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

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

Evidence-based Design
The process of basing decisions about the built
environment on credible research to achieve the
best possible outcomes.

project
wisdom
Design
Intelligence
Institutional
Intelligence
Constituency
Intelligence
Thought
Leaders
Intelligence
Research
Intelligence

restorative-beauty
experiential-accountable
care
efficient|effectiv
e- health reform
saf
e- IOM

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
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
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
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
often did nurses listen carefully to
you?
1
 Never
2
 Sometimes
3
 Usually
4
 Always
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

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 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

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

WHY SO NOISY?
Sources of sound

Sources are numerous & loud
Staff voices, paging systems, alarms, bedrails, telephones,
ice machines, pneumatic tubes, trolleys…

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

Sound-reflecting vs sound-absorbing Surfaces
Long reverberation times enable noise to echo, linger, and propagate over large areas and into patient rooms

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

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

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

cro
w
ded
waiting room
open
o
ffice
Public Transporta
t
io
n
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.
125
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
Sleep | Stress | Pain | Communication | SatisfactionPain

COMMUNICATION
& SPEECH PRIVACY
Sleep | Stress | Pain | Communication | SatisfactionCommunication

Effective COMMUNICATION
to prevent readmission
Sleep | Stress | Pain | Communication | SatisfactionCommunication

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

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

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

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.

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.

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.

Open (or Closed)
Door Policy?
Policy regarding keeping patient
doors open should be re-examined.

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.

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

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.

Ice Machines
Should be architecturally
isolated from patient areas or
dramatically re-engineered.
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
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)

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).

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

Talking ROOMS
Increase privacy with private discussion
rooms away from waiting rooms. Also include
on patient floors that have multibed rooms.

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 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.

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

ORIENTED TO
THE FUTURE
ORIENTED TO
THE PRESENT
VALUES
DRIVEN
ECONOMY
DRIVEN
GET HERE
2
1
3
2
Get Here
Decision Making Determinants
Value $$$
Lag - baselineInnovate
Values (belief)

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.

Project Profile
JWT Atlanta
Acoustical
Wall Surfaces

Carpet
Aesthetic and noise reduction appeal,
not suitable everywhere.
Tandus
Hybrid resilient sheet flooring

Cushioned Rubber

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, Emotions, & Memory
Listening to music activates many different areas of the
brain, including the emotion centers involved with pleasure.

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

“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.

“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

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
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
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
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
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
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
your overall health?
1
 Excellent
2
 Very good
3
 Good
4
 Fair
5
 Poor
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
often did nurses treat you with
courtesy and respect?
1
 Never
2
 Sometimes
3
 Usually
4
 Always
often did nurses listen carefully to
you?
1
 Never
2
 Sometimes
3
 Usually
4
 Always
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.

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.”
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
“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
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

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
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
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.
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

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
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.
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.
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).
incrEaSEd SatiSfaction
satisfaction with noise levels is on average
11.2% higher for patients in private rooms
than for those in multibed 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.
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.
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.

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 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.

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