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PubMed2002

A review of guidelines for nutrition care of renal patients.

The third edition of the Guidelines for Nutrition Care of Renal Patients has been developed to follow the American Dietetic Association's Medical Nutrition Therapy (MNT) Protocol format and to further assist dietitians in providing optimal and consistent care to renal patients. The guidelines define the level, content, and frequency of nutrition care that is appropriate based on the best available scientific information and expert opinion. Seven separate guidelines, primarily written for care provided in the outpatient setting, are defined in the publication. Each guideline focuses on a different patient population and/or treatment modality for renal disease: Pre-End-Stage Renal Disease, Hemodialysis and Peritoneal Dialysis, Hospitalized Dialysis, Transplantation, Acute Renal Failure, Enteral/Parenteral Nutrition Support, and Pregnancy in Renal Disease. The Guidelines for Nutrition Care of Renal Patients, Third Edition is meant to support and assist dietitians as providers of MNT in kidney disease, to provide uniform treatment care guidelines and nutritional status identification criteria for all aspects of kidney disease and its complications, and to help secure the dietitian as the provider of these services for optimum cost-effective care. The guidelines should help to increase effectiveness of care by promoting consistency among practitioners and should facilitate the measurement of the quality and effectiveness of care.

Humans↗

PubMed2001

Can guidelines for the treatment of respiratory infections lead to reduced rates of antibiotic resistance?

Guidelines have been developed for the therapy of both community-acquired pneumonia (CAP) and hospital-acquired pneumonia (HAP), and, potentially, if applied appropriately, could lead to a containment or reduction in the frequency of antibiotic resistance. In the therapy of CAP, guidelines could minimize the use of excessive antibiotic therapy, and if they also improve the accuracy of therapy, they could minimize the emergence of resistant organisms in the community. However, the impact of such guidelines on resistance remains to be shown. In the near future, CAP guidelines could help contain the growing problem of quinolone-resistant pneumococci by advocating the use of the most effective of the new agents, administered at the optimal dosages. When managing HAP, the use of guidelines could improve outcome by leading to a greater percentage of patients receiving adequate empiric antibiotic therapy. It remains uncertain whether such an approach can minimize the emergence of antibiotic resistance, particularly in the intensive care unit (ICU), but it is clear that if guidelines are to be accurate, they must account for the resistance patterns that are unique to each individual hospital setting. To date, the use of computer-assisted guidelines for the therapy of nosocomial infections has been successful in minimizing the frequency of inadequate therapy, with no negative impact on antibiotic resistance. Antibiotic restriction policies have been proposed as a way to have an impact on resistance, with variable effects. In the future, antibiotic rotation is likely to be studied as a way to reduce resistance, particularly in the ICU, but a number of practical issues may limit the efficacy of such an approach.

Community-Acquired Infections↗

PubMed2000

[The new German resuscitation guidelines in the context of international recommendations].

The German Guidelines for Cardiopulmonary Resuscitation were adapted to match the revised International Guidelines. The revised German edition was based both on the guidelines issued by the American Heart Association (AHA) in 1992 and on those of the European Resuscitation Council (ERC) of 1998, as well as on those released by the International Liaison Committee on Resuscitation (ILCOR) in 1997. Due to the diverging instructions for action the emergency physicians felt considerably unsafe as to what they should really do to achieve maximum results. Only 10.3 per cent of the german emergency physicians followed the recommendations given by the German Federal Chamber of Physicians. Innovations in respect of the basic checkup concern the time for controlling the respiration and circulation (ten seconds). Contrary to the international recommendations the "diagnostic block" is performed in Germany without interspersing basic reanimation. In artificial respiration the tidal volume has been reduced to 600 ml in accordance to the ERC and ILCOR guidelines. The search for the pressure point for cardiac pressure massage has also been adapted to the international recommendations. Also in accordance with the international recommendations defibrillation in case of ventricular fibrillation is now being performed only thrice in series without interspersed basic reanimation. There is some uncertainty with regard to choosing the requisite energy: 16.6% of the emergency physicians opt for less than 200 joule in primary defibrillation whereas 13% are in favour of more than 200 joule. Contrary to the international recommendations which prescribe peripheral venous access as application site for reanimation by drugs, the german guidelines favour the endobronchial path, which is already being practised by 57.4% of the emergency physicians. Hence, emergency medication can be effected in Germany 4 minutes earlier than in other countries. After three unsuccessful applications of 1 mg each of adrenalin the dosage is increased to 5 mg, and in agreement with the AHA guidelines escalating doses are also possible. Sodium bicarbonate is recommended only after more than 20 minutes of reanimation and if so, only in a reduced dose of 0.5 mval/kg body weight. In accordance with the international recommendations there is now a universal algorithm that decides on application only between ventricular fibrillation and nonfibrillation. The new german recommendations have adapted the reanimation procedure in agreement with ERC to national usage without abandoning any principles of the international guidelines.

Cardiopulmonary Resuscitation↗

PubMed2002

Antibiotic prophylaxis of infective endocarditis during digestive endoscopy: over- and underuse in Switzerland despite professed adherence to guidelines.

BACKGROUND AND STUDY AIMS: Guidelines for antibiotic prophylaxis of infective endocarditis associated with gastrointestinal endoscopy are not uniform. Though based on weak scientific evidence, they do represent an attempt to unify the management of antibiotic prophylaxis. We investigated whether physicians who profess to adhere to these guidelines actually do apply them correctly. MATERIALS AND METHODS: A questionnaire was sent to all 195 Swiss gastroenterologists asking whether they adhered to antibiotic prophylaxis guidelines and under what conditions did they apply antibiotic prophylaxis in gastrointestinal endoscopy. We analysed whether the Swiss gastroenterologists who claim to adhere to these guidelines actually do so in practice. RESULTS: The response rate to our questionnaire was 95%. Of the Swiss gastroenterologists, 60% correctly employ antibiotic prophylaxis guidelines in gastroscopy, as do 47% in colonoscopy. In therapeutic endoscopy, the percentage of correct antibiotic prophylaxis use depends upon the type of intervention and varies between 21 and 58%. Overuse of antibiotic prophylaxis is at least twice as frequent in colonoscopy and therapeutic endoscopy than in gastroscopy. CONCLUSIONS: Guidelines for antibiotic prophylaxis are not well applied and do not lead to uniform management despite a high degree of professed adherence to them. This phenomenon can be explained by "cognitive dissonance" and "reactance." We conclude that guidelines based on unconvincing data may even prove harmful.

Antibiotic Prophylaxis↗

PubMed2002

Practice guidelines and performance measures in emergency medical services for children.

Practice guidelines and performance measures are critical elements of an effective quality improvement process for emergency medical services for children (EMSC). Practice guidelines address the clinical management of individual patients, and performance measures assess the quality of care delivered to a population. The public and private sectors have invested considerable resources in developing practice guidelines and performance measures to improve the quality of health care services. As organizations continue development efforts, health care professionals who are actively involved in emergency care must collaborate to develop guidelines that address the unique physiologic, psychologic, and cultural needs of children. The Emergency Medical Services for Children Managed Care Task Force recommended the development of a series of white papers to focus on issues related to practice guidelines and performance measures in EMSC. The Maternal and Child Health Bureau, Health Resources and Services Administration, the National Highway Traffic Safety Administration, and the Robert Wood Johnson Foundation jointly sponsored the project. The paper was developed by a panel selected from a pool of experts in managed care, quality improvement, and emergency medical services. After a review of the literature, the panelists met to discuss critical issues related to practice guidelines and performance measures in EMSC. The panelists developed recommendations that can serve as resources for managed care organizations, health care providers, professional associations, and governmental policy makers. The panel recognized the lack of nationally recognized pediatric emergency care guidelines and performance measures and called for immediate action in these areas.

Child↗

PubMed2005

Encouraging a systems approach for adherence to national asthma guidelines.

PURPOSE: There is a lack of information in the literature reflecting systems effects on adherence to national asthma guidelines. The purpose of this pilot study is to provide a descriptive account of the preparedness of academic primary care sites to follow national asthma guidelines related to spirometry, peak flow meters, standard history forms, severity assessment, follow-up assessment sheets, patient self-assessment sheets, and asthma action plan templates. METHODS: This was a cross-sectional descriptive study. A short survey was mailed to medical directors on behalf of primary care academic clinical sites to assess the availability of guideline tools in their practices. Medical directors were also asked to rate their perception of how essential the guidelines were in the management of asthma. RESULTS: Medical directors agreed that the guideline tools were essential in managing asthma. However, with the exceptions of peak flow meters and standard history forms, most sites were not equipped with these tools for providers to use. CONCLUSIONS: The findings highlight the importance of the practice environment on the implementation of national asthma guidelines and encourage larger studies to include an assessment of the systems in place to enable guideline adherence. By taking systems into account, interventions may be potentially much more effective in improving the quality of care.

Academic Medical Centers↗

PubMed2001

Implementing evidence in Finnish primary care. Use of electronic guidelines in daily practice.

In Finland, electronic guidelines have provided general practitioners (GPs) with a source of up-to-date information at their fingertips since 1989. The Physician's Desk Reference and Database (PDRD) covers the majority of problems encountered in primary care with some 1,000 articles. These are available in electronic format, updated every 4 months, and as a book published in a fully revised edition every 2 years. Physicians use these guidelines as a routine part of their daily work. They seek information for both common and rare health problems and use it to plan diagnostic strategies as well as treatment and follow-up. In nearly 90% of cases the doctor finds the information she needs from the guidelines. The electronic version is user-friendly; typically the relevant article is found and read in 2 min. Patients find it reassuring when their doctor uses guidelines to select optimal treatment. Other Nordic countries are aslo producing several national guidelines, but Finland has so far the widest scope and longest experience in this area. An English version of the PDRD guidelines (Evidence-Based Medicine Guidelines) is available, and a Swedish-language version will be completed in 2002.

Decision Support Systems, Clinical↗

PubMed2006

Weighing the evidence to formulate dietary guidelines.

Dietary guidelines have broad implications for the health of individuals and populations. Increasingly, government agencies and medical organization that issue guidelines have pursued evidence-based approaches. These approaches emphasize a comprehensive, critical, and explicit examination of the scientific evidence that the proposed dietary practice will improve health. Evidence-based guidelines typically feature an explicit methodology, include as their foundation a systematic review of the evidence, provide graded recommendations that are linked directly to the supporting evidence, and state explicitly when recommendations are based on opinion. Guideline development usually involves some combination of six steps: (1) specification of the topic and the guideline development methodology, (2) systematic review of the evidence, (3) consideration of expert opinion, (4) public policy analysis, (5) drafting of the document, and (6) peer review. The supporting evidence undergoes critical appraisal, including an assessment of the magnitude of the effect on outcomes observed in studies, the quality of the studies reporting the effect, or both. Dietary guidelines should also consider untoward effects, potential harms, and economic implications to society, the food industry, and others. A hallmark of evidence-based guidelines is making explicit the strength of recommendations and the quality of the evidence on which they are based. Grading systems are commonly used to rate the quality of the supporting evidence.

Diet↗

PubMed2001

Do guidelines for community-acquired pneumonia improve the cost-effectiveness of hospital care?

There is growing pressure to demonstrate the value of practice guidelines. We have reviewed the evidence that guidelines for the treatment of community-acquired pneumonia (CAP) change current practices and that the standardization of practices reduces costs and/or improves outcome. The most obvious barrier to implementation of the guidelines is lack of knowledge about their content; equally important are the attitudes and behavior of professionals, patients, and their caregivers. Guidelines may improve the outcome of CAP, provided that there is an association between variations in outcome and some specific processes of care. Conversely, when there is no such relationship, guidelines may reduce the cost of care without having an adverse effect on outcome. The cost-effectiveness of CAP guidelines in an individual hospital depends on the systems that are available to identify patients with CAP and to measure the processes of care. There is good evidence that following the recommendations of the CAP guidelines does improve the cost-effectiveness of care and, therefore, that an audit of CAP may be worth the effort.

Community-Acquired Infections↗

PubMed1994

Modern strategies to prevent coronary sequelae and stroke in hypertensive patients differ from the JNC V Consensus Guidelines.

In recent years, government agencies of many countries have established consensus guidelines for the evaluation and treatment of hypertension. Once published, guidelines tend to be perceived as directives by a variety of health care providers. Unfortunately, these guidelines often do not reflect the practices of most hypertension experts. This report summarizes the opinions of seven hypertension experts concerning the impact of "official" guidelines on clinical practice. In addition, the individual therapeutic recommendations of these panel members are summarized. Their different treatment strategies reflect the diversity of first rate treatment plans that aim to reduce the cardiovascular sequelae in individual patients with essential hypertension. Most importantly, not one of these seven treatment strategies followed the "preferred" treatment of the U.S. guidelines, which recommend diuretics and beta-blockers as first-line therapy. The present authors approach the treatment of hypertension as a means to reduce cardiovascular events. Thus, reduction of blood pressure is not the most important therapeutic endpoint. The panel believes that whereas many different drugs can produce effective blood pressure reduction, the modern primary goal of antihypertensive drug therapy is to select a regimen most likely to prolong the quality and duration of life. In real terms, this means that the primary goal of treatment is the prevention of the major vascular sequelae of hypertension (heart attack, ventricular remodeling, hypertrophy, heart failure, and stroke) that shorten useful life. There are a number of effective hypertensive treatments, which can be selected based on individual patient requirements. However, many consensus guidelines do not allow the flexibility required to optimize individual patient treatment. As a result, health care providers should not feel compelled to regard the preferences of "official" guidelines as the best, modern, state-of-the-art therapy for an individual patient. All seven experts who are deeply involved in the daily care of patients preferred drugs other than beta-blockers and diuretics (the Joint National Committee [JNC] choices) for first-line therapy of hypertension.

Cardiovascular Diseases↗

PubMed1995

Effect of prescribing guidelines on the use of neuromuscular blocking agents.

The effect of prescribing guidelines on the use of neuromuscular blocking agents (NMBs) was studied. Voluntary guidelines on the appropriate prescribing of formulary NMBs in the operating rooms at a university hospital were approved in January 1993. Patients who underwent inpatient surgery with neuromuscular blockade during a preguideline period (March 1, 1992, through May 31, 1992) or a postguideline period (March 1, 1993, through May 31, 1993) were randomly selected (n = 200 per group) and compared to determine the relative appropriateness, effectiveness, safety, and cost of NMB use. The preguideline and post-guideline groups were demographically similar. There were significantly more instances of appropriate NMB use after than before the guidelines were established. Neuromuscular blockade was maintained inall patients. The overall rates of NMB-associated adverse events were 5.5% and 7.5% for the preguideline and postguideline groups, respectively. The acquisition cost of NMBs and drugs used to treat NMB-associated adverse events for the preguideline patients was $4261, versus $2978 for the postguideline patients. Extrapolated to the estimated 10,000 operations per year requiring neuromuscular blockade at the institution, the total cost was $213,000 before guideline introduction and $149,000 afterward, for a guideline-associated cost reduction of $64,000. Prescribing guidelines reduced expenditures for NMBs without affecting clinical outcomes.

Drug Costs↗

PubMed2003

Transferring policies for treating sexually transmitted infections: what's wrong with global guidelines?

The paper uses a case study of the development of syndromic management for treating sexually transmitted infections (STIs) and subsequent policies recommending worldwide use of syndromic management guidelines. These treatment policies emerged in the late 1970s from researchers and public health physicians working in sub-Saharan Africa where they had to treat large numbers of STIs in difficult circumstances. Syndromic management was initially developed in specific local epidemiological and resource situations. By the late 1980s, the World Health Organization had adopted syndromic management as policy, and began to promote it globally in the form of algorithms and training guidelines. Dissemination was assisted by the context of the rapid spread of HIV/AIDS and the apparent effectiveness of syndromic management for treating STIs and slowing the transmission of HIV/AIDS. In the mid 1990s, international donors interested in HIV control and women's reproductive health took it up, and encouraged national programmes to adopt the new guidelines. Implementation, however, was a great deal more complex than anticipated, and was exacerbated by differences between three rather separate policy networks involved in the dissemination and execution of the global guidelines. The analysis focuses on two parts of the process of policy transfer: the organic development of scientific and medical consensus around a new policy for the treatment of STIs; and the formulation and subsequent dissemination of international policy guidelines. Using a political science approach, we analyze the transition from clinical tools to global guidelines, and the associated debates that accompanied their use. Finally, we comment on the way current global guidelines need to be adapted, given the growth in knowledge.

Africa South of the Sahara↗

PubMed2005

Guidelines for preoperative assessment: impact on clinical practice and costs.

OBJECTIVE: To describe preoperative evaluation in the San Giovanni Battista Hospital in Turin and to forecast the economic impact when preoperative assessment guidelines are implemented. DESIGN: We enrolled, in a month, 702 consecutive patients, excluding cardiac, thoracic, neuro- and vascular surgery, as well as emergency operations. Preoperative assessment data were collected individually, followed by simulating various applications of guidelines based on: (i) preoperative tests relying on full medical history and physical examination to discriminate preoperative risk patients; (ii) organization of a preoperative evaluation unit and tests before patient hospitalization. MAIN MEASURES: Mean number of tests prescribed, preoperative assessment cost per patient. RESULTS: The application of preoperative guidelines would decrease the mean number of tests prescribed from 20 laboratory and 1.9 instrumental to, respectively, 3 and 1.4 per patient. Tests deemed inappropriate by guidelines did not add any relevant clinical information to our study. Economic analysis estimates a reduction of 63% in cost per patient for preoperative tests by introducing guideline criteria (from 69 euros to 26 euros). As regards the cost per patient for preoperative evaluation and hospital stay (115 euros considering only variable costs, 580 euros including all costs), the application of the guidelines would reduce costs by 41-52% according to different cost evaluation approaches for hospital stay. CONCLUSION: Preoperative guidelines fully introduced in practice could notably increase efficiency without affecting the quality of care.

Adolescent↗

PubMed2005

Improving quality of care for depression: the German Action Programme for the implementation of evidence-based guidelines.

ISSUE: Depressive disorders are of great medical and political significance. The potential inherent in achieving better guideline orientation and a better collaboration between different types of care is clear. Throughout the 1990s, educational initiatives were started for implementing guidelines. Evidence-based guidelines on depression have been formulated in many countries. PURPOSE: This article presents an action programme for structural, educational, and research-related measures to implement evidence-based care of depressive disorders in the German health system. The starting points of the programme are the 'Guidelines Critical Appraisal Reports' of the 'Guideline Clearing House' and measures from the 'Competence Network on Depression and Suicidality' (CNDS) funded by the Federal Ministry of Education and Research. The article gives an overview of the steps achieved as recommended by the Guidelines Critical Appraisal Reports and the ongoing transfer process into the German health care system. RESULTS: The action programme shows that comprehensive interventions to develop and introduce evidence-based guidelines for depression can achieve benefits in the care of depression, e.g. in recognition, management, and clinical outcome. CONCLUSION: It was possible to implement the German Action Programme in selected care settings, and initial evaluation results suggest some improvements. The action programme provides preliminary work, materials, and results for developing a future 'Disease Management Programme' (DMP) for depression.

Depressive Disorder↗

PubMed1996

Dietary guidelines in perspective.

To assess whether dietary guidelines for Americans are appropriate for young children, the evolution of dietary guidance, the nature of the guidelines, evidence used to support the concept of diet modification to prevent heart disease and the rationale for extending application of the guidelines to children have been examined. As health improved during this century, life expectancy lengthened, and diseases associated with aging became major causes of death. As a consequence, emphasis on dietary advice for selecting a nutritionally adequate diet--the primary need of children--declined, whereas emphasis on dietary advice for preventing chronic and degenerative diseases increased. It is clear from reading the text accompanying the guidelines that they were proposed to prevent diseases of aging by reducing consumption of animal products. Critical evaluation of evidence bearing on the concept of the guidelines reveals that there are grounds for skepticism about claims for the effectiveness of diet modification as a measure for reducing the incidence of heart disease. Also, the rationale for extending the guidelines to young children is based on inferences from observations on adults, not on direct evidence that children will benefit from following them. There is, thus, ample justification for proposing separate dietary guidelines for children.

Adult↗

PubMed1997

National Kidney Foundation: Dialysis Outcome Quality Initiative--development of methodology for clinical practice guidelines.

BACKGROUND: The NKF-DOQI (National Kidney Foundation--Dialysis Outcomes Quality Initiative) began in March 1995 with the following objectives: To improve end-stage renal disease (ESRF) patient survival, to reduce patient morbidity, to increase efficiency of care, and to improve quality of life for ESRF patients. METHODS: The development of the NKF-DOQI Clinical Practice Guidelines focused on haemodialysis adequacy, peritoneal dialysis adequacy, vascular access, and anaemia. Principles guiding the methodology included scientific and methodological rigour, interdisciplinary approach, independence of the Work Groups, and an open review process. Unique features of this evidence-based guideline development process included the use of mock guidelines and rationales to guide the literature research, and an unprecedented three-stage review process. RESULTS: Work Groups reviewed more than 11,000 articles. A total of 114 clinical practice guidelines were developed by the Work Groups; these have been reviewed by more than 1200 professionals and patients. CONCLUSION: The NKF-DOQI Clinical Practice Guidelines has been a unifying effort for the entire renal community. The guidelines are an important step in the process of improving the quality of dialysis practice and improving ESRF patient outcomes. Priorities for implementation of the guidelines include education of ESRF professionals and patients, working with providers and insurers to encourage compliance, and follow-up evaluation of patient outcomes to quantify compliance results.

Foundations↗

PubMed2000

Lessons learned in applying the U.S. EPA proposed cancer guidelines to specific compounds.

An expert panel was convened to evaluate the U.S. Environmental Protection Agency's "Proposed Guidelines for Carcinogen Risk Assessment" through their application to data sets for chloroform (CHCl3) and dichloroacetic acid (DCA). The panel also commented on perceived strengths and limitations encountered in applying the guidelines to these specific compounds. This latter aspect of the panel's activities is the focus of this perspective. The panel was very enthusiastic about the evolution of these proposed guidelines, which represent a major step forward from earlier EPA guidance on cancer-risk assessment. These new guidelines provide the latitude to consider diverse scientific data and allow considerable flexibility in dose-response assessments, depending on the chemical's mode of action. They serve as a very useful template for incorporating state-of-the-art science into carcinogen risk assessments. In addition, the new guidelines promote harmonization of methodologies for cancer- and noncancer-risk assessments. While new guidance on the qualitative decisions ensuing from the determination of mode of action is relatively straightforward, the description of the quantitative implementation of various risk-assessment options requires additional development. Specific areas needing clarification include: (1) the decision criteria for judging the adequacy of the weight of evidence for any particular mode of action; (2) the role of mode of action in guiding development of toxicokinetic, biologically based or case-specific models; (3) the manner in which mode of action and other technical considerations provide guidance on margin-of-exposure calculations; (4) the relative roles of the risk manager versus the risk assessor in evaluating the margin of exposure; and (5 ) the influence of mode of action in harmonizing cancer and noncancer risk assessment methodologies. These points are elaborated as recommendations for improvements to any revisions. In general, the incorporation of examples of quantitative assessments for specific chemicals would strengthen the guidelines. Clearly, any revisions should retain the emphasis present in these draft guidelines on flexibility in the use of scientific information with individual compounds, while simultaneously improving the description of the processes by which these mode-of-action data are organized and interpreted.

Animals↗

PubMed2000

Effects of guidelines implementation in a surgical intensive care unit to control nighttime light and noise levels.

OBJECTIVE: Because of around-the-clock activities, environmental noise and light are among the many causes of sleep disturbance in an intensive care unit (ICU). The implementation of guidelines may potentially change behavior rules and improve sleep quality. DESIGN: A prospective interventional study, observing the effects of simple nighttime guidelines on light and noise levels in an ICU. SETTING: A modern surgical ICU, subdivided into six identical three-bed rooms. PATIENTS: Critically ill adult patients. INTERVENTION: Between two observation periods, five guidelines were implemented to decrease both light and noise during the night shift in the patient's room. MEASUREMENT: Light levels and noise levels were obtained using a luxmeter and a sound level meter [A-weighted decibels (dB) scale] and were monitored continuously from 11 pm to 5 am both before (period P1) and after (period P2) the implementation of guidelines. MAIN RESULTS: Similar patient's gravity and nursing workload scores were observed between P1 and P2. A low mean (<5 Lux) and maximal light level were measured during both P1 and P2. The implementation of guidelines lowered mean light disturbance intensity with a greater variability of light during P2. All noise levels were high and corresponded more to a quiet office for noise level equivalents and to a busy restaurant for peak noise levels during both P1 and P2. Guidelines decreased the noise level equivalent (P1, 51.3 dB; P2, 48.3 dB), peak noise level (P1, 74.9 dB; P2, 70.8 dB), and the number of acoustic identified alarms (P1, 22.1 dB; P2, 15.8 dB) during P2. CONCLUSION: The night light levels were low during both periods, and lowering the light levels induced a greater variation of light, which may impair sleep quality. All measured noise levels were high during both periods, which could contribute to sleep disturbance, and the implementation of guidelines significantly lowers some important noise levels. The background noise level was unchanged.

Adult↗