPK) cellular pathway has emerged as a promising approach to attenuate NIHL, but the molecular targets and the mechanism of protection are not fully understood. Here, we tested specifically the role of the kinases ERK1/2 in noise otoprotection using a newly developed, highly specific ERK1/2 inhibitor, tizaterkib, in preclinical animal models. Tizaterkib is currently being tested in phase 1 clinical trials for cancer treatment and has high oral bioavailability and low predicted systemic toxicity in mice and humans. In this study, we performed dose-response measurements of tizaterkib's efficacy against permanent NIHL in adult FVB/NJ mice, and its minimum effective dose (0.5 mg/kg/bw), therapeutic index (>50), and window of opportunity (<48 h) were determined. The drug, administered orally twice daily for 3 days, 24 h after 2 h of 100 dB or 106 dB SPL noise exposure, at a dose equivalent to what is prescribed currently for humans in clinical trials, conferred an average protection of 20-25 dB SPL in both female and male mice. The drug shielded mice from the noise-induced synaptic damage which occurs following loud noise exposure. Equally interesting, tizaterkib was shown to decrease the number of CD45- and CD68-positive immune cells in the mouse cochlea following noise exposure. This study suggests that repurposing tizaterkib and the ERK1/2 kinases' inhibition could be a promising strategy for the treatment of NIHL.

The Role of the Built Environment in Supporting Older Adults' Engagement: A Narrative Literature Review.

OBJECTIVE: This literature review aimed to summarize the existing knowledge surrounding the role of the built environment in supporting older adults' physical and social engagement and identify opportunities for future research and design that facilitates older adults' engagement at multiple environmental scales: from interior spaces to neighborhoods. BACKGROUND: Physical environments can support or impede older adults' physical and social engagement: willful, motivated involvement in meaningful activity or occupation. Research shows that engagement is a core component of health and well-being and relates to positive health outcomes, including reduced disease risk, better mental health, and improved physical and cognitive function. Thus, designing supportive built environments for engagement can yield significant, positive health and well-being impacts. METHODS: A systematized search of five databases, a hand search, and an iterative screening process identified 55 studies for inclusion in this review. Through inductive thematic analysis, this review summarizes findings regarding the built environment's role in physical and social engagement in older age and design strategies to facilitate engagement and support health and well-being. RESULTS: Evidence indicates that built environment characteristics can influence older people's physical and social engagement in homes, neighborhoods, and care settings. The thematic analysis of the included studies identified three key themes concerning the relationships of built environment characteristics to older adults' engagement across multiple environmental scales: connection, access, and security. CONCLUSIONS: Built environments influence older people's physical and social engagement, significantly affecting their health, well-being, abilities, and longevity. Numerous design strategies can support older adults' engagement, but more research is needed.

Can pre-visit exposure to virtual tours of healthcare facilities help reduce child and parent anxiety during outpatient surgical procedures?

AIM: The study aims to evaluate the impact of exposure to a highly realistic virtual facility tour prior to the on-site visit on patients and their parent/care partner's self-reported anxiety and physiological measures on the day of the procedure. BACKGROUND: Preoperative anxiety impacts pediatric surgical outcomes; therefore, it is important for healthcare providers to address and manage preoperative anxiety in pediatric patients to promote better outcomes and overall wellbeing. Providing patients with a preview of the care setting before the actual procedure can be highly beneficial in mitigating preoperative anxiety. METHODOLOGY: In this pilot randomized experimental study, sixteen patient-care partner dyads scheduled to undergo a gastrointestinal procedure either received a virtual tour identical to the places experienced on the day of the procedure (experimental group) or received no virtual tour (control group). Self-reported measures of anxiety were collected from participants before and on the day of the procedure. Physiological measures of heart rate variability and skin conductance were collected on the day of the procedure from both groups. RESULTS: There were no significant differences between the self-reported and physiological measures of anxiety between the child groups. However, parents in the control group reported lower levels of anxiety and demonstrated lower levels of stress based on their physiological measures. CONCLUSION: Exposure to virtual facility tours days before the surgery was not helpful in positively impacting the psychological measures related to preoperative anxiety levels for the participants.

Influence of the Physical Environment on Maternal Care for Culturally Diverse Women: A Narrative Review.

OBJECTIVES: This narrative literature review aims to develop a framework that can be used to understand, study, and design maternal care environments that support the needs of women from diverse racial and ethnic groups. BACKGROUND: Childbirth and the beginning of life hold particular significance across many cultures. People's cultural orientation and experiences influence their preferences within healthcare settings. Research suggests that culturally sensitive care can help improve the experiences and outcomes and reduce maternal health disparities for women from diverse cultures. At the same time, the physical environment of the birth setting influences the birthing experience and maternal outcomes such as the progression of labor, the use of interventions, and the type of birth. METHODS: The review synthesizes articles from three categories: (a) physical environment of birthing facilities, (b) physical environment and culturally sensitive care, and (c) physical environment and culturally sensitive birthing facilities. RESULTS: Fifty-five articles were identified as relevant to this review. The critical environmental design features identified in these articles were categorized into different spatial scales: community, facility, and room levels. CONCLUSIONS: Most studies focus on maternal or culturally sensitive care settings outside the United States. Since the maternal care environment is an important aspect of their culturally sensitive care experience, further studies exploring the needs and perspectives of racially and ethnically diverse women within maternal care settings in the United States are necessary. Such research can help future healthcare designers contribute toward addressing the ongoing maternal health crisis within the country.

Design of Pediatric Outpatient Procedure Environments: A Pilot Study to Understand the Perceptions of Patients and Their Parents.

OBJECTIVE: To understand parent and child perception of spaces experienced during outpatient procedures and to measure their anxiety in these spaces. BACKGROUND: Same-day procedures are becoming prevalent among children in the United States. While studies conducted in different types of healthcare settings show that the physical environment influences healthcare experiences of patients, there is a lack of research on patient and family perceptions of the physical environment of the outpatient centers where such procedures are conducted. METHODS: This study used ecological momentary assessment to collect patient experience and anxiety data at different points during the patient's journey through an ambulatory surgical center where pediatric gastrointestinal (GI) procedures were performed. Objective and subjective measures of anxiety were collected. A Qualtrics survey asked participants' perceptions about four spaces-waiting, preprocedure, procedure, and recovery. RESULTS: Child participants reported liking murals, double chairs, patient beds, wall color, and access to a television. They disliked medical equipment and lack of child-friendly furniture. Most parents liked the murals, access to a television, and nature photos, while disliking the lack of privacy, lack of toys in waiting areas, and lack of child-friendly furniture. On average, both children and parents experienced the highest anxiety levels before and during the procedure and the lowest during recovery. Between the four spaces, no significant differences were observed in the heart rate variability and skin conductance responses for both groups. CONCLUSIONS: Despite the outpatient nature of the procedures, participants experienced anxiety before the GI procedure. Comfortable design features that provide distractions are preferred by children and their parents.

The compatibility of exoskeletons in perioperative environments and workflows: an analysis of surgical team members' perspectives and workflow simulation.

Surgical team members in perioperative environments experience high physical demands. Interventions such as exoskeletons, external wearable devices that support users, have the potential to reduce these work-related physical demands. However, barriers such as workplace environment and task compatibility may limit exoskeleton implementation. This study gathered the perspectives of 33 surgical team members: 12 surgeons, four surgical residents, seven operating room (OR) nurses, seven surgical technicians (STs), two central processing technicians (CPTs), and one infection control nurse to understand their workplace compatibility. Team members were introduced to passive exoskeletons via demonstrations, after which surgical staff (OR nurses, STs, and CPTs) were led through a simulated workflow walkthrough where they completed tasks representative of their workday. Five themes emerged from the interviews (workflow, user needs, hindrances, motivation for intervention, and acceptance) with unique subthemes for each population. Overall, exoskeletons were largely compatible with the duties and workflow of surgical team members.

The goal of this study was to identify exoskeleton compatibility across various surgical team members through a thematic analysis of interviews and a simulated workflow walkthrough. Results revealed five unique themes (workflow, user needs, hinderances, motivation for intervention, acceptance) and that exoskeletons were largely compatible with daily duties.

Identifying Built Environment Risk Factors to Provider Workflow and Patient Safety Using Simulation-Based Evaluation of a Pediatric ICU Room.

OBJECTIVE: This study aimed to identify latent conditions in a pediatric intensive care unit (PICU) by analyzing characteristics of flow disruptions (FD) during a simulation of a three-phased scenario. BACKGROUND: The built environment of healthcare facilities contributes to FD that can lead to clinical errors and patient harm. In the facility design process, there is an opportunity to identify built environment features that cause FD and pose safety risks. Simulation-based evaluation of proposed designs may help in identifying and mitigating safety concerns before construction and occupancy. METHODOLOGY: During design development for a new 400-bed children's hospital, a series of simulations were conducted using physical mock-ups in a large warehouse. A three-phased scenario, (1) admission and intubation, (2) cardiac arrest, and (3) bedside surgery involving a cannulation to extracorporeal membrane oxygenation, was conducted in a PICU room mock-up. Each scenario was video recorded from four angles. The videos were systematically coded to identify FD. RESULTS: Analysis identified FDs in three ICU zones: respiratory therapists (RT) zone, nurse zone, and head of the patient. Challenges in these zones were related to spatial constraints in the RT zone and head of the bed, equipment positioning in the RT zone and nurse zone, and impeded visibility related to the location of the boom monitor in the nurse zone. CONCLUSION: Simulation-based evaluation of prototypes of patient care spaces can help identify characteristics of minor and major FD related to the built environment and can provide valuable information to inform the iterative design process.

Anesthesia Workspaces for Safe Medication Practices: Design Guidelines.

BACKGROUND: Studies show that workspace for the anesthesia providers is prone to interruptions and distractions. Anesthesia providers experience difficulties while performing critical medication tasks such as medication preparation and administration due to poor ergonomics and configurations of workspace, equipment clutter, and limited space which ultimately may impact patient safety, length of surgery, and cost of care delivery. Therefore, improving design of anesthesia workspace for supporting safe and efficient medication practices is paramount. OBJECTIVES: The objective of this study was to develop a set of evidence-based design guidelines focusing on design of anesthesia workspace to support safer anesthesia medication tasks in operating rooms (ORs). METHODS: Data collection was based on literature review, observation, and coding of more than 30 prerecorded videos of outpatient surgical procedures to identify challenges experienced by anesthesia providers while performing medication tasks. Guidelines were then reviewed and validated using short survey. RESULTS: Findings are summarized into seven evidence-based design guidelines, including (1) locate critical tasks within a primary field of vision, (2) eliminate travel into and through the anesthesia zone (for other staff), (3) identify and demarcate a distinct anesthesia zone with adequate space for the anesthesia provider, (4) optimize the ability to reposition/reconfigure the anesthesia workspace, (5) minimize clutter from equipment, (6) provide adequate and appropriately positioned surfaces for medication preparation and administration, and (7) optimize task and surface lighting. CONCLUSION: This study finds many areas for improving design of ORs. Improvements of anesthesia work area will call for contribution and cooperation of entire surgical team.

ERK1/2 Inhibition Alleviates Noise-Induced Hearing Loss While Tempering Down the Immune Response.

Noise-induced hearing loss (NIHL) is a major cause of hearing impairment, yet no FDA-approved drugs exist to prevent it. Targeting the mitogen activated protein kinase (MAPK) cellular pathway has emerged as a promising approach to attenuate NIHL. Tizaterkib is an orally bioavailable, highly specific ERK1/2 inhibitor, currently in Phase-1 anticancer clinical trials. Here, we tested tizaterkib's efficacy against permanent NIHL in mice at doses equivalent to what humans are currently prescribed in clinical trials. The drug given orally 24 hours after noise exposure, protected an average of 20-25 dB SPL in three frequencies, in female and male mice, had a therapeutic window >50, and did not confer additional protection to KSR1 genetic knockout mice, showing the drug works through the MAPK pathway. Tizaterkib shielded from noise-induced cochlear synaptopathy, and a 3-day, twice daily, treatment with the drug was the optimal determined regimen. Importantly, tizaterkib was shown to decrease the number of CD45 and CD68 positive immune cells in the cochlea following noise exposure, which could be part of the protective mechanism of MAPK inhibition.

Safety in Health Care: The Impact of Operating Room Design.

The science of operating room design has grown over the past 20 years due to the realization that the physical environment influences health care provider performance and patient outcomes. Medical errors occur when the normal workflow in an operating room is disrupted as providers must overcome sub-optimal conditions. All aspects of the physical environment can impact operating room flow. Studying the layout, contents, ergonomics, and environmental parameters of the operating can lead improved work conditions resulting improved patient and provider safety. At the forefront of operating room design science is the use of simulation and the evaluation of new technologies.

Effects of the physical environment on children and families in hospital-based emergency departments: A systematic literature review.

Every year, millions of children seek care in emergency departments (EDs) for various conditions. Though the physical environment of the ED provides the context and setting for care delivery, influences workflows, and shapes interactions between users, the noisy, sterile, stimulating nature of the ED can be counter-therapeutic to pediatric patients and families. This systematic literature review investigates this complex dynamic and asks how the physical environment of emergency departments affects children and their families or guardians. Using PRISMA methods, this review searched four databases to identify and analyze twenty-one peer-reviewed articles that explored the impacts of the physical environment of hospital-based EDs on children or family members. Several themes emerged from the literature - concerning control, positive distractions, family and social supports, and designing for a safe and comfortable experience - that illustrate opportunities for future ED design and highlight knowledge gaps and avenues for future research.

Designing for Family Engagement in Neonatal ICUs: How Is the Interior Design of Single-Family Rooms Supporting Family Behaviors, From Passive to Active?

PURPOSE: Understand how the interior design of single-family rooms (SFRs) in neonatal intensive care units (NICUs) can support family engagement behaviors. BACKGROUND: Family members are integral contributors to infant care in NICUs, impacting infant development. While at the NICU, parents are encouraged to participate in a process called family engagement, where they are expected to move from passive to active caregivers, in preparation for their role after discharge. While family engagement is affected by the built environment, no studies have investigated this relationship in any depth. NICU settings morphed to involve families through the SFR design model, but the interior environment of SFRs have not been sufficiently explored as a resource to support specific family engagement behaviors. METHODS: We interviewed family and staff and observed family engagement behaviors in SFRs at two NICUs. Behaviors were observed and described in terms of their location, number of people, and design elements involved. Built environment characteristics were collected through physical assessments, and interviews elicited participants' perceptions about design factors impacting family behaviors inside SFRs. Data analysis followed grounded theory segments and pattern matching. RESULTS: Three behavioral patterns and five themes were identified showing how SFRs' private bathrooms, family storage, family zone partitions, positive distractions, and information boards can support families' home-like, educational, collaborative, and infant care behaviors. CONCLUSIONS: The interior design of SFRs can be a resource to family engagement in the NICU. Future research should operationalize SFR features found in our study to measure and validate their impact on family engagement outcomes.

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

Background: Heart disease is the leading cause of death in the United States. The length of stay (LOS) is a well-established parameter used to evaluate health outcomes among critically ill patients with heart disease in cardiac intensive care units (CICUs). While evidence suggests that the presence of daylight and window views can positively influence patients' LOS, no studies to date have differentiated the impact of daylight from window views on heart disease patients. Also, existing research studies on the impact of daylight and window views have failed to account for key clinical and demographic variables that can impact the benefit of such interventions in CICUs. Methods: This retrospective study investigated the impact of access to daylight vs. window views on CICU patients' LOS. The study CICU is located in a hospital in the southeast United States and has rooms of the same size with different types of access to daylight and window views, including rooms with daylight and window views (with the patient bed located parallel to full-height, south-facing windows), rooms with daylight and no window views (with the patient bed located perpendicular to the windows), and windowless rooms. Data from electronic health records (EHRs) for the time-period September 2015 to September 2019 (n=2936) were analyzed to investigate the impact of room type on patients' CICU LOS. Linear regression models were developed for the outcome of interest, controlling for potential confounding variables. Results: Ultimately, 2319 patients were finally included in the study analysis. Findings indicated that patients receiving mechanical ventilation in rooms with access to daylight and window views had shorter LOS durations (16.8 h) than those in windowless rooms. Sensitivity analysis for a subset of patients with LOS ≤3 days revealed that parallel bed placement to the windows and providing access to both daylight and window views significantly reduced their LOS compared to windowless rooms in the unit (P=0.007). Also, parallel bed placement to the window significantly reduced LOS in this patient subset for those with an experience of delirium (P=0.019), dementia (P=0.008), anxiety history (P=0.009), obesity (P=0.003), and those receiving palliative care (P=0.006) or mechanical ventilation (P=0.033). Conclusions: Findings from this study could help architects make design decisions and determine optimal CICU room layouts. Identifying the patients who benefit most from direct access to daylight and window views may also help CICU stakeholders with patient assignments and hospital training programs.

Operating room design using agent-based simulation to reduce room obstructions.

This study seeks to improve the safety of clinical care provided in operating rooms (OR) by examining how characteristics of both the physical environment and the procedure affect surgical team movement and contacts. We video recorded staff movements during a set of surgical procedures. Then we divided the OR into multiple zones and analyzed the frequency and duration of movement from origin to destination through zones. This data was abstracted into a generalized, agent-based, discrete event simulation model to study how OR size and OR equipment layout affected surgical staff movement and total number of surgical team contacts during a procedure. A full factorial experiment with seven input factors - OR size, OR shape, operating table orientation, circulating nurse (CN) workstation location, team size, number of doors, and procedure type - was conducted. Results were analyzed using multiple linear regression with surgical team contacts as the dependent variable. The OR size, the CN workstation location, and team size significantly affected surgical team contacts. Also, two- and three-way interactions between staff, procedure type, table orientation, and CN workstation location significantly affected contacts. We discuss implications of these findings for OR managers and for future research about designing future ORs.

Measuring Potential Visual Exposure of Physicians During Shift-End Handoffs and Its Impact on Interruptions, Privacy, and Collaboration.

BACKGROUND: Frequent interruptions, inadequate privacy, and lack of collaboration are barriers to safe and efficient end-of-shift handoffs between emergency physicians. Varying levels of visibility to and from physicians can impact these outcomes. This study quantifies potential visual exposure of physicians in workstations with varying enclosure levels using isovist connectivity (IC) as a measure. Further, this study examines the association of IC with number of interruptions/hour, perceived collaboration, and privacy during handoffs. METHODS: In-person observations were conducted during 60 handoffs to capture interruptions. Surveys were administered to the incoming and outgoing physicians to garner their perceptions of the extent of interruptions, collaboration, and privacy. Spatial analysis was conducted using DepthmapX. RESULTS: Findings demonstrate significant differences in IC scores based on (a) physicians location within the workstation during; (b) handoff approach (individual or collaborative); (c) position during handoff (sitting or standing). Documented interruptions were highest in the high IC locations and lowest in the medium and low IC locations. Physicians in low IC locations perceived to have sufficient privacy to conduct handoffs. LIMITATIONS AND CONCLUSION: It should be noted that the three pods, each housing a physician workstation with different enclosure levels, varied in number of patient rooms, patient acuity, overall size, and the location of workstations. While contextual variables were considered to the extent possible, several other factors could have resulted in differences in number of interruptions and collaboration levels. This study provides design recommendations for handoff locations and a method to test emergency physician workstation designs prior to construction.

Using Discrete Choice Methodology to Explore the Impact of Patient Room Window Design on Hospital Choice.

Evidence-based design has been fundamental to designing healthcare environments for patient outcomes and experience, yet few studies have studied how design factors drive patient choice. 652 patients who recently received care at hospitals across the United States were administered an online discrete choice survey to investigate the factors playing into their choice between hypothetical hospitals. Discrete choice models are widely used to model patient preferences among treatment alternatives, but few studies have utilized this approach to investigate healthcare design alternatives. In the current study, respondents were asked to choose between hypothetical hospitals that differed in patient room design, window features of the room, appointment availability, distance from home, insurance coverage, and HCAHPS ratings. The results demonstrate that patient room design that allowed unobscured access to daylight and views through windows, in-network insurance coverage, closer distance from home, and one-star higher patient experience rating increased the likelihood of a patient's hospital choice. The study broadly explores discrete choice model's applicability to healthcare design and its ability to quantify patient perceptions with a metric meaningful for hospital administrators.

Improving safety in the operating room: Medication icon labels increase visibility and discrimination.

Misreading labels, syringes, and ampoules is reported to make up a 54.4% of medication administration errors. The addition of icons to medication labels in an operating room setting could add additional visual cues to the label, allowing for improved discrimination, visibility, and easily processed information that might reduce medication administration errors. A multi-disciplinary team proposed a method of enhancing visual cues and visibility of medication labels applied to vasoactive medication infusions by adding icons to the labels. Participants were 1.12 times more likely to correctly identify medications from farther away (p < 0.001, AOR = 1.12, 95% CI: 1.02, 1.22) with icons. When icons were present, participants were 2.16 times more likely to be more confident in their identifications (p < 0.001, AOR = 2.16, 95%CI: 1.80, 2.57). Carefully designed icons may offer an additional method for identifying medications, and thus reducing medication administration errors.

A mobile application-based home assessment tool for patients undergoing joint replacement surgery: A qualitative feasibility study.

BACKGROUND: Most adults prefer to age in place. However, the majority of homes are not designed to support resident needs, especially for adults undergoing joint replacement surgeries such as total knee arthroplasty (TKA) or total hip arthroplasty (THA). It is of paramount importance to proactively assess and modify the homes of adults undergoing TKA/THA such that they can safely transition home following surgery. Several tools utilize emerging technology like virtual reality, augmented reality, or teleconferencing to assess home environments. These are meant to be used by professionals like occupational therapists. However, the acceptance and uptake of simple technology like mobile applications for assessing homes proactively by residents has not been explored. OBJECTIVE: A qualitative exploratory study was conducted to evaluate the feasibility and potential acceptance of a mobile application for resident-initiated home assessment. METHODS: Semi-structured interviews were conducted with 22 patient-care partner dyads before and after THA/TKA to understand the perceived usefulness, likelihood of using a mobile application-based home assessment tool, and perceived barriers and facilitators of using the tool. RESULTS: About 68% of the patient-care partner dyads interviewed for this study perceived benefits of using a mobile application-based tool. All the participants who perceived the tool to be useful showed high likelihood of using it. A comparison of responses between pre-and post-surgery interviews revealed that around 50% of participants showed an increased intention of using an assessment tool after experiencing challenges in their homes post-surgery. Participants provided recommendations for key content, potential features to include in the assessment tool, and preferred formats (e.g., checklists, visuals, and videos). CONCLUSIONS: To increase acceptance of a mobile application-based home assessment tool, it is crucial that residents are made aware of the home environment challenges and the importance of an assessment tool to improve their safety and independence. The content, features, formats, and usability suggestions from the participants in this study provide a framework for health mobile application and interface developers to design a home assessment tool.

Understanding "Work as Done": Using a Structured Video-Based Observational Method to Understand and Model the Role of the Physical Environment in Complex Clinical Work Systems.

OBJECTIVE: To describe the planning, development, and implementation of a structured video-based observational method that can be used to systematically examine and model the role of the physical environment within healthcare systems. BACKGROUND: Direct observation methods are often used in healthcare to study complex healthcare systems. However, these observations often occur in real time, which predisposes the collected data to shortcomings such as time lags in recording of activities, overlooking events, or limiting the scope of information than can be collected. Video observation approaches eliminate many of these challenges and provide opportunities for researchers to understand and model the role of the physical environment. METHODS: An approach to developing and implementing a structured video-based observational method to study and model complex health systems is presented. RESULTS: A structured observational approach can be highly effective for collecting multiple layers of data necessary for understanding interactions between the physical environment and other systems components in healthcare settings. The proposed video-based observation method is effective in settings that have clearly defined environmental boundaries, limited number of people, are complex and fast-paced such as the OR, ED trauma rooms, and ICU rooms. CONCLUSIONS: Video-based observation is an effective complement to the traditional observational method for in-depth study of the built environment in health systems, enabling researchers to employ quantitative approaches to data collection and analysis, in addition to qualitative interpretations.

Pediatric Intensive Care Unit (PICU) Patient Room Design: Identifying Safety Risks in Mirrored Rooms Through a Graphical Systems Analysis.

OBJECTIVE: The objectives of this study are to graphically depict specific clinical challenges encountered in a mirrored pediatric intensive care unit patient room and to represent potential solutions to address these challenges using a systems approach. BACKGROUND: The intensive care unit (ICU) patient room is a highly complex patient care environment where the design of the room must support patient care delivery safely and efficiently. There is a lack of research examining how ICU design elements interact with other system components to impact patient care. METHODS: An observational case study method utilizing a systems approach was used to observe and graphically depict clinical challenges with mirrored room configurations and to identify potential solutions. Video recordings of the three clinical scenarios were analyzed in detail in conjunction with three rounds of interviews with a clinical expert. RESULTS: Equipment or task characteristics that require orienting to a specific side of a patient create challenges in a mirrored room. In order to deliver care safely and efficiently in the mirrored room, adaptations would be required including changing boom, equipment and team member locations, purchasing new equipment, staff training, and inventory management. Some procedures such as extracorporeal membrane oxygenation would be difficult to conduct safely in the mirrored room, even with significant adaptations. CONCLUSION: Solutions to the challenges presented in mirrored room configurations are multifaceted and require simultaneous and ongoing changes to multiple systems elements, while others can be addressed relatively easily, for example, purchasing new equipment.