2014 0503-2 sound and silence national council of acoustical consultants

NatioNal CouNCil of aCoustiCal CoNsultaNts 2014 aNNual meetiNg

Rosalyn Cama, FASID, EDAC

[email protected] camaincorporated.com

S o u n d & S i l e n c eS o u n d

EvidEncE-baSEd dESign

the process of basing decisions about the built environment on credible research to achieve the best possible outcomes.

projectwisdom

DesignIntelligence

InstitutionalIntelligence

ConstituencyIntelligence

ThoughtLeaders

IntelligenceResearchIntelligence

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4 March 2013

22. Would you recommend this hospital to your friends and family?1 Definitely no2 Probably no3 Probably yes4 Definitely yes

UNDERSTANDING YOUR CAREWHEN YOU LEFT THE HOSPITAL

23. During this hospital stay, staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left.1 Strongly disagree2 Disagree3 Agree4 Strongly agree

24. When I left the hospital, I had a good understanding of the things I was responsible for in managing my health.1 Strongly disagree2 Disagree3 Agree4 Strongly agree

25. When I left the hospital, I clearly understood the purpose for taking each of my medications.1 Strongly disagree2 Disagree3 Agree4 Strongly agree5 I was not given any medication

when I left the hospital

ABOUT YOUThere are only a few remaining items left.26. During this hospital stay, were you

admitted to this hospital through the Emergency Room? 1 Yes2 No

27. In general, how would you rate your overall health? 1 Excellent2 Very good3 Good4 Fair5 Poor

28. In general, how would you rate your overall mental or emotional health?1 Excellent2 Very good3 Good4 Fair5 Poor

29. What is the highest grade or level of school that you have completed?1 8th grade or less2 Some high school, but did not

graduate3 High school graduate or GED4 Some college or 2-year degree5 4-year college graduate6 More than 4-year college degree

March 2013 1

HCAHPS Survey

SURVEY INSTRUCTIONS

♦ You should only fill out this survey if you were the patient during the hospital stay named in the cover letter. Do not fill out this survey if you were not the patient.

♦ Answer all the questions by checking the box to the left of your answer.♦ You are sometimes told to skip over some questions in this survey. When this happens

you will see an arrow with a note that tells you what question to answer next, like this: Yes No If No, Go to Question 1

You may notice a number on the survey. This number is used to let us know if you returned your survey so we don't have to send you reminders.Please note: Questions 1-25 in this survey are part of a national initiative to measure the quality of care in hospitals. OMB #0938-0981

Please answer the questions in this survey about your stay at the hospital named on the cover letter. Do not include any other hospital stays in your answers.

YOUR CARE FROM NURSES

1. During this hospital stay, how often did nurses treat you with courtesy and respect?1 Never2 Sometimes 3 Usually4 Always

2. During this hospital stay, how often did nurses listen carefully to you?1 Never2 Sometimes 3 Usually4 Always

3. During this hospital stay, how often did nurses explain things in a way you could understand?1 Never2 Sometimes 3 Usually4 Always

4. During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it?1 Never2 Sometimes3 Usually4 Always9 I never pressed the call button

“Would you recommend this hospital to your friends and family?”

DefiNitely No

PRobably No

PRobably yes

DefiNitely yes

choice architectureDESIgn InFluEnCES bEhAvIor

“Small and apparEntly inSignificant dEtailS can havE major impactS on pEoplE’S bEhavior.”

-- Richard Thaler & Cass Sunstein authors of Nudge: Improving Decisions About Health, Wealth, and Happiness

SMELL

LISTEN

LOOK

* Remember

* Relax

* Imagine

TOUCH

TASTE

* Discover

* Savor

hoW noiSy arE hoSpitalS?MEASurIng DECIbElS

hoSpital noiSE lEvElS around thE World havE bEEn riSing conSiStEntly SincE thE 1960s

World HealtH organization recommended levelsFor continuous background noise in hospital patient rooms:DAY - 35 dB NIGHT - 30 dBNIGHT PeAks - NoT To exceeD 40 dB 4

0 d B R A I N D R

oP

s

De

cIB

el

sc

Ale

louder

iN Reality…background noiSE 45-68 db pEakS oftEn ExcEEd 85-90 db

85

db

b

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ffic

90 db h

air

dr

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r

10

5 db rock concErt

110 db chainSaW

140 db g

un

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ot

40

db raindro

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60 d b c o nvEr

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120 db jackhammEr

11

5 d

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po

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Eak volumE

Why So noiSy?SourCES oF SounD

SourcES arE numErouS & loudstaff voices, paging systems, alarms, bedrails, telephones, ice machines, pneumatic tubes, trolleys…

mEdical EquipmEnt & Staff voicESProduce noise at 70–75 db levels at the patient’s head, which approach the noise level in a busy restaurant

70-7

5 db buSy rEStauran

t

alarmS & EquipmEntPortable X-ray machines exceed 90 db, comparable to walking next to a busy highway when a motorcycle or large truck passes.

90 d

b buSy highWay Wh

En t

ru

ck

pa

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ES

Shift changESone study recorded 113 db during shift changes at a large hospital

115

db ip

od at pEak volumE

Sound-rEflEcting vS Sound-abSorbing SurfacESlong reverberation times enable noise to echo, linger, and propagate over large areas and into patient rooms

multibEd roomSmany patients are housed in multibed rooms in which much noise originates from other patients

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patiEnt outcomESPlEASE Do not DISturb

“during thiS hoSpital Stay, hoW oftEn WaS thE arEa around your room quiEt at night?”

-- HCAHPS Survey Question

SlEEp diSruption & dEprivationstudies show that noise often leads to fragmented sleep patterns; preventing patients from progressing into deeper and more restorative sleep stages

Sleep | StreSS | pain | CommuniCation | SatiSfaCtionSlEEp

intEnSivE carE unitSin a survey of neurosurgery iCu patients, among those who reported sleep disturbance, 58% considered environmental noise a frequent disturbing factor.

another study of iCus suggested that about 20% of arousals and awakenings were related to noise.

another study showed that participants assigned to iCu noise conditions took longer to fall asleep, slept less, and experienced more awakenings and poorer sleep quality.


pSychological StrESS as indicated by negative feelings such as anxiety and annoyance

phySiological StrESSDetrimental physiological changes such as elevated heart rate and blood pressure

Sleep | StreSS | pain | CommuniCation | SatiSfaCtionStrESS

nEonatal intEnSivE carE a study in a NiCu measured peak levels once per minute and found that 31% of pEakS ExcEEd 90 db. High noise levels elevate blood pressure, heart, and respiration rates, and decrease oxygen saturation, thereby increasing the need for oxygen support therapy.

90 db hair dryEr


cro

WdEd Waiting room

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coping With uncontrollablE noiSE “EarphonES arE thE nEW Wall.”


mri Produce random, noises that can be as loud as 125 db. Procedure can last up to an hour or more, and the patient must hold very still. open mRi machines offer an almost 360-degree panoramic view, ideal for claustrophobic and obese patients.1

25 d

b jEt EnginE takE o

ff


Sleep | StreSS | pain | CommuniCation | SatiSfaCtionpain

“Sound StrEaming in through my EarS blaStEd my brain SEnSElESS So that WhEn pEoplE SpokE, i could not diStinguiSh thEir voicES from thE undErlying clattEr of thE EnvironmEnt. from my pErSpEctivE, EvEryonE clamorEd En maSSE and rESonatEd likE a diScordant pack of rEStlESS animalS.”

-- JILL BOLTE TAYLOR, neuroanatomist, author of My Stroke of Insight


communication & SpEEch privacy

Sleep | StreSS | pain | CommuniCation | SatiSfaCtioncommunication

EffEctivE communication to prEvEnt rEadmiSSion

Sleep | StreSS | pain | CommuniCation | SatiSfaCtioncommunication

patiEnt SatiSfactionPatients often complain about temperatures (“too cold”) and high noise levels (“so noisy”) in their rooms.

Sleep | StreSS | pain | privacy | SatiSfactionSatiSfaction

quiEt kitS

noiSE and pErcEption of carEstudy found that patients treated during the good acoustic period (with sound-absorbing ceiling tiles) considered staff attitude to be much better, implying that good room acoustics has an effect on patient satisfaction with staff.


Staff outcomES hAbItuAtIon

“it’S a lot morE plEaSant bEing at Work...i don’t hEar alarmS in my drEamS anymorE.”

-- Amanda Gerety, staff nurse of Boston Medical Center. The hospital is recognized nationally for its approach to conquering alarm fatigue.

StreSS | error | Productivity | SatiSfactionStrESS

nurSE burnoutfew studies have focused on the impact of noise on staff. Noise-induced stress correlates with reported emotional exhaustion or burnout among critical care nurses.

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SE

StreSS | error | Productivity | SatiSfactionError

habituation & alarm fatiguE

a boston medical Center telemetry unit rEducEd audiblE alarmS by 89%. most “warning” alarms, indicating potential problems such as low heart rate were turned off. other alarms deemed more critical, such as a pause in heart rhythm, were turned to a higher level.

Sta

rtlE rEflEx


mEdication diSpEnSingPrescription error rates increase sharply when there is an interruption or distraction from an unpredicted noise (e.g., a telephone call).

unprEdictablE noiSE | complicatEd taSkSthe combination of unpredictable noise and complicated tasks can increase errors in calculation, tracking, and monitoring tasks, and lead to slower learning and poor memorization.


monitoring vital SignSHospital staff often complain that noise levels make their work more difficult, particularly when it comes to monitoring patients’ vital signs.

StreSS | error | Productivity | SatiSfactionproductivity

pErformancE quality not affEctEd by noiSEeven in operating theaters where background noise levels can be 80–85 db with intermittent spikes of 110–115 db. but can lead to longer procedure times.

110 db ch

ain

SaW


StreSS | error | Productivity | SatiSfactionSatiSfaction

chronic EffEctS on pErformancE and StrESSSome studies have identified long-term negative effects of noise on staff.

Staff turnovEr$62,000 pEr nurSE rEplacEdinvestments in the environment to increase staff satisfaction could potentially reduce the cost of staff turnover.

dESign intErvEntionS

Culture | eliminate SourCeS | Private roomS | Sound-abSorbing materialSculturE

quiEt cuESDim hall lights at night to cue staff and visitors to keep voices low.

yackEr trackErthe cardiac care unit at st. Joseph’s Hospital Health Center utilizes a yacker tracker, a stoplight-looking device to measure sound levels. at 60 db and above the stoplight changes from green to red and is synchronized to dim the overhead lights at nurse stations.

opEn (or cloSEd) door policy?Policy regarding keeping patient doors open should be re-examined.


quiEt culturE vS EnvironmEntal changESenvironmental approaches to quiet healthcare settings can be more successful than organizational interventions such as staff education or establishing quiet hours.


phonE & intravEnouS infuSion pump alarmSmost distracting, negatively impact patient sleep. solutioNs: answer iv alarms promptly, lower background sound levels / Reduce telephone ring tone volume to prevent transmission beyond patient rooms / set telephones to stop after a specific number of rings.

Culture | eliminate SourCeS | Private roomS | Sound-abSorbing materialS EliminatE SourcES

WirElESS communicationSstaff conversations, as well as voice paging, highly disruptive to patient sleep, especially in the light sleep stages. Wireless communications prevent staff from raising their voices to be heard across large sapces or down hallways.


icE machinESshould be architecturally isolated from patient areas or dramatically re-engineered.


door hardWarElimit latch noises; door gasket to block noise from hall and nurse station

hand toWEl diSpEnSErSQuieter or low-tech alternatives for automatic hand towel dispensers should be substituted.

Culture | eliminate SourCeS | Private roomS | Sound-abSorbing materialS privatE roomS

TOILET LOCATEDON HEADWALL

HA

ND

RA

IL

SLIDINGDOOR

HAND WASHING SINK AT ENTRY

VARIABLE-ACUITY HEADWALL

NURSE SERVER

WARDROBE W/ LOCKABLE STORAGE

FAMILY ZONE ROOMING-IN

FLAT SCREEN TV

DAYLIGHT & VIEWS

PRIVATE ROOM300 SQ FT

LIKE-HANDED

SinglE vS multibEdPrivate patient room is the most effective environmental approach to noise control. No noise from the presence of other patients (visitors, staff, patient sounds - coughing, crying, rattling bedrails)

Culture | eliminate SourCeS | Private roomS | Sound-abSorbing materialSprivatE roomS

rEducEd StrESSa survey in NiCus found that staff perceived a unit with single-patient rooms to be less stressful for both family and staff than an open-bay unit, owing to better privacy and control over the environment.

improvEd SlEEpin a study of iCus, average noise and peak levels were higher in the open iCu than in the single room. total sleep time in the single-bed room (9.5 hours) was greater than that in the open iCu (8.2 hours).


incrEaSEd SatiSfactionsatisfaction with noise levels is on average 11.2% higher for patients in private rooms than for those in multibed rooms


talking roomSincrease privacy with private discussion rooms away from waiting rooms. also include on patient floors that have multibed rooms.


Staff collaboration SpacEDesignated consulting spaces for nurses away from open hall areas, yet not far from nursing stations.


Culture | eliminate SourCeS | Private roomS | Sound-abSorbing materialSSound-abSorbing matErialS

incorporatE Sound abSorbing matErialSinstall high-performance sound-absorbing materials on ceilings, floors, and walls to reduce noise levels, reverberation or echoing, and sound propagation.


ORIENTED TOTHE FUTURE

ORIENTED TOTHE PRESENT

VALUESDRIVEN

ECONOMYDRIVEN

GET HERE 2

1

3

2

values (belief)

value $$$

lag - baselineinnovate

gEt hErE

dEciSion making dEtErminantS

ORIENTED TOTHE FUTURE

ORIENTED TOTHE PRESENT

VALUESDRIVEN

ECONOMYDRIVEN

GET HERE 2

1

3

2


gEt hErE

dEciSion making dEtErminantS

value $$$

lag - baselineinnovate

values (belief)


Sound-abSorbing acouStical cEiling tilESWith sound-absorbing ceiling tiles in place, coronary intensive care patients evidenced lower physiological stress, slept better, reported better care from nurses, and had a lower incidence of rehospitalization in the weeks following discharge.

rEvErbEration timE & SlEEpeven if noise levels remain almost the same, reduction in reverberation time with sound-absorbing ceiling tiles can improve sleep quality. meanwhile, even relatively low decibel levels but with longer reverberation times can negatively impact sleep.

act & Staff StrESSNurses perceived significantly lower work demands and reported less pressure and strain when the sound-absorbing tiles were in place.

Project ProfileJWT Atlanta

acouStical Wall SurfacES



carpEtaesthetic and noise reduction appeal, not suitable everywhere.

tanduSHybrid resilient sheet flooring

cuShionEd rubbEr


hum of WEllnESS

lifE and dEathbabies in the womb actively listen to their mother’s voice during the last ten weeks of pregnancy. Hearing is thought to be the last sense to go in the dying process.

muSic thErapythe 20th century discipline began after World War i and World War ii when community musicians went to veterans hospitals around the country to play for the thousands of veterans suffering both physical and emotional trauma from the wars. the patients’ notable physical and emotional responses to music led the doctors and nurses to request the hiring of musicians by the hospitals.

muSic, EmotionS, & mEmorylistening to music activates many different areas of the brain, including the emotion centers involved with pleasure.

muSic and brand - StarbuckSWhat would the coffeehouse be without great music? Well it wouldn’t be starbucks, for one thing. We’re just as passionate about music as we are about coffee. that’s why we handpick all the tunes you hear in our stores.

muSic and brand - SmiloW cancEr hoSpital at yalE nEW havEn

SMELL

LISTEN

LOOK

* Remember

* Relax

* Imagine

TOUCH

TASTE

* Discover

* Savor

“bEauty iS our Word for pErfEction of thoSE qualitiES of EnvironmEnt that havE

contributEd moSt to human Survival.”

-- E.O. WILSON in Kellert, S.R. and Finnegan, B. (Producers). (2011). a Design: The Architecture of Life [Motion picture]. United States: Tamarack Media.

AMERICANSSPEND ABOUT

OR MORE OF THEIR TIME INDOORS.

“oppoSitE of bEauty iS injury not uglinESS.”

-- Elaine Scarry (1999). On Beauty and Being Just. Princeton: Princeton University Press.

Injury | StabIlIze | rehabIlItate | reStore | beauty injury

Injury | StabIlIze | rehabIlItate | reStore | beauty

Injury | StabIlIze | rehabIlItate | reStore | beauty bEauty

NatioNal CouNCil of aCoustiCal CoNsultaNts 2014 aNNual meetiNg

Rosalyn Cama, FASID, EDAC

[email protected] camaincorporated.com

S o u n d & S i l e n c eS o u n d

EvidEncE-baSEd dESignEBD Definition retrieved fromhttp://edac.healthdesign.org/

Cama, R. (2009). Evidence-Based Healthcare Design, John Wiley & sons.

hcahpS SurvEyRetrieved from http://www.hcahpsonline.org/files/HCAHPS%20v8.0%20appendix%20a%20-%20HCaHPs%20mail%20survey%20materials%20(english)%20march%202013.pdf

choicE architEcturEthaler, R.H & sunstein, C.R (2008). Nudge: Improving Decisions About Health, Wealth, and Happiness. london: Penguin books.

hoW noiSy arE hoSpitalS?busch-vishniac, i., West, J., barnhill, C., Hunter, t., orellana, D.,& Chivukula, R. (2005). Noise levels in Johns Hopkins Hospital.Journal of the Acoustical Society of America, 118(6), 3629–3645.

World hEalth organization rEcommEndEd dEcibEl lEvElSberglund, b., lindvall, t., & schwela, D. H. (1999). Guidelines for community noise. World Health organization: Protection of theHuman environment.

in rEality...typical dEcibEl lEvElSulrich, R.s., zimring, C., zhu, X., Dubose, J., seo, H., Choi, y., Quan, X., Joseph, a. (2008). a Review of the Research literature on evidence-based Healthcare Design. HERD 1(3), 109.

SourcES arE numErouS and loudulrich, R.s., zimring, C., zhu, X., Dubose, J., seo, H., Choi, y., Quan, X., Joseph, a. (2008). a Review of the Research literature on evidence-based Healthcare Design. HERD 1(3), 109.

mEdical EquipmEnt & Staff voicESblomkvist, v., eriksen, C. a., theorell, t., ulrich, R. s., & Rasmanis,g. (2005). acoustics and psychosocial environment in intensive coronary care. Occupational and Environmental Medicine, 62, 132–139.

alarmS & EquipmEntulrich, R.s., zimring, C., zhu, X., Dubose, J., seo, H., Choi, y., Quan, X., Joseph, a. (2008). a Review of the Research literature on evidence-based Healthcare Design. HERD 1(3), 109.

Shift changESCmiel, C. a., Karr, D. m., gasser, D. m., oliphant, l. m., & Neveau, a. J. (2004). Noise control: a nursing team’s approach to sleep promotion. American Journal of Nursing, 104, 40–48.

WoRlD HealtH oRgaNizatioN ReCommeNDeD levelsfor continuous background noise in hospital patient rooms:day - 35 db night - 30 dbnight pEakS - not to ExcEEd 40 db 4

0 d b r a i n d r

op

S

dE

cib

El

Sc

alE

souND PRessuRe level

HigHeR

iN Reality…background noiSE 45-68 db pEakS oftEn ExcEEd 85-90 db

85

db

b

uSy cit y tra

ffic

90 db h

air

dr

yE

r

10

5 db rock concErt

110 db chainSaW

140 db g

un

Sh

ot

40

db raindro

pS

60 d b c o nvEr

Sa

tio

n

120 db jackhammEr

11

5 d

b i

po

d a

t p

Eak volumE

mEdical EquipmEnt & Staff voicESProduce noise at 70–75 db levels at the patient’s head, which approach the noise level in a busy restaurant

70-7

5 db buSy rEStauran

t

alarmS & EquipmEntPortable X-ray machines exceed 90 db, comparable to walking next to a busy highway when a motorcycle or large truck passes.

90 d

b buSy highWay Wh

En t

ru

ck

pa

SS

ES

Shift changESone study recorded 113 db during shift changes at a large hospital

115

db ip

od at pEak volumE

SourcES arE numErouS & loudstaff voices, paging systems, alarms, bedrails, telephones, ice machines, pneumatic tubes, trolleys…

4 March 2013

22. Would you recommend this hospital to your friends and family?1 Definitely no2 Probably no3 Probably yes4 Definitely yes

UNDERSTANDING YOUR CAREWHEN YOU LEFT THE HOSPITAL

23. During this hospital stay, staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left.1 Strongly disagree2 Disagree3 Agree4 Strongly agree

24. When I left the hospital, I had a good understanding of the things I was responsible for in managing my health.1 Strongly disagree2 Disagree3 Agree4 Strongly agree

25. When I left the hospital, I clearly understood the purpose for taking each of my medications.1 Strongly disagree2 Disagree3 Agree4 Strongly agree5 I was not given any medication

when I left the hospital

ABOUT YOUThere are only a few remaining items left.26. During this hospital stay, were you

admitted to this hospital through the Emergency Room? 1 Yes2 No

27. In general, how would you rate your overall health? 1 Excellent2 Very good3 Good4 Fair5 Poor

28. In general, how would you rate your overall mental or emotional health?1 Excellent2 Very good3 Good4 Fair5 Poor

29. What is the highest grade or level of school that you have completed?1 8th grade or less2 Some high school, but did not

graduate3 High school graduate or GED4 Some college or 2-year degree5 4-year college graduate6 More than 4-year college degree

March 2013 1

HCAHPS Survey

SURVEY INSTRUCTIONS

♦ You should only fill out this survey if you were the patient during the hospital stay named in the cover letter. Do not fill out this survey if you were not the patient.

♦ Answer all the questions by checking the box to the left of your answer.♦ You are sometimes told to skip over some questions in this survey. When this happens

you will see an arrow with a note that tells you what question to answer next, like this: Yes No If No, Go to Question 1

You may notice a number on the survey. This number is used to let us know if you returned your survey so we don't have to send you reminders.Please note: Questions 1-25 in this survey are part of a national initiative to measure the quality of care in hospitals. OMB #0938-0981

Please answer the questions in this survey about your stay at the hospital named on the cover letter. Do not include any other hospital stays in your answers.

YOUR CARE FROM NURSES

1. During this hospital stay, how often did nurses treat you with courtesy and respect?1 Never2 Sometimes 3 Usually4 Always

2. During this hospital stay, how often did nurses listen carefully to you?1 Never2 Sometimes 3 Usually4 Always

3. During this hospital stay, how often did nurses explain things in a way you could understand?1 Never2 Sometimes 3 Usually4 Always

4. During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it?1 Never2 Sometimes3 Usually4 Always9 I never pressed the call button

“Would you recommend this hospital to your friends and family?”

DefiNitely No

PRobably No

PRobably yes

DefiNitely yes

choice architectureDESIgn InFluEnCES bEhAvIor

“Small and apparEntly inSignificant dEtailS can havE major impactS on pEoplE’S bEhavior.”

-- Richard Thaler & Cass Sunstein authors of Nudge: Improving Decisions About Health, Wealth, and Happiness

hoW noiSy arE hoSpitalS?MEASurIng DECIbElS

hoSpital noiSE lEvElS around thE World havE bEEn riSing conSiStEntly SincE thE 1960s

EvidEncE-baSEd dESign

the process of basing decisions about the built environment on credible research to achieve the best possible outcomes.

Sound-rEflEcting vS Sound-abSorbingblomkvist, v., eriksen, C. a., theorell, t., ulrich, R. s., & Rasmanis,g. (2005). acoustics and psychosocial environment in intensive coronary care. Occupational and Environmental Medicine, 62, 132–139.

ulrich, R. s. (2003). Research on building design and patient outcomes. in Exploring the patient environment: An NHS estates workshop. London: The Stationery Office.

multi-bEd roomSbaker, C. f. (1984). sensory overload and noise in the iCu: sources of environmental stress. Critical Care Quarterly, 6(4), 66–80.southwell, m. t., & Wistow, g. (1995). sleep in hospitals at night - are patients’ needs being met? Journal of Advanced Nursing, 21(6), 1101–1109.yinnon, a. m., ilan, y., tadmor, b., altarescu, g., & Hershko, C. (1992). Quality of sleep in the medical department. British Journal of Clinical Practice, 46(2), 88–91.

patiEnt outcomESHCaHPs surveyRetrieved from http://www.hcahpsonline.org/files/HCAHPS%20v8.0%20appendix%20a%20-%20HCaHPs%20mail%20survey%20materials%20(english)%20march%202013.pdf

SlEEp diSruption & dEprivationbaHammam, a. (2006). sleep in acute care units. Sleep andBreathing, 10(1), 6–15.

intEnSivE carE ugras, g. a., & oztekin, s. D. (2007). Patient perception of environmental and nursing factors contributing to sleep disturbances in a neurosurgical intensive care unit. Tohoku Journal of Experimental Medicine, 212(3), 299–308.Parthasarathy, s., & tobin, m. J. (2004). sleep in the intensive careunit. Intensive Care Medicine, 30(2), 197–206.topf, m., bookman, m., & arand, D. (1996). effects of critical care unit noise on the subjective quality of sleep. Journal of Advanced Nursing, 24(3), 545–551.

StrESSbentley, s., murphy, f., & Dudley, H. (1977). Perceived noise in surgical wards and an intensive care area: an objective analysis. British Medical Journal, 2(6101), 1503–1506.

morrison, W. e., Haas, e. C., shaffner, D. H., garrett, e. s., &fackler, J. C. (2003). Noise, stress, and annoyance in a pediatricintensive care unit. Critical Care medicine, 31(1), 113–119.

nEonatal intEnSivE carEslevin, m., farrington, N., Duffy, g., Daly, l., & murphy, J. f.(2000). altering the NiCu and measuring infants’ responses. ActaPaediatrica, 89(5), 577–581.

coping With uncontrollablE noiSETierney, J. (2012). From cubicles, cry for quiet pierces office buzz. New york times. Retrieved from http://www.nytimes.com/2012/05/20/science/when-buzz-at-your-cubicle-is-too-loud-for-work.html?pagewanted=all

mriNoise canceling headphones by optoacoustics. Retrieved from http://www.optoacoustics.com/

noiSE and paintaylor, J.b. (2009). My Stroke of Insight: A Brain Scientist’s Personal Journey, New york, Ny; Penguin group.

malenbaum, s., Keefe, f. J., Williams, a. C., ulrich, R., and somers,t. J. (2008). Pain in its environmental context: implications for designing environments to enhance pain control. Pain, 134, 241–244.

intEnSivE carE unitSin a survey of neurosurgery iCu patients, among those who reported sleep disturbance, 58% considered environmental noise a frequent disturbing factor.

another study of iCus suggested that about 20% of arousals and awakenings were related to noise.

another study showed that participants assigned to iCu noise conditions took longer to fall asleep, slept less, and experienced more awakenings and poorer sleep quality.


pSychological StrESS as indicated by negative feelings such as anxiety and annoyance

phySiological StrESSDetrimental physiological changes such as elevated heart rate and blood pressure


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mri Produce random, noises that can be as loud as 125 db. Procedure can last up to an hour or more, and the patient must hold very still. open mRi machines offer an almost 360-degree panoramic view, ideal for claustrophobic and obese patients.1

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“Sound StrEaming in through my EarS blaStEd my brain SEnSElESS So that WhEn pEoplE SpokE, i could not diStinguiSh thEir voicES from thE undErlying clattEr of thE EnvironmEnt. from my pErSpEctivE, EvEryonE clamorEd En maSSE and rESonatEd likE a diScordant pack of rEStlESS animalS.”

-- JILL BOLTE TAYLOR, neuroanatomist, author of My Stroke of Insight


nEonatal intEnSivE carE a study in a NiCu measured peak levels once per minute and found that 31% of pEakS ExcEEd 90 db. High noise levels elevate blood pressure, heart, and respiration rates, and decrease oxygen saturation, thereby increasing the need for oxygen support therapy.

90 db hair dryEr


multibEd roomSmany patients are housed in multibed rooms in which much noise originates from other patients

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patiEnt outcomESPlEASE Do not DISturb

“during thiS hoSpital Stay, hoW oftEn WaS thE arEa around your room quiEt at night?”

-- HCAHPS Survey Question

SlEEp diSruption & dEprivationstudies show that noise often leads to fragmented sleep patterns; preventing patients from progressing into deeper and more restorative sleep stages


Sound-rEflEcting vS Sound-abSorbing SurfacESlong reverberation times enable noise to echo, linger, and propagate over large areas and into patient rooms

patiEnt SatiSfactionPress ganey, inc (2007). Hospital pulse report: Patient perspectives on american health care. Retrieved march 18, 2008, from http://www.pressganey.com/galleries/default-file/hospital-report.pdf

pErcEption of carEHagerman, i., Rasmanis, g., blomkvist, v., ulrich, R., eriksen,C. A., & Theorell, T. (2005). Influence of intensive coronary careacoustics on the quality of care and physiological state of patients. International Journal of Cardiology, 98(2), 267–270.

Staff outcomESKnox, R. (2014, January 27). silencing many Hospital alarms leads to better Health Care. NPR. Retrieved from http://www.npr.org/blogs/health/2014/01/24/265702152/silencing-many-hospital-alarms-leads-to-better-health-care

nurSE burnouttopf, m., & Dillon, e. (1988). Noise-induced stress as a predictor of burnout in critical care nurses. Heart and Lung: The Journal of Critical Care, 17(5), 567–574.

habituation & alarm fatiguE sternberg, e. (2009). Healing Spaces: The Science of Place and Wellbeing. Cambridge, ma: Harvard university Press.

Knox, R. (2014, January 27). silencing many Hospital alarms leads to better Health Care. NPR. Retrieved from http://www.npr.org/blogs/health/2014/01/24/265702152/silencing-many-hospital-alarms-leads-to-better-health-care

mEdication diSpEnSingleather, P., beale, D., & sullivan, l. (2003). Noise, psychosocial stress and their interaction in the workplace. Journal of Environmental Psychology, 23(2), 213–222.

unprEdictablE noiSE, complicatEd taSksundstrom, e., & sundstrom, m. g. (1986). Work places: The psychology of the physical environment in offices and factories. Cambridge: Cambridge university Press.

monitoring vitalSzun, l. s., & Downey, l. (2005). the effect of noise in the emergency department. Academic Emergency Medicine, 12(7), 663–666.

pErformancE qualityulrich, R.s., zimring, C., zhu, X., Dubose, J., seo, H., Choi, y., Quan, X., Joseph, a. (2008). a Review of the Research literature on evidence-based Healthcare Design. HERD 1(3), 109.

SatiSfaction and Staff turnovErJones, C. b. (2004). the costs of nurse turnover: Part 1: an economic perspective. The Journal of Nursing Administration, 34(12), 562–570.


habituation & alarm fatiguE

a boston medical Center telemetry unit rEducEd audiblE alarmS by 89%. most “warning” alarms, indicating potential problems such as low heart rate were turned off. other alarms deemed more critical, such as a pause in heart rhythm, were turned to a higher level.

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mEdication diSpEnSingPrescription error rates increase sharply when there is an interruption or distraction from an unpredicted noise (e.g., a telephone call).

monitoring vital SignSHospital staff often complain that noise levels make their work more difficult, particularly when it comes to monitoring patients’ vital signs.


pErformancE quality not affEctEd by noiSEeven in operating theaters where background noise levels can be 80–85 db with intermittent spikes of 110–115 db. but can lead to longer procedure times.

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StreSS | error | Productivity | SatiSfactionSatiSfaction

chronic EffEctS on pErformancE and StrESSSome studies have identified long-term negative effects of noise on staff.

Staff turnovEr$62,000 pEr nurSE rEplacEdinvestments in the environment to increase staff satisfaction could potentially reduce the cost of staff turnover.

unprEdictablE noiSE | complicatEd taSkSthe combination of unpredictable noise and complicated tasks can increase errors in calculation, tracking, and monitoring tasks, and lead to slower learning and poor memorization.


noiSE and pErcEption of carEstudy found that patients treated during the good acoustic period (with sound-absorbing ceiling tiles) considered staff attitude to be much better, implying that good room acoustics has an effect on patient satisfaction with staff.


Staff outcomES hAbItuAtIon

“it’S a lot morE plEaSant bEing at Work...i don’t hEar alarmS in my drEamS anymorE.”

-- Amanda Gerety, staff nurse of Boston Medical Center. The hospital is recognized nationally for its approach to conquering alarm fatigue.

StreSS | error | Productivity | SatiSfactionStrESS

nurSE burnoutfew studies have focused on the impact of noise on staff. Noise-induced stress correlates with reported emotional exhaustion or burnout among critical care nurses.

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patiEnt SatiSfactionPatients often complain about temperatures (“too cold”) and high noise levels (“so noisy”) in their rooms.


quiEt kitS

quiEt cuES - yackEr trackErgabel, m (2009, July 28, ). Hospitals using yacker tracker in effort to reduce noise. syracuse.com Retrieved from http://www.syracuse.com/today/index.ssf/2009/07/hospitals_using_yacker_tracker.html

opEn (or cloSEd) door policy?ulrich, R.s., zimring, C., zhu, X., Dubose, J., seo, H., Choi, y., Quan, X., Joseph, a. (2008). a Review of the Research literature on evidence-based Healthcare Design. HERD 1(3), 109.

quiEt culturE vS EnvironmEntal changESmoore, m. m., Nguyen, D., Nolan, s. P., Robinson, s. P., Ryals, b.,imbrie, J. z., et al. (1998). interventions to reduce decibel levels on patient care units. American Surgeon, 64(9), 894–899.

phonE and intravEnouS infuSion pump alarmSWang, W (2010). evidence-based Design meets evidence-based medicine: the sound sleep study. the Center for Health Design. Retrieved from https://www.healthdesign.org/sites/default/files/Validating%20Acoustic%20Guidelines%20for%20HC%20facilities_sound%20sleep%20study.pdf

WirElESS communication Wang, W (2010). evidence-based Design meets evidence-based medicine: the sound sleep study. the Center for Health Design. Retrieved from https://www.healthdesign.org/sites/default/files/Validating%20Acoustic%20Guidelines%20for%20HC%20facilities_sound%20sleep%20study.pdf

icE machinES, Etc.Wang, W (2010). evidence-based Design meets evidence-based medicine: the sound sleep study. the Center for Health Design. Retrieved from https://www.healthdesign.org/sites/default/files/validating%20acoustic%20guidelines%20for%20HC%20facilities_sound%20sleep%20study.pdf

SinglE vS multi-bEdgabor, J. y., Cooper, a. b., Crombach, s. a., lee, b., Kadikar, N., bettger, H. e., et al. (2003). Contribution of the intensive care unit environment to sleep disruption in mechanically ventilated patients and healthy subjects. American Journal of Respiratory and Critical Care Medicine, 167(5), 708–715.yinnon, a. m., ilan, y., tadmor, b., altarescu, g., & Hershko, C. (1992). Quality of sleep in the medical department. British Journal of Clinical Practice, 46(2), 88–91.

rEducEd StrESSHarris, D. D., shepley, m. m., White, R. D., Kolberg, K. J. s., & Harrell, J. W. (2006). the impact of single family room design on patients and caregivers: executive summary. Journal of Perinatology, 26, s38–s48.

improvEd SlEEpsouthwell, m. t., & Wistow, g. (1995). sleep in hospitals at night—are patients’ needs being met? Journal of Advanced Nursing, 21(6),1101–1109.

incrEaSEd SatiSfactionPress ganey, inc. (2003). National satisfaction data for 2003 comparing patients with versus without a roommate.

WirElESS communicationSstaff conversations, as well as voice paging, highly disruptive to patient sleep, especially in the light sleep stages. Wireless communications prevent staff from raising their voices to be heard across large sapces or down hallways.


icE machinESshould be architecturally isolated from patient areas or dramatically re-engineered.


door hardWarElimit latch noises; door gasket to block noise from hall and nurse station

hand toWEl diSpEnSErSQuieter or low-tech alternatives for automatic hand towel dispensers should be substituted.


rEducEd StrESSa survey in NiCus found that staff perceived a unit with single-patient rooms to be less stressful for both family and staff than an open-bay unit, owing to better privacy and control over the environment.

improvEd SlEEpin a study of iCus, average noise and peak levels were higher in the open iCu than in the single room. total sleep time in the single-bed room (9.5 hours) was greater than that in the open iCu (8.2 hours).


incrEaSEd SatiSfactionsatisfaction with noise levels is on average 11.2% higher for patients in private rooms than for those in multibed rooms


Culture | eliminate SourCeS | Private roomS | Sound-abSorbing materialS privatE roomS

TOILET LOCATEDON HEADWALL

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HAND WASHING SINK AT ENTRY

VARIABLE-ACUITY HEADWALL

NURSE SERVER

WARDROBE W/ LOCKABLE STORAGE

FAMILY ZONE ROOMING-IN

FLAT SCREEN TV

DAYLIGHT & VIEWS

PRIVATE ROOM300 SQ FT

LIKE-HANDED

SinglE vS multibEdPrivate patient room is the most effective environmental approach to noise control. No noise from the presence of other patients (visitors, staff, patient sounds - coughing, crying, rattling bedrails)

opEn (or cloSEd) door policy?Policy regarding keeping patient doors open should be re-examined.


quiEt culturE vS EnvironmEntal changESenvironmental approaches to quiet healthcare settings can be more successful than organizational interventions such as staff education or establishing quiet hours.


phonE & intravEnouS infuSion pump alarmSmost distracting, negatively impact patient sleep. solutioNs: answer iv alarms promptly, lower background sound levels / Reduce telephone ring tone volume to prevent transmission beyond patient rooms / set telephones to stop after a specific number of rings.



quiEt cuESDim hall lights at night to cue staff and visitors to keep voices low.

yackEr trackErthe cardiac care unit at st. Joseph’s Hospital Health Center utilizes a yacker tracker, a stoplight-looking device to measure sound levels. at 60 db and above the stoplight changes from green to red and is synchronized to dim the overhead lights at nurse stations.

talking roomSJoseph, a., & ulrich, R. (2007). sound control for improved outcomes in healthcare settings. Concord, Ca: the Center for Health Design.

Staff collaboration SpacEulrich, R.s., zimring, C., zhu, X., Dubose, J., seo, H., Choi, y., Quan, X., Joseph, a. (2008). a Review of the Research literature on evidence-based Healthcare Design. HERD 1(3), 109.

Sound-abSorbing matErialSberg, s. (2001). impact of reduced reverberation time on soundinduced arousals during sleep. Sleep, 24(3), 289–292.

Philbin, m. K., & gray, l. (2002). Changing levels of quiet in an intensive care nursery. Journal of Perinatology, 22(6), 455–460.

acouStical cEiling tilESHagerman, i., Rasmanis, g., blomkvist, v., ulrich, R., eriksen,C. A., & Theorell, T. (2005). Influence of intensive coronary care acoustics on the quality of care and physiological state of patients. International Journal of Cardiology, 98(2), 267–270.

berg, s. (2001). impact of reduced reverberation time on soundinduced arousals during sleep. Sleep, 24(3), 289–292.

lifE and dEath Dying matters. Retrieved from http://dyingmatters.org/page/being-someone-when-they-die#end

mccarthy, l.f. What babies learn in the Womb. Parenting.Retrieved from http://www.parenting.com/article/what-babies-learn-in-the-womb

muSic thErapythe american music therapy association. Retrieved from http://www.musictherapy.org/

muSic, Emotion, and mEmorysternberg, e. (2009). Healing Spaces: The Science of Place and Wellbeing. Cambridge, ma: Harvard university Press.

muSic and brand - StarbuckSRetrieved from http://www.starbucks.com/coffeehouse/entertainment

muSic and brand - SmiloW cancEr hoSpitalRetrieved from http://www.closertofree.com/

lifE and dEathbabies in the womb actively listen to their mother’s voice during the last ten weeks of pregnancy. Hearing is thought to be the last sense to go in the dying process.

muSic thErapythe 20th century discipline began after World War i and World War ii when community musicians went to veterans hospitals around the country to play for the thousands of veterans suffering both physical and emotional trauma from the wars. the patients’ notable physical and emotional responses to music led the doctors and nurses to request the hiring of musicians by the hospitals.

muSic and brand - StarbuckSWhat would the coffeehouse be without great music? Well it wouldn’t be starbucks, for one thing. We’re just as passionate about music as we are about coffee. that’s why we handpick all the tunes you hear in our stores.

muSic and brand - SmiloW cancEr hoSpital at yalE nEW havEn

muSic, EmotionS, & mEmorylistening to music activates many different areas of the brain, including the emotion centers involved with pleasure.

Staff collaboration SpacEDesignated consulting spaces for nurses away from open hall areas, yet not far from nursing stations.



incorporatE Sound abSorbing matErialSinstall high-performance sound-absorbing materials on ceilings, floors, and walls to reduce noise levels, reverberation or echoing, and sound propagation.


Sound-abSorbing acouStical cEiling tilESWith sound-absorbing ceiling tiles in place, coronary intensive care patients evidenced lower physiological stress, slept better, reported better care from nurses, and had a lower incidence of rehospitalization in the weeks following discharge.

rEvErbEration timE & SlEEpeven if noise levels remain almost the same, reduction in reverberation time with sound-absorbing ceiling tiles can improve sleep quality. meanwhile, even relatively low decibel levels but with longer reverberation times can negatively impact sleep.

act & Staff StrESSNurses perceived significantly lower work demands and reported less pressure and strain when the sound-absorbing tiles were in place.

talking roomSincrease privacy with private discussion rooms away from waiting rooms. also include on patient floors that have multibed rooms.


2014 0503-2 sound and silence national council of acoustical consultants

Design

Transcript of 2014 0503-2 sound and silence national council of acoustical consultants