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

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

  1. 1. National Council of Acoustical Consultants 2014 annual meeting Rosalyn Cama, FASID, EDAC rcama@camainc.com camaincorporated.com S o u n d & S i l e n c e S o u n d
  2. 2. Evidence-based Design The process of basing decisions about the built environment on credible research to achieve the best possible outcomes.
  3. 3. project wisdom Design Intelligence Institutional Intelligence Constituency Intelligence Thought Leaders Intelligence Research Intelligence
  4. 4. restorative-beauty experiential-accountable care efficient|effectiv e- health reform saf e- IOM
  5. 5. 4 March 2013 22. Would you recommend this hospital to your friends and family? 1  Definitely no 2  Probably no 3  Probably yes 4  Definitely yes UNDERSTANDING YOUR CARE WHEN 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 disagree 2  Disagree 3  Agree 4  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 disagree 2  Disagree 3  Agree 4  Strongly agree 25. When I left the hospital, I clearly understood the purpose for taking each of my medications. 1  Strongly disagree 2  Disagree 3  Agree 4  Strongly agree 5  I was not given any medication when I left the hospital ABOUT YOU There are only a few remaining items left. 26. During this hospital stay, were you admitted to this hospital through the Emergency Room? 1  Yes 2  No 27. In general, how would you rate your overall health? 1  Excellent 2  Very good 3  Good 4  Fair 5  Poor 28. In general, how would you rate your overall mental or emotional health? 1  Excellent 2  Very good 3  Good 4  Fair 5  Poor 29. What is the highest grade or level of school that you have completed? 1  8th grade or less 2  Some high school, but did not graduate 3  High school graduate or GED 4  Some college or 2-year degree 5  4-year college graduate 6  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  Never 2  Sometimes 3  Usually 4  Always 2. During this hospital stay, how often did nurses listen carefully to you? 1  Never 2  Sometimes 3  Usually 4  Always 3. During this hospital stay, how often did nurses explain things in a way you could understand? 1  Never 2  Sometimes 3  Usually 4  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  Never 2  Sometimes 3  Usually 4  Always 9  I never pressed the call button “Would you recommend this hospital to your friends and family?” Definitely no Probably no Probablyyes Definitelyyes
  6. 6. Choice Architecture Design 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
  7. 7. SMELL LISTEN LOOK * Remember * Relax * Imagine TOUCH TASTE * Discover * Savor
  8. 8. HOW NOISY ARE HOSPITALS? Measuring Decibels Hospital noise levels around the world have been rising consistently since the 1960s
  9. 9. World Health Organization Recommended levels For continuous background noise in hospital patient rooms: DAY - 35 dB NIGHT - 30 dB Night Peaks - Not to exceed 40 dB 40 d b R a i n d r o ps DecibelSca l e Louder
  10. 10. In reality… Background noise 45-68 dB peaks often exceed 85-90 dB 85db B u sy Cit y Tra f fic 90 db H a ir Dryer 105 d b Rock Concert 110 d b Chainsaw 140 db Gunshot 40 db Raindr o ps 60 d b C o n v e rsation 120 db Jackhammer 115dbiPodat P ea k Volume
  11. 11. WHY SO NOISY? Sources of sound
  12. 12. Sources are numerous & loud Staff voices, paging systems, alarms, bedrails, telephones, ice machines, pneumatic tubes, trolleys…
  13. 13. Medical Equipment & Staff Voices Produce noise at 70–75 dB levels at the patient’s head, which approach the noise level in a busy restaurant 70-75 db Busy Restaura n t
  14. 14. Alarms & Equipment Portable X-ray machines exceed 90 dB, comparable to walking next to a busy highway when a motorcycle or large truck passes. 90 db Busy highway w h en truckpasses
  15. 15. Shift Changes One study recorded 113 dB during shift changes at a large hospital 115db i P o d at Peak Volum e
  16. 16. Sound-reflecting vs sound-absorbing Surfaces Long reverberation times enable noise to echo, linger, and propagate over large areas and into patient rooms
  17. 17. Multibed Rooms Many patients are housed in multibed rooms in which much noise originates from other patients C o u gh Cough,Snore,S n eeze, Blah-blah-bl a h
  18. 18. PATIENT OUTCOMES Please Do not Disturb “During this hospital stay, how often was the area around your room quiet at night?” -- HCAHPS Survey Question
  19. 19. Sleep disruption & deprivation Studies 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
  20. 20. Intensive Care Units In 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. Sleep | Stress | Pain | Communication | SatisfactionSleep
  21. 21. Psychological Stress As indicated by negative feelings such as anxiety and annoyance Physiological Stress Detrimental physiological changes such as elevated heart rate and blood pressure Sleep | Stress | Pain | Communication | SatisfactionStress
  22. 22. 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. 9 0 db Hair Dryer Sleep | Stress | Pain | Communication | SatisfactionStress
  23. 23. cro w ded waiting room open o ffice Public Transporta t io n Coping with uncontrollable noise “Earphones are the new wall.” Sleep | Stress | Pain | Communication | SatisfactionStress
  24. 24. 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. 125 d b Jet Engine take o ff Sleep | Stress | Pain | Communication | SatisfactionStress
  25. 25. Sleep | Stress | Pain | Communication | SatisfactionPain
  26. 26. “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 Sleep | Stress | Pain | Communication | SatisfactionPain
  27. 27. COMMUNICATION & SPEECH PRIVACY Sleep | Stress | Pain | Communication | SatisfactionCommunication
  28. 28. Effective COMMUNICATION to prevent readmission Sleep | Stress | Pain | Communication | SatisfactionCommunication
  29. 29. PATIENT SATISFACTION Patients often complain about temperatures (“too cold”) and high noise levels (“so noisy”) in their rooms. Sleep | Stress | Pain | Privacy | SatisfactionSatisfaction Quiet Kits
  30. 30. Noise and Perception of Care Study 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. Sleep | Stress | Pain | Privacy | SatisfactionSatisfaction
  31. 31. 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.
  32. 32. Stress | Error | Productivity | SatisfactionStress Nurse Burnout Few studies have focused on the impact of noise on staff. Noise-induced stress correlates with reported emotional exhaustion or burnout among critical care nurses. 47year s - Average age of N u rse
  33. 33. 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
  34. 34. Stress | Error | Productivity | SatisfactionError Medication Dispensing Prescription error rates increase sharply when there is an interruption or distraction from an unpredicted noise (e.g., a telephone call).
  35. 35. Unpredictable Noise | Complicated Tasks The combination of unpredictable noise and complicated tasks can increase errors in calculation, tracking, and monitoring tasks, and lead to slower learning and poor memorization. Stress | Error | Productivity | SatisfactionError
  36. 36. Monitoring Vital signs Hospital staff often complain that noise levels make their work more difficult,particularly when it comes to monitoring patients’ vital signs. Stress | Error | Productivity | SatisfactionProductivity
  37. 37. Performance quality not affected by noise Even 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 a in saw Stress | Error | Productivity | SatisfactionProductivity
  38. 38. Stress | Error | Productivity | SatisfactionSatisfaction Chronic effects on performance and stress Some studies have identified long-term negative effects of noise on staff. Staff turnover $62,000 per nurse replaced Investments in the environment to increase staff satisfaction could potentially reduce the cost of staff turnover.
  39. 39. DESIGN INTERVENTIONS
  40. 40. Culture | Eliminate Sources | Private Rooms | Sound-Absorbing MaterialsCulture Quiet Cues Dim hall lights at night to cue staff and visitors to keep voices low. Yacker Tracker The cardiac care unit at St. Joseph’s Hospital Health Center utilizes aYacker 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.
  41. 41. Open (or Closed) Door Policy? Policy regarding keeping patient doors open should be re-examined. Culture | Eliminate Sources | Private Rooms | Sound-Absorbing MaterialsCulture
  42. 42. QUIET CULTURE VS Environmental Changes Environmental approaches to quiet healthcare settings can be more successful than organizational interventions such as staff education or establishing quiet hours. Culture | Eliminate Sources | Private Rooms | Sound-Absorbing MaterialsCulture
  43. 43. Phone & Intravenous Infusion Pump Alarms Most 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 MaterialsEliminate Sources
  44. 44. Wireless CommunicationS Staff 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. Culture | Eliminate Sources | Private Rooms | Sound-Absorbing MaterialsEliminate Sources
  45. 45. Ice Machines Should be architecturally isolated from patient areas or dramatically re-engineered. Culture | Eliminate Sources | Private Rooms | Sound-Absorbing MaterialsEliminate Sources Door Hardware Limit latch noises; door gasket to block noise from hall and nurse station Hand Towel Dispensers Quieter or low-tech alternatives for automatic hand towel dispensers should be substituted.
  46. 46. Culture | Eliminate Sources | Private Rooms | Sound-Absorbing MaterialsPrivate Rooms TOILET LOCATED ON HEADWALL HANDRAIL SLIDING DOOR HAND WASHING SINK AT ENTRY VARIABLE-ACUITY HEADWALL NURSE SERVER WARDROBE W/ LOCKABLE STORAGE FAMILY ZONE ROOMING-IN FLAT SCREEN TV DAYLIGHT & VIEWS PRIVATE ROOM 300 SQ FT LIKE-HANDED SINGLE VS MULTIBED Private 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)
  47. 47. Culture | Eliminate Sources | Private Rooms | Sound-Absorbing MaterialsPrivate Rooms Reduced Stress A 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.
  48. 48. Improved Sleep In 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). Culture | Eliminate Sources | Private Rooms | Sound-Absorbing MaterialsPrivate Rooms
  49. 49. Increased Satisfaction Satisfaction 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 MaterialsPrivate Rooms
  50. 50. Talking ROOMS Increase privacy with private discussion rooms away from waiting rooms. Also include on patient floors that have multibed rooms. Culture | Eliminate Sources | Private Rooms | Sound-Absorbing MaterialsPrivate Rooms
  51. 51. STAFF COLLABORATION SPACE Designated consulting spaces for nurses away from open hall areas, yet not far from nursing stations. Culture | Eliminate Sources | Private Rooms | Sound-Absorbing MaterialsPrivate Rooms
  52. 52. Culture | Eliminate Sources | Private Rooms | Sound-Absorbing MaterialsSound-Absorbing Materials INCORPORATE SOUND ABSORBING MATERIALS Install high-performance sound-absorbing materials on ceilings, floors, and walls to reduce noise levels, reverberation or echoing, and sound propagation.
  53. 53. Culture | Eliminate Sources | Private Rooms | Sound-Absorbing MaterialsSound-Absorbing Materials ORIENTED TO THE FUTURE ORIENTED TO THE PRESENT VALUES DRIVEN ECONOMY DRIVEN GET HERE 2 1 3 2 Values (belief) Value $$$ Lag - baselineInnovate Get Here Decision Making Determinants
  54. 54. ORIENTED TO THE FUTURE ORIENTED TO THE PRESENT VALUES DRIVEN ECONOMY DRIVEN GET HERE 2 1 3 2 Culture | Eliminate Sources | Private Rooms | Sound-Absorbing MaterialsSound-Absorbing Materials Get Here Decision Making Determinants Value $$$ Lag - baselineInnovate Values (belief)
  55. 55. Culture | Eliminate Sources | Private Rooms | Sound-Absorbing MaterialsSound-Absorbing Materials Sound-absorbing Acoustical Ceiling tiles With 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 & Sleep Even 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 stress Nurses perceived significantly lower work demands and reported less pressure and strain when the sound-absorbing tiles were in place.
  56. 56. Project Profile JWT Atlanta Acoustical Wall Surfaces Culture | Eliminate Sources | Private Rooms | Sound-Absorbing MaterialsSound-Absorbing Materials
  57. 57. Culture | Eliminate Sources | Private Rooms | Sound-Absorbing MaterialsSound-Absorbing Materials Carpet Aesthetic and noise reduction appeal, not suitable everywhere. Tandus Hybrid resilient sheet flooring
  58. 58. Cushioned Rubber Culture | Eliminate Sources | Private Rooms | Sound-Absorbing MaterialsSound-Absorbing Materials
  59. 59. hum of WelLness
  60. 60. Life and Death Babies 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.
  61. 61. Music Therapy The 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.
  62. 62. Music, Emotions, & Memory Listening to music activates many different areas of the brain, including the emotion centers involved with pleasure.
  63. 63. Music and Brand - Starbucks What 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.
  64. 64. Music and Brand - Smilow Cancer Hospital at Yale New Haven
  65. 65. SMELL LISTEN LOOK * Remember * Relax * Imagine TOUCH TASTE * Discover * Savor
  66. 66. “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. Americans spend about or more of their time indoors.
  67. 67. “Opposite of beauty is injury not ugliness.” -- Elaine Scarry (1999). On Beauty and Being Just. Princeton: Princeton University Press.
  68. 68. Injury | Stabilize | Rehabilitate | Restore | BeautY Injury
  69. 69. Injury | Stabilize | Rehabilitate | Restore | BeautY
  70. 70. Injury | Stabilize | Rehabilitate | Restore | BeautY BeautY
  71. 71. National Council of Acoustical Consultants 2014 annual meeting Rosalyn Cama, FASID, EDAC rcama@camainc.com camaincorporated.com S o u n d & S i l e n c e S o u n d
  72. 72. Evidence-based Design EBD Definition retrieved from http://edac.healthdesign.org/ Cama, R. (2009). Evidence-Based Healthcare Design, John Wiley & Sons. HCAHPS Survey Retrieved from http://www.hcahpsonline.org/files/HCAHPS%20 V8.0%20Appendix%20A%20-%20HCAHPS%20Mail%20 Survey%20Materials%20(English)%20March%202013.pdf Choice Architecture Thaler, 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 levels Berglund, B., Lindvall,T., & Schwela, D. H. (1999). Guidelines for community noise. World Health Organization: Protection of the Human Environment. In Reality...Typical Decibel Levels 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. Sources are Numerous and Loud 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. Medical Equipment & Staff Voices Blomkvist,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 & Equipment 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. Shift Changes Cmiel, 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 levels for continuous background noise in hospital patient rooms: day - 35 db night - 30 db night pEakS - not to ExcEEd 40 db 40 d b r a i n d r o pS dEcibElSca l E souND PRessuRe level HigHeR iN Reality… background noiSE 45-68 db pEakS oftEn ExcEEd 85-90 db 85db b u Sy cit y tra f fic 90 db h a ir dryEr 105 d b rock concErt 110 d b chainSaW 140 db gunShot 40 db raindr o pS 60 d b c o n v E rSation 120 db jackhammEr 115dbipodat p Ea k volumE mEdical EquipmEnt & Staff voicES Produce noise at 70–75 db levels at the patient’s head, which approach the noise level in a busy restaurant 70-75 db buSy rEStaura n t alarmS & EquipmEnt Portable X-ray machines exceed 90 db, comparable to walking next to a busy highway when a motorcycle or large truck passes. 90 db buSy highWay W h En truckpaSSES Shift changES one study recorded 113 db during shift changes at a large hospital 115db i p o d at pEak volum E SourcES arE numErouS & loud staff 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 no 2  Probably no 3  Probably yes 4  Definitely yes UNDERSTANDING YOUR CARE WHEN 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 disagree 2  Disagree 3  Agree 4  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 disagree 2  Disagree 3  Agree 4  Strongly agree 25. When I left the hospital, I clearly understood the purpose for taking each of my medications. 1  Strongly disagree 2  Disagree 3  Agree 4  Strongly agree 5  I was not given any medication when I left the hospital ABOUT YOU There are only a few remaining items left. 26. During this hospital stay, were you admitted to this hospital through the Emergency Room? 1  Yes 2  No 27. In general, how would you rate your overall health? 1  Excellent 2  Very good 3  Good 4  Fair 5  Poor 28. In general, how would you rate your overall mental or emotional health? 1  Excellent 2  Very good 3  Good 4  Fair 5  Poor 29. What is the highest grade or level of school that you have completed? 1  8th grade or less 2  Some high school, but did not graduate 3  High school graduate or GED 4  Some college or 2-year degree 5  4-year college graduate 6  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  Never 2  Sometimes 3  Usually 4  Always 2. During this hospital stay, how often did nurses listen carefully to you? 1  Never 2  Sometimes 3  Usually 4  Always 3. During this hospital stay, how often did nurses explain things in a way you could understand? 1  Never 2  Sometimes 3  Usually 4  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  Never 2  Sometimes 3  Usually 4  Always 9  I never pressed the call button “Would you recommend this hospital to your friends and family?” DefiNitely No PRobably No PRobablyyes DefiNitelyyes choice architecture DESIgn 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.
  73. 73. Sound-Reflecting vs Sound-Absorbing Blomkvist,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 Rooms Baker, 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 outcomes HCAHPS Survey Retrieved from http://www.hcahpsonline.org/files/HCAHPS%20 V8.0%20Appendix%20A%20-%20HCAHPS%20Mail%20 Survey%20Materials%20(English)%20March%202013.pdf Sleep Disruption & Deprivation BaHammam,A. (2006). Sleep in acute care units. Sleep and Breathing, 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 care unit. 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. Stress Bentley, 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 pediatric intensive care unit. Critical Care Medicine, 31(1), 113–119. Neonatal Intensive Care Slevin, M., Farrington, N., Duffy, G., Daly, L., & Murphy, J. F. (2000).Altering the NICU and measuring infants’ responses. Acta Paediatrica, 89(5), 577–581. Coping with uncontrollable noise Tierney, J. (2012). From cubicles, cry for quiet pierces office buzz. NewYork Times. Retrieved from http://www.nytimes. com/2012/05/20/science/when-buzz-at-your-cubicle-is-too-loud-for- work.html?pagewanted=all MRI Noise canceling headphones by OptoAcoustics. Retrieved from http://www.optoacoustics.com/ Noise and Pain Taylor, J.B. (2009). My Stroke of Insight:A Brain Scientist’s Personal Journey, NewYork, 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 unitS in 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. Sleep | StreSS | pain | CommuniCation | SatiSfaCtionSlEEp pSychological StrESS as indicated by negative feelings such as anxiety and annoyance phySiological StrESS Detrimental physiological changes such as elevated heart rate and blood pressure Sleep | StreSS | pain | CommuniCation | SatiSfaCtionStrESS cro W dEd Waiting room opEn o fficE public tranSporta t io n coping With uncontrollablE noiSE “EarphonES arE thE nEW Wall.” Sleep | StreSS | pain | CommuniCation | SatiSfaCtionStrESS 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. 125 d b jEt EnginE takE o ff Sleep | StreSS | pain | CommuniCation | SatiSfaCtionStrESS “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 Sleep | StreSS | pain | CommuniCation | SatiSfaCtionpain 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. 9 0 db hair dryEr Sleep | StreSS | pain | CommuniCation | SatiSfaCtionStrESS multibEd roomS many patients are housed in multibed rooms in which much noise originates from other patients c o u gh cough,SnorE,S n EEzE, blah-blah-bl a h patiEnt outcomES PlEASE Do not DISturb “during thiS hoSpital Stay, hoW oftEn WaS thE arEa around your room quiEt at night?” -- HCAHPS Survey Question SlEEp diSruption & dEprivation studies 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 Sound-rEflEcting vS Sound-abSorbing SurfacES long reverberation times enable noise to echo, linger, and propagate over large areas and into patient rooms
  74. 74. Patient Satisfaction Press 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 Care Hagerman, 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. Staff outcomes 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 Nurse Burnout Topf, 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 Dispensing Leather, 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 Task Sundstrom, E., & Sundstrom, M. G. (1986). Work places:The psychology of the physical environment in offices and factories. Cambridge: Cambridge University Press. Monitoring Vitals Zun, L. S., & Downey, L. (2005).The effect of noise in the emergency department. Academic Emergency Medicine, 12(7), 663–666. Performance quality 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. Satisfaction and Staff Turnover Jones, C. B. (2004).The costs of nurse turnover: Part 1:An economic perspective. The Journal of Nursing Administration, 34(12), 562–570. 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 StreSS | error | Productivity | SatiSfactionError mEdication diSpEnSing Prescription error rates increase sharply when there is an interruption or distraction from an unpredicted noise (e.g., a telephone call). monitoring vital SignS Hospital 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 noiSE even 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 a in SaW StreSS | error | Productivity | SatiSfactionproductivity StreSS | error | Productivity | SatiSfactionSatiSfaction chronic EffEctS on pErformancE and StrESS Some studies have identified long-term negative effects of noise on staff. Staff turnovEr $62,000 pEr nurSE rEplacEd investments in the environment to increase staff satisfaction could potentially reduce the cost of staff turnover. unprEdictablE noiSE | complicatEd taSkS the combination of unpredictable noise and complicated tasks can increase errors in calculation, tracking, and monitoring tasks, and lead to slower learning and poor memorization. StreSS | error | Productivity | SatiSfactionError noiSE and pErcEption of carE study 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. Sleep | StreSS | pain | privacy | SatiSfactionSatiSfaction 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 burnout few studies have focused on the impact of noise on staff. Noise-induced stress correlates with reported emotional exhaustion or burnout among critical care nurses. 47yEar S - avEragE agE of n u rSE patiEnt SatiSfaction Patients often complain about temperatures (“too cold”) and high noise levels (“so noisy”) in their rooms. Sleep | StreSS | pain | privacy | SatiSfactionSatiSfaction quiEt kitS
  75. 75. Quiet Cues - Yacker Tracker Gabel, M (2009, July 28, ). Hospitals usingYacker 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 Changes Moore, 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 Alarms 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%20 HC%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%20 HC%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-bed Gabor, 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 Stress Harris, 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 Sleep Southwell, M.T., & Wistow, G. (1995). Sleep in hospitals at night— Are patients’ needs being met? Journal of Advanced Nursing, 21(6), 1101–1109. Increased Satisfaction Press Ganey, Inc. (2003). National satisfaction data for 2003 comparing patients with versus without a roommate. WirElESS communicationS staff 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. Culture | eliminate SourCeS | Private roomS | Sound-abSorbing materialSEliminatE SourcES icE machinES should be architecturally isolated from patient areas or dramatically re-engineered. Culture | eliminate SourCeS | Private roomS | Sound-abSorbing materialSEliminatE SourcES door hardWarE limit latch noises; door gasket to block noise from hall and nurse station hand toWEl diSpEnSErS Quieter or low-tech alternatives for automatic hand towel dispensers should be substituted. Culture | eliminate SourCeS | Private roomS | Sound-abSorbing materialSprivatE roomS rEducEd StrESS a 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 SlEEp in 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). Culture | eliminate SourCeS | Private roomS | Sound-abSorbing materialSprivatE roomS incrEaSEd SatiSfaction satisfaction 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 materialSprivatE roomS Culture | eliminate SourCeS | Private roomS | Sound-abSorbing materialSprivatE roomS TOILET LOCATED ON HEADWALL HANDRAIL SLIDING DOOR HAND WASHING SINK AT ENTRY VARIABLE-ACUITY HEADWALL NURSE SERVER WARDROBE W/ LOCKABLE STORAGE FAMILY ZONE ROOMING-IN FLAT SCREEN TV DAYLIGHT & VIEWS PRIVATE ROOM 300 SQ FT LIKE-HANDED SinglE vS multibEd Private 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. Culture | eliminate SourCeS | Private roomS | Sound-abSorbing materialSculturE quiEt culturE vS EnvironmEntal changES environmental approaches to quiet healthcare settings can be more successful than organizational interventions such as staff education or establishing quiet hours. Culture | eliminate SourCeS | Private roomS | Sound-abSorbing materialSculturE phonE & intravEnouS infuSion pump alarmS most 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 materialSEliminatE SourcES Culture | eliminate SourCeS | Private roomS | Sound-abSorbing materialSculturE quiEt cuES Dim hall lights at night to cue staff and visitors to keep voices low. yackEr trackEr the cardiac care unit at st. Joseph’s Hospital Health Center utilizes ayacker 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.
  76. 76. Talking Rooms Joseph,A., & Ulrich, R. (2007). Sound control for improved outcomes in healthcare settings. Concord, CA:The Center for Health Design. Staff Collaboration Space 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. Sound-Absorbing Materials Berg, 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 Tiles Hagerman, 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 Therapy The American Music Therapy Association. Retrieved from http://www.musictherapy.org/ Music, Emotion, and Memory Sternberg, E. (2009). Healing Spaces:The Science of Place andWellbeing. Cambridge, MA: Harvard University Press. Music and Brand - Starbucks Retrieved from http://www.starbucks.com/coffeehouse/entertainment Music and Brand - Smilow Cancer Hospital Retrieved from http://www.closertofree.com/ lifE and dEath babies 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 thErapy the 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 - StarbuckS What 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, & mEmory listening to music activates many different areas of the brain, including the emotion centers involved with pleasure. Staff collaboration SpacE Designated consulting spaces for nurses away from open hall areas, yet not far from nursing stations. Culture | eliminate SourCeS | Private roomS | Sound-abSorbing materialSprivatE roomS Culture | eliminate SourCeS | Private roomS | Sound-abSorbing materialSSound-abSorbing matErialS incorporatE Sound abSorbing matErialS install high-performance sound-absorbing materials on ceilings, floors, and walls to reduce noise levels, reverberation or echoing, and sound propagation. Culture | eliminate SourCeS | Private roomS | Sound-abSorbing materialSSound-abSorbing matErialS Sound-abSorbing acouStical cEiling tilES With 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 & SlEEp even 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 StrESS Nurses perceived significantly lower work demands and reported less pressure and strain when the sound-absorbing tiles were in place. talking roomS increase privacy with private discussion rooms away from waiting rooms. also include on patient floors that have multibed rooms. Culture | eliminate SourCeS | Private roomS | Sound-abSorbing materialSprivatE roomS

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