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Whole-Human Approaches for Lighting That Cares
Karyn Gayle, MIES, EDAC
Vice-President – Healthcare, Acuity Brands
Karyn.Gayle@acuitybrands.com, Twitter: @karyngayle
Acuity Brands Lighting is a Registered Provider with The American Institute of Architects Continuing Education
Systems. Credit earned on completion of this program will be reported to CES Records for AIA members. Certificates
of Completion for non-AIA members are available on request.
This program is registered with the AIA/CES for continuing professional education, under AB325. As such, it does not
include content that may be deemed or construed to be an approval or endorsement by the AIA of any material of
construction of any method or manner of handling, using, distributing, or dealing in any material or product. Questions
related to specific materials, methods, and services will be addressed at the conclusion of this presentation.
Continuing Education Best Practices
Light & Healthcare: Whole-Human Approaches
Learning Objectives
• Describe key trends impacting healthcare
• Discuss functional, physiological, and psychological aspects of lighting in
healthcare settings
• Review key design interventions in facility lighting design and the link to
health outcomes
• Examine current and future state of lighting technologies and their
application for care environments
Light & Healthcare: Whole-Human Approaches
Key Healthcare Trends
• Light + Health
• Demographic Shifts
• Evidence-Based Design
Light & Healthcare: Whole-Human Approaches
First things first…
Light & Healthcare: Whole-Human Approaches
Health ≠ Healthcare
Healthcare ≈ Sickcare
…would we be better off if we designed
for health as well as care?
The Realities:
Costs are high and expected to double in 10 years…
Light & Healthcare: Whole-Human Approaches
Source: OECD Health Data 2013, graphic by Huffington Post
Reimbursement Changes:
From volume to value…
• HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) developed by Center
for Medicare & Medicaid Services (CMS) in 2006
• Scores capture patients’ perspectives on acute care hospital care experience
• Migration from optional data collection to pay for performance (October 2012)
• For acute care hospitals, performance will drive 2% of CMS reimbursements as part of Value-Based
Purchasing
Patient Experience & Reimbursements
• Avoidance of hospital-acquired infections & shortened stays
• Readmissions can be 20% of inpatient volume, reimbursements for excess readmissions will be reduced,
starting in Federal FY2013 (October 2012)
Patient Outcomes
• Fall prevention
• Hygiene, germ & dust management
Patient Safety
Light & Healthcare: Whole-Human Approaches
Sustainable Design & Energy Usage
• Based on 2008 data from the US
DOE’s Energy Information
Administration:
– Lighting accounts for 42 percent of
overall health care electricity use:
 Inpatient: 42%
 Outpatient: 40%
• Healthcare buildings account for 7
percent of electricity use by all
commercial and industrial buildings.
HVAC
37%
Water
Heating
2%
Lighting
42%
Office
Equipme
nt &
Computer
s
6%
Refrigerat
ion
2%
Other
11%
US Electricity Consumption
(kWh), 2003 - Inpatient Health
Care Facilities
Light & Healthcare: Whole-Human Approaches
Going back to our premise…
Light & Healthcare: Whole-Human Approaches
Health ≠ Healthcare
Healthcare ≈ Sickcare
…would we be better off if we designed
for health as well as care?
The root of the problem…what makes us so unhealthy?
Light & Healthcare: Whole-Human Approaches
Chronic Disease
• More than three-fourths of United
States healthcare costs are due to
chronic diseases (CDC)
• And, many preventable behaviors are
linked to chronic disease:
 Tobacco use
 Insufficient physical activity
 Poor nutrition
 Excessive alcohol consumption
 (Also, unmanaged stress)
Light & Healthcare: Whole-Human Approaches
Source: Centers for Disease Control, 2009
“Everyone wants it, but nobody is
getting any...”
- Anonymous
Light & Healthcare: Whole-Human Approaches
The Importance of Sleep
Light & Healthcare: Whole-Human Approaches
Some Less-Obvious Implications of Sleep…
• People who get sufficient sleep have increased gray matter in their brains, which is connected
to psychological health. (Harvard Medical School Study)
• Brain clears out waste proteins between cells, and this waste product is linked to Alzheimer’s
disease, (Dr. Maiken Nedergaard, University of Rochester)
• People who are chronically sleep-deprived are 7 times more likely to feel helpless and 5x
more likely to feel alone (Great British Sleep Survey)
Light & Healthcare: Whole-Human Approaches
Source: http://www.greatbritishsleepsurvey.com/
Sleep deprivation is the “epidemic of the 21st century”.
Obesity
• Higher BMI with insufficient sleep
• Disruption of appetite hormone secretion (leptin & ghrelin)
Diabetes • Slower processing of glucose
Hypertension
• Elevated blood pressure
• Link to heart disease & stroke
Mood Disorders • Sadness, irritability, negative outlook, reduced sociability
Immunity • Increased susceptibility to infection
Self-Medication
• Potential for increased alcohol consumption, dependence
on sleep aids
Life Expectancy • Sleeping 5 hours or less increases mortality risk by 15%
Light & Healthcare: Whole-Human Approaches
Source: Division of Sleep Medicine at Harvard Medical School
Sleep…the perfect storm.
Light & Healthcare: Whole-Human Approaches
The Role of the 3rd Photoreceptor
• Rods and cones are photoreceptors for our visual system
• Intrinsically photoreceptive retinal ganglion cells (IPRGCs) impact our circadian systems (seeks
blue light during the day)
Light & Healthcare: Whole-Human Approaches
What are Circadian Rhythms?
Light & Healthcare: Whole-Human Approaches
Photopic, Scotopic, and Circadian Spectral Functions
Light & Healthcare: Whole-Human Approaches
Regulating Circadian Rhythms
• Early morning exposure to higher light levels, especially in the short wavelength region of the
visible spectrum (460-490 nm)
• Early morning outdoor activities between 7 a.m. and 10 a.m., or indoors with daylight
• Maximum benefit in winter at high latitudes where it’s often dark going to work
• Warmer, long-wavelength light in late afternoon and evening
• Dark or amber light at night to allow for melatonin production
Light & Healthcare: Whole-Human Approaches
Circadian rhythms have gone mainstream…
Light & Healthcare: Whole-Human Approaches
Really mainstream…
• $10 million “WELL Certified” apartment in
Greenwich Village
• Includes “vitamin C-infused showers, heat
reflexology flooring, aromatherapy air supply, and
dawn-simulating circadian lighting design”
• The “Kardashian-ization” of circadian light?
Light & Healthcare: Whole-Human Approaches
Source: http://pagesix.com/2014/05/05/dicaprio-buys-10-million-greenwich-village-apartment/
Light, Sleep, and Appetite
• Chronic and acute sleep deprivation results in
decreases in leptin (satiety hormone) and
ghrelin (hunger hormone)
• Prior studies established linkages between
timing of leptin & ghrelin secretions and the
circadian clock (i.e., hungrier during the day,
more sated at night)
Light & Healthcare: Whole-Human Approaches
Source: Mariana G. Figueiro, Barbara Plitnick, and Mark S. Rea, “Light Modulates Leptin and Ghrelin in Sleep-Restricted Adults,”
International Journal of Endocrinology, vol. 2012, Article ID 530726
Light, Sleep, and Appetite
• Subjects maintained a 5-hour sleep schedule for 5 days (as compared to an 8-hour baseline)
• Hypothesis that light could counteract the effects of sleep deprivation
• Subjects exposed to 4 lighting conditions via calibrated goggles:
 60 lux of red light (633nm)
 60 lux of green light (532nm)
 60 lux of blue light (475nm)
 Dim light (<0.5 lux at eye, 630nm)
• Morning red, green, and blue light significantly increased concentrations of leptin
(feeling of fullness); only red and green light exposure reduced ghrelin concentrations
(sensation of hunger).
• More studies need to be done to determine mechanism (likely not acute melatonin
suppression)
Light & Healthcare: Whole-Human Approaches
Source: Mariana G. Figueiro, Barbara Plitnick, and Mark S. Rea, “Light Modulates Leptin and Ghrelin in Sleep-Restricted Adults,”
International Journal of Endocrinology, vol. 2012, Article ID 530726
Light, Positive Distraction, and Mood
Light & Healthcare: Whole-Human Approaches
“The art of medicine consists of
amusing the patient while nature
cures the disease.”
- Voltaire
Light & Healthcare: Whole-Human Approaches
Light & Healthcare: Whole-Human Approaches
Credit: Clemson University Patient Room Prototype
Minimally Invasive Procedures & Treatments
• Interventional Radiology
• Cardiac Catheterization
• Oncology/Infusion
• In-Center Hemodialysis
Light & Healthcare: Whole-Human Approaches
In-Center Hemodialysis – Comfort, Positive Distraction
Light & Healthcare: Whole-Human Approaches
Credit: Queens-Long Island Renal Institute, Tobin & Parnes
Recommended Maintained Illuminance Targets
(In Footcandles, horizontal)
Visual Age of Observers (in years)
Applications & Tasks
<25 25-65 >65
Treatment Area
(Chair/Bed)
25 50 100
Treatment Room
(General)
10 20 40
Treatment Room
(Needle Insertion)
50 100 200
Dialysis Treatment – Example
How could lighting design make this procedure more
comfortable for the patient?Light & Healthcare: Whole-Human Approaches
Chemotherapy Infusion – Distraction, Comfort, Empowerment
Light & Healthcare: Whole-Human Approaches
Credit: Spellman Brady
Radiation Oncology
Light & Healthcare: Whole-Human Approaches
Credit: Fort Belvoir Community Hospital, Architecture/Lighting Design: HDR Architecture
Lighting in MRI Settings
• Illumination for preparation and procedure
• Lighting for patient relaxation and
distraction
–30% of patients experience some
distress during MRI examination
–Noise: MRI Sounds
–Claustrophobia: Some patients
need mild sedative; in some
cases, procedures must be
terminated prematurely
• Note: Non-ferromagnetic construction of
MRI lighting systems is of paramount
importance.
Light & Healthcare: Whole-Human Approaches
Radiology: Visual Tasks
Recommended Maintained Illuminance Targets
(In Footcandles, horizontal)
Visual Age of Observers (in years)
Applications &
Tasks
<25 25-65 >65
Preparation 25 50 100
Procedure 2.5 5 10
Ceiling Art Introduce back-lighted murals or art panels on ceiling above
recumbent patient’s head position.
Light & Healthcare: Whole-Human Approaches
Which views are considered therapeutic?
Light & Healthcare: Whole-Human Approaches
Credit: Clemson Patient Room Prototype 2012/2013
• Balance of prospect & refuge, no perceived
threats
• Restorative nature images can reduce
stress, anxiety, and pain (Ulrich, 2009 and
Hathorn & Nanda, 2008)
• Studies have used both observation tools
as well as fMRI
• Applications in patient rooms, diagnostic &
treatment spaces, waiting rooms (ED and
general)
Enabling deeper connections to nature…
Light & Healthcare: Whole-Human Approaches
Image: Spaulding Rehabilitation Hospital
Incorporating biophilic design into ambulatory settings…
Light & Healthcare: Whole-Human Approaches
Exploration of increasing organic forms and materials…
Light & Healthcare: Whole-Human Approaches
De-institutionalization of the physical environment…
Light & Healthcare: Whole-Human Approaches
Using sparkle
and dimension to
connect with
people…
Light & Healthcare: Whole-Human Approaches
Shown: CS Mott Children’s Hospital, HKS Architects
Personal Expression
through Color & Light
Light & Healthcare: Whole-Human Approaches
• Current literature is inconclusive, in terms of linking specific colors of light with emotion,
health, and behavior (Edelstein et al., 2008)
• White walls and bright white light are the hallmark of institutional settings.
• Concern about use of light in certain spectra (460-480nm, blue) at night due to potential of
circadian disruption
• Project uses RGB LEDs to color space
Room Design Hypothesis: Giving patients the ability to define their color
environment will result in improved self-reported perceptions of mood.
Expression through Color and Light
Light & Healthcare: Whole-Human Approaches
Room as Color-Light Vessel
Light & Healthcare: Whole-Human Approaches
How easy can we make controls for healthcare?
 DMX controller can be enabled via
“tethered” apps
 Control color, intensity, speed of “show”
from patient bed
 Astronomical time clock can be used to
enable visual cues for activity schedule,
tunable white light for daylight simulation
 Ease of use important for impaired, high
acuity, and pediatric patients
Light & Healthcare: Whole-Human Approaches
What if you could use color without “tinting” the space?
Light & Healthcare: Whole-Human Approaches
How do we make lighting more connected &
immersive…more experiential?
What about our aging population?
Light & Healthcare: Whole-Human Approaches
People Are Getting Older, Living Longer…
• US: The “oldest” baby
boomers turned 65 in 2011
• Life expectancy:
– US is 78 years (76 for males,
81 for females)
– Canadians & Spaniards can
expect 81 years
– 80 years in the UK
– 76 years in Mexico
Light & Healthcare: Whole-Human Approaches
Healthcare & Aging Eyes
• Older adults make up a large percentage of healthcare facility occupants
(staff, patients, volunteers).
 Patients 65 and up make up half of hospital visits, according to the CDC.
 Over 50% of medical facility volunteers are >65.
 Adults over age 65 visit a physician 7x a year (<4 visits/year for general population).
 People over 65 can spend up to 4x longer in the hospital than younger population.
• Average age of patient in skilled nursing facility is 79
• Lighting requirements for aging eyes are different than for younger
populations.
Light & Healthcare: Whole-Human Approaches
Source: IESNA RP-29-06 (Lighting for Hospitals and Health Care Facilities); Mass General, The Graying American Patient, 2009
Changes in the Eye Occur With Aging…
• Less light is transmitted to the retina – from
100% at age 25, to roughly 25% at age 75
• Pupils become smaller, less able to adapt
• Lenses darken over time
• Increased prevalence of eye diseases
(aging and related to other chronic
conditions)
Light & Healthcare: Whole-Human Approaches
Prevalence of sensory impairments increases with age
Light & Healthcare: Whole-Human Approaches
Age Distribution of Registered Nurses
Light & Healthcare: Whole-Human Approaches
Eye Conditions and Care Environments
• Long-Term Care – Older population and
prevalence of vision impairments
• In-Center Hemodialysis – Diabetes &
hypertension are the two most common
causes of chronic kidney disease & end-
stage renal disease
• Stroke Patients – Hypertension, ocular
pressure, and glaucoma
Light & Healthcare: Whole-Human Approaches
Source: United States Renal Disease Statistics
Resources
Light & Healthcare: Whole-Human Approaches
NIBS – Lighting & Low Vision
IES – Lighting for Aging Eye
IES RP-28-07 (Lighting
– Senior Living) will
now be “Lighting for the
Aged & Partially
Sighted (revision in
progress)
Evidence-Based Design &
Healing Environments
• Evidence-Based Design (EBD) –
 “the deliberate attempt to base building decisions on the best available
research evidence with the goal of improving outcomes and of continuing
to monitor the success or failure for subsequent decision-making.”
• Focuses on patient stress and fatigue, staff stress, and facility operational efficiency &
productivity
Source: A Visual Reference for Evidence-Based Design, Jain Malkin 2008
Light & Healthcare: Whole-Human Approaches
Selected Evidence-Based Design Research Areas
Connection to
nature
Control (choice and
empowerment)
Social support
Positive distraction Elimination of
environmental
stressors
Acceptance of
complementary
therapies
Source: A Visual Reference for Evidence-Based Design, Jain Malkin 2008
Light & Healthcare: Whole-Human Approaches
Process of Evidence-Based Design
Measure and
share
outcomes.
Hypothesize
outcomes,
innovate, and
implement
translational
design.
• Design interventions &
expected outcomes
• Mockups/Pilots for to
test hypotheses prior
to construction
Map strategic,
cultural, and
research
goals.
• Identify key strategic
objectives & project
vision, guiding
principles
• Develop research
agenda (baseline and
benchmarking)
Gather
qualitative and
quantitative
intelligence in
the pre-design
phase.
• Interdisciplinary team
• Existing facility data &
information from
similar projects
• Organizational goals
• Documented & peer-
reviewed studies
Light & Healthcare: Whole-Human Approaches
Source: Evidence-Based Healthcare Design, Rosalyn Cama, 2009.
Research Area Conclusions/Findings
Safety – Infection
Control
Hand hygiene is the most important measure for preventing pathogen spread
(Boyce & Pittet, 2002), and hand-washing compliance is usually around 20-35%
(Malleret et al., 1998).
A few studies link an increase in number & accessibility of hand-hygiene sinks with
a rise in hand-washing compliance; however, results have been mixed.
Safety – Fall
Prevention
Most patient falls occur in the bedroom and bathroom, respectively, and transfers
to/from the bed are the source of most falls, at 42% (Brandis, 1999).
The location of the bathroom on patient headwall works to reduce walking distance;
however, studies indicate that bedrails, a popular fall prevention design feature, can
actually increase severity and injury of falls (Tan et al, 2005).
Higher ambient lighting levels, with effective glare control, is related to lower fall
risks. (Vu et al., 2004)
Research : Light + Safety
Light & Healthcare: Whole-Human Approaches
Research Area Conclusions/Findings
Circadian Systems &
Daylight
Exposure to light linked to length of stay (LOS); patients in cardiac ICU stayed one
day shorter when placed in the sunny room, versus the shaded one (Beauchemin &
Hays, 1998).
Patients staying on sunny side of hospital perceived less stress, reported lower
levels of pain, and took 22% less pain-relieving medication than those in the dim
rooms (Walch et al., 2005).
Communication &
Privacy
Lower lighting levels in patient rooms can foster enhanced communication between
patient and caregivers (Miwa & Hanyu, 2006).
Empowerment and
Control
Increasing patients’ control over their physical environment can result in a greater
sense of empowerment, which is linked to improved outcomes (Steptoe & Appels,
1989).
Views of Nature &
Biophilic Design
Views to nature may elicit positive emotions, distracting patients from pain and
anxiety (Malenbaum et al., 2008). Patients who viewed well-lit images of trees and
water needed fewer doses of pain relievers (Ulrich et al., 1993).
Research : Light + Wellbeing
Light & Healthcare: Whole-Human Approaches
Research Area Conclusions/Findings
Sleep Efficiency
Thirty minutes or more of daily sunlight exposure resulted in improved nighttime
sleep duration. (Alessi et al., 2005)
Higher daytime light levels (between 7am and 7pm) were associated with
improved sleep/wake cycles in skilled nursing residents. (Shochat et al., 2000;
Wallace-Guy et al., 2002)
Reduction of light levels at night and resultant reduction of peak noise level at
night were associated with improved sleep efficiency. (Schnelle et al., 1999)
Research : Light + Wellbeing
Light & Healthcare: Whole-Human Approaches
Evidence-Based Design Techniques
Patient Comfort
• Single patient rooms with access
to natural light and views
• Use of daylight for visual and
biological functions
• Dedicated spaces for family in
patient care rooms
• Meditation rooms and positive
diversions such as artwork,
gardens, fountains, green spaces
• Noise-reduction and acoustic
improvements
Caregiver Performance
• Acuity-adaptable rooms
• Decentralized nursing stations
• Enhanced physician lounges
• Same-handed versus “mirror”
patient room design
• Ceiling lifts in patient rooms to
prevent caregiver injury & fatigue
(back injuries account for 44% of
lost workdays for nursing staff*)
Light & Healthcare: Whole-Human Approaches
Source: A Visual Reference for Evidence-Based Design, Jain Malkin 2008
* Fragala & Bailey reported in Joseph & Fritz, 2006.
How do we manage patient/staff tradeoffs?
Light & Healthcare: Whole-Human Approaches
Credit: Fort Belvoir Community Hospital, Architecture/Lighting Design: HDR Architecture
Patient Room: Space Considerations
• Room configuration and
intended purpose (Med/Surg,
ICU, Protective Environments,
Pediatric, etc.)
• Furniture layout
• Windows & room Orientation
• Location of medical equipment,
lift systems and tracks
Light & Healthcare: Whole-Human Approaches
Credit: Fort Belvoir Community Hospital, Architecture/Lighting Design: HDR Architecture
Patient Room: Occupant Needs
Patient
• Reading/writing
• Watching TV
• Visiting with guests
• Sleeping
• Restroom
Caregiver Staff
• Routine nursing
• Observation of patients
• Night lighting
• Patient examination
Light & Healthcare: Whole-Human Approaches
Patient Room: Lighting Requirements
Recommended Maintained Illuminance Targets
(In Footcandles, horizontal)
Visual Age of Observers (in years)
Applications & Tasks
<25 25-65 >65
Examination 25 50 100
Reading 10 20 40
Television Viewing 2.5 5 10
Shower 5 10 20
Vanities 7.5 15 30
Night Lights 0.05 0.1 0.2
Reference: 10,000 footcandles = sunny day, 0.01 footcandles = full moonlight
Light & Healthcare: Whole-Human Approaches
Caregiver Activities
• “Time and Motion Study”, 2007
• Answered questions about how nurses spend
their time
– Primary activities: documentation, medication
administration, locating supplies, and
communication
– Median distance traveled by nurses in a 10-hour
shift is 3 miles
• Lean Design – Focuses on the elimination of
waste in processes to realize improvements in
quality, delivery, and cost
• Implications for decentralized nursing stations
and other layout changes
48%
28%
8%
16%
Percentage of Time
– Nurse Activities
Indirect Care Direct Care
Waste Other
Source: “Time & Motion Study”, Ascension Health & Kaiser Permanente, presented 2007
Light & Healthcare: Whole-Human Approaches
Nursing Station: Illuminance Levels
Recommended Maintained Illuminance Targets
(In Footcandles, horizontal)
Visual Age of Observers (in years)
Applications &
Tasks
<25 25-65 >65
Work Station – Day
(Inpatient &
Intensive Care)
25 50 100
Work Station –
Night (Inpatient)
5 10 20
Work Station –
Night (Intensive
Care)
15 30 60
Corridors (Day) 5 10 20
Corridors (Night) 2.5 5 10
Light & Healthcare: Whole-Human Approaches
How do patients perceive their environment of care?
Light & Healthcare: Whole-Human Approaches
79 82
68 71
64
73
61
85
0
10
20
30
40
50
60
70
80
90
Average "Top Box" HCAHPS Scores
October 2012 to September 2013 Discharges
How should corridors adapt throughout the 24-hour day?
Light & Healthcare: Whole-Human Approaches
Credit: Theda Care/HGA
Post-Anesthesia Care Units (PACU)/Recovery
• Used for patients coming out of anesthesia,
post-operative care
• Caregivers monitor vital signs of the patient,
inspect surgical site for tissue changes that
could be cause for concern
• Patients coming out of sedation may
experience nausea and vomiting, and
intense light may exacerbate these
conditions
• Visually comfortable, dimmable light for
observation (25-100fc) and rest (5-20fc)
recommended
Light & Healthcare: Whole-Human Approaches
Credit: Columbia Orthopedic Group, Christner, Inc.
What about shift work?
• Lighting Research Center at Rensselaer
Polytechnic Institute did a study with
subjects to see if red light could
increase their alertness
• Subjects were given either blue or red
LED glasses at night.
• Hypothesis: Blue glasses were the
control which would suppress
melatonin, and red would make them
alert
• Red light increased alertness, but the
exact mechanism is unclear
• (More study required)
Light & Healthcare: Whole-Human Approaches
Nursing Performance – Further Research
• Limited knowledge that is specific to nursing work and critical task performance
• Understanding of how nurses adapt when lighting is contradicts patient’s desires
• Impact of areas of respite on staff (some studies on staff retention)
• Need for inclusive design, mockups, and simulations
Light & Healthcare: Whole-Human Approaches
Closing Thoughts
• Technology will cease to
be the constraint
 Wayfinding & positional
tracking
 Connectivity & IoT
• We can design for
healthcare, but designing
for health will be the true
breakthrough
Light & Healthcare: Whole-Human Approaches
Credit: Fort Belvoir Community Hospital, Architecture/Lighting Design: HDR Architecture
Thank you!!

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Healthcare Designs: Can Modern Lighting Cure the ill's of Ailing Institutions. Presented by Karyn Gayle, Acuity Brands

  • 1. Whole-Human Approaches for Lighting That Cares Karyn Gayle, MIES, EDAC Vice-President – Healthcare, Acuity Brands Karyn.Gayle@acuitybrands.com, Twitter: @karyngayle
  • 2. Acuity Brands Lighting is a Registered Provider with The American Institute of Architects Continuing Education Systems. Credit earned on completion of this program will be reported to CES Records for AIA members. Certificates of Completion for non-AIA members are available on request. This program is registered with the AIA/CES for continuing professional education, under AB325. As such, it does not include content that may be deemed or construed to be an approval or endorsement by the AIA of any material of construction of any method or manner of handling, using, distributing, or dealing in any material or product. Questions related to specific materials, methods, and services will be addressed at the conclusion of this presentation. Continuing Education Best Practices Light & Healthcare: Whole-Human Approaches
  • 3. Learning Objectives • Describe key trends impacting healthcare • Discuss functional, physiological, and psychological aspects of lighting in healthcare settings • Review key design interventions in facility lighting design and the link to health outcomes • Examine current and future state of lighting technologies and their application for care environments Light & Healthcare: Whole-Human Approaches
  • 4. Key Healthcare Trends • Light + Health • Demographic Shifts • Evidence-Based Design Light & Healthcare: Whole-Human Approaches
  • 5. First things first… Light & Healthcare: Whole-Human Approaches Health ≠ Healthcare Healthcare ≈ Sickcare …would we be better off if we designed for health as well as care?
  • 6. The Realities: Costs are high and expected to double in 10 years… Light & Healthcare: Whole-Human Approaches Source: OECD Health Data 2013, graphic by Huffington Post
  • 7. Reimbursement Changes: From volume to value… • HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) developed by Center for Medicare & Medicaid Services (CMS) in 2006 • Scores capture patients’ perspectives on acute care hospital care experience • Migration from optional data collection to pay for performance (October 2012) • For acute care hospitals, performance will drive 2% of CMS reimbursements as part of Value-Based Purchasing Patient Experience & Reimbursements • Avoidance of hospital-acquired infections & shortened stays • Readmissions can be 20% of inpatient volume, reimbursements for excess readmissions will be reduced, starting in Federal FY2013 (October 2012) Patient Outcomes • Fall prevention • Hygiene, germ & dust management Patient Safety Light & Healthcare: Whole-Human Approaches
  • 8. Sustainable Design & Energy Usage • Based on 2008 data from the US DOE’s Energy Information Administration: – Lighting accounts for 42 percent of overall health care electricity use:  Inpatient: 42%  Outpatient: 40% • Healthcare buildings account for 7 percent of electricity use by all commercial and industrial buildings. HVAC 37% Water Heating 2% Lighting 42% Office Equipme nt & Computer s 6% Refrigerat ion 2% Other 11% US Electricity Consumption (kWh), 2003 - Inpatient Health Care Facilities Light & Healthcare: Whole-Human Approaches
  • 9. Going back to our premise… Light & Healthcare: Whole-Human Approaches Health ≠ Healthcare Healthcare ≈ Sickcare …would we be better off if we designed for health as well as care?
  • 10. The root of the problem…what makes us so unhealthy? Light & Healthcare: Whole-Human Approaches
  • 11. Chronic Disease • More than three-fourths of United States healthcare costs are due to chronic diseases (CDC) • And, many preventable behaviors are linked to chronic disease:  Tobacco use  Insufficient physical activity  Poor nutrition  Excessive alcohol consumption  (Also, unmanaged stress) Light & Healthcare: Whole-Human Approaches Source: Centers for Disease Control, 2009
  • 12. “Everyone wants it, but nobody is getting any...” - Anonymous Light & Healthcare: Whole-Human Approaches
  • 13. The Importance of Sleep Light & Healthcare: Whole-Human Approaches
  • 14. Some Less-Obvious Implications of Sleep… • People who get sufficient sleep have increased gray matter in their brains, which is connected to psychological health. (Harvard Medical School Study) • Brain clears out waste proteins between cells, and this waste product is linked to Alzheimer’s disease, (Dr. Maiken Nedergaard, University of Rochester) • People who are chronically sleep-deprived are 7 times more likely to feel helpless and 5x more likely to feel alone (Great British Sleep Survey) Light & Healthcare: Whole-Human Approaches Source: http://www.greatbritishsleepsurvey.com/
  • 15. Sleep deprivation is the “epidemic of the 21st century”. Obesity • Higher BMI with insufficient sleep • Disruption of appetite hormone secretion (leptin & ghrelin) Diabetes • Slower processing of glucose Hypertension • Elevated blood pressure • Link to heart disease & stroke Mood Disorders • Sadness, irritability, negative outlook, reduced sociability Immunity • Increased susceptibility to infection Self-Medication • Potential for increased alcohol consumption, dependence on sleep aids Life Expectancy • Sleeping 5 hours or less increases mortality risk by 15% Light & Healthcare: Whole-Human Approaches Source: Division of Sleep Medicine at Harvard Medical School
  • 16. Sleep…the perfect storm. Light & Healthcare: Whole-Human Approaches
  • 17. The Role of the 3rd Photoreceptor • Rods and cones are photoreceptors for our visual system • Intrinsically photoreceptive retinal ganglion cells (IPRGCs) impact our circadian systems (seeks blue light during the day) Light & Healthcare: Whole-Human Approaches
  • 18. What are Circadian Rhythms? Light & Healthcare: Whole-Human Approaches
  • 19. Photopic, Scotopic, and Circadian Spectral Functions Light & Healthcare: Whole-Human Approaches
  • 20. Regulating Circadian Rhythms • Early morning exposure to higher light levels, especially in the short wavelength region of the visible spectrum (460-490 nm) • Early morning outdoor activities between 7 a.m. and 10 a.m., or indoors with daylight • Maximum benefit in winter at high latitudes where it’s often dark going to work • Warmer, long-wavelength light in late afternoon and evening • Dark or amber light at night to allow for melatonin production Light & Healthcare: Whole-Human Approaches
  • 21. Circadian rhythms have gone mainstream… Light & Healthcare: Whole-Human Approaches
  • 22. Really mainstream… • $10 million “WELL Certified” apartment in Greenwich Village • Includes “vitamin C-infused showers, heat reflexology flooring, aromatherapy air supply, and dawn-simulating circadian lighting design” • The “Kardashian-ization” of circadian light? Light & Healthcare: Whole-Human Approaches Source: http://pagesix.com/2014/05/05/dicaprio-buys-10-million-greenwich-village-apartment/
  • 23. Light, Sleep, and Appetite • Chronic and acute sleep deprivation results in decreases in leptin (satiety hormone) and ghrelin (hunger hormone) • Prior studies established linkages between timing of leptin & ghrelin secretions and the circadian clock (i.e., hungrier during the day, more sated at night) Light & Healthcare: Whole-Human Approaches Source: Mariana G. Figueiro, Barbara Plitnick, and Mark S. Rea, “Light Modulates Leptin and Ghrelin in Sleep-Restricted Adults,” International Journal of Endocrinology, vol. 2012, Article ID 530726
  • 24. Light, Sleep, and Appetite • Subjects maintained a 5-hour sleep schedule for 5 days (as compared to an 8-hour baseline) • Hypothesis that light could counteract the effects of sleep deprivation • Subjects exposed to 4 lighting conditions via calibrated goggles:  60 lux of red light (633nm)  60 lux of green light (532nm)  60 lux of blue light (475nm)  Dim light (<0.5 lux at eye, 630nm) • Morning red, green, and blue light significantly increased concentrations of leptin (feeling of fullness); only red and green light exposure reduced ghrelin concentrations (sensation of hunger). • More studies need to be done to determine mechanism (likely not acute melatonin suppression) Light & Healthcare: Whole-Human Approaches Source: Mariana G. Figueiro, Barbara Plitnick, and Mark S. Rea, “Light Modulates Leptin and Ghrelin in Sleep-Restricted Adults,” International Journal of Endocrinology, vol. 2012, Article ID 530726
  • 25. Light, Positive Distraction, and Mood Light & Healthcare: Whole-Human Approaches
  • 26. “The art of medicine consists of amusing the patient while nature cures the disease.” - Voltaire Light & Healthcare: Whole-Human Approaches
  • 27. Light & Healthcare: Whole-Human Approaches Credit: Clemson University Patient Room Prototype
  • 28. Minimally Invasive Procedures & Treatments • Interventional Radiology • Cardiac Catheterization • Oncology/Infusion • In-Center Hemodialysis Light & Healthcare: Whole-Human Approaches
  • 29. In-Center Hemodialysis – Comfort, Positive Distraction Light & Healthcare: Whole-Human Approaches Credit: Queens-Long Island Renal Institute, Tobin & Parnes
  • 30. Recommended Maintained Illuminance Targets (In Footcandles, horizontal) Visual Age of Observers (in years) Applications & Tasks <25 25-65 >65 Treatment Area (Chair/Bed) 25 50 100 Treatment Room (General) 10 20 40 Treatment Room (Needle Insertion) 50 100 200 Dialysis Treatment – Example How could lighting design make this procedure more comfortable for the patient?Light & Healthcare: Whole-Human Approaches
  • 31. Chemotherapy Infusion – Distraction, Comfort, Empowerment Light & Healthcare: Whole-Human Approaches Credit: Spellman Brady
  • 32. Radiation Oncology Light & Healthcare: Whole-Human Approaches Credit: Fort Belvoir Community Hospital, Architecture/Lighting Design: HDR Architecture
  • 33. Lighting in MRI Settings • Illumination for preparation and procedure • Lighting for patient relaxation and distraction –30% of patients experience some distress during MRI examination –Noise: MRI Sounds –Claustrophobia: Some patients need mild sedative; in some cases, procedures must be terminated prematurely • Note: Non-ferromagnetic construction of MRI lighting systems is of paramount importance. Light & Healthcare: Whole-Human Approaches
  • 34. Radiology: Visual Tasks Recommended Maintained Illuminance Targets (In Footcandles, horizontal) Visual Age of Observers (in years) Applications & Tasks <25 25-65 >65 Preparation 25 50 100 Procedure 2.5 5 10 Ceiling Art Introduce back-lighted murals or art panels on ceiling above recumbent patient’s head position. Light & Healthcare: Whole-Human Approaches
  • 35. Which views are considered therapeutic? Light & Healthcare: Whole-Human Approaches Credit: Clemson Patient Room Prototype 2012/2013 • Balance of prospect & refuge, no perceived threats • Restorative nature images can reduce stress, anxiety, and pain (Ulrich, 2009 and Hathorn & Nanda, 2008) • Studies have used both observation tools as well as fMRI • Applications in patient rooms, diagnostic & treatment spaces, waiting rooms (ED and general)
  • 36. Enabling deeper connections to nature… Light & Healthcare: Whole-Human Approaches Image: Spaulding Rehabilitation Hospital
  • 37. Incorporating biophilic design into ambulatory settings… Light & Healthcare: Whole-Human Approaches
  • 38. Exploration of increasing organic forms and materials… Light & Healthcare: Whole-Human Approaches
  • 39. De-institutionalization of the physical environment… Light & Healthcare: Whole-Human Approaches
  • 40. Using sparkle and dimension to connect with people… Light & Healthcare: Whole-Human Approaches Shown: CS Mott Children’s Hospital, HKS Architects
  • 41. Personal Expression through Color & Light Light & Healthcare: Whole-Human Approaches
  • 42. • Current literature is inconclusive, in terms of linking specific colors of light with emotion, health, and behavior (Edelstein et al., 2008) • White walls and bright white light are the hallmark of institutional settings. • Concern about use of light in certain spectra (460-480nm, blue) at night due to potential of circadian disruption • Project uses RGB LEDs to color space Room Design Hypothesis: Giving patients the ability to define their color environment will result in improved self-reported perceptions of mood. Expression through Color and Light Light & Healthcare: Whole-Human Approaches
  • 43. Room as Color-Light Vessel Light & Healthcare: Whole-Human Approaches
  • 44. How easy can we make controls for healthcare?  DMX controller can be enabled via “tethered” apps  Control color, intensity, speed of “show” from patient bed  Astronomical time clock can be used to enable visual cues for activity schedule, tunable white light for daylight simulation  Ease of use important for impaired, high acuity, and pediatric patients Light & Healthcare: Whole-Human Approaches
  • 45. What if you could use color without “tinting” the space? Light & Healthcare: Whole-Human Approaches How do we make lighting more connected & immersive…more experiential?
  • 46. What about our aging population? Light & Healthcare: Whole-Human Approaches
  • 47. People Are Getting Older, Living Longer… • US: The “oldest” baby boomers turned 65 in 2011 • Life expectancy: – US is 78 years (76 for males, 81 for females) – Canadians & Spaniards can expect 81 years – 80 years in the UK – 76 years in Mexico Light & Healthcare: Whole-Human Approaches
  • 48. Healthcare & Aging Eyes • Older adults make up a large percentage of healthcare facility occupants (staff, patients, volunteers).  Patients 65 and up make up half of hospital visits, according to the CDC.  Over 50% of medical facility volunteers are >65.  Adults over age 65 visit a physician 7x a year (<4 visits/year for general population).  People over 65 can spend up to 4x longer in the hospital than younger population. • Average age of patient in skilled nursing facility is 79 • Lighting requirements for aging eyes are different than for younger populations. Light & Healthcare: Whole-Human Approaches Source: IESNA RP-29-06 (Lighting for Hospitals and Health Care Facilities); Mass General, The Graying American Patient, 2009
  • 49. Changes in the Eye Occur With Aging… • Less light is transmitted to the retina – from 100% at age 25, to roughly 25% at age 75 • Pupils become smaller, less able to adapt • Lenses darken over time • Increased prevalence of eye diseases (aging and related to other chronic conditions) Light & Healthcare: Whole-Human Approaches
  • 50. Prevalence of sensory impairments increases with age Light & Healthcare: Whole-Human Approaches
  • 51. Age Distribution of Registered Nurses Light & Healthcare: Whole-Human Approaches
  • 52. Eye Conditions and Care Environments • Long-Term Care – Older population and prevalence of vision impairments • In-Center Hemodialysis – Diabetes & hypertension are the two most common causes of chronic kidney disease & end- stage renal disease • Stroke Patients – Hypertension, ocular pressure, and glaucoma Light & Healthcare: Whole-Human Approaches Source: United States Renal Disease Statistics
  • 53. Resources Light & Healthcare: Whole-Human Approaches NIBS – Lighting & Low Vision IES – Lighting for Aging Eye IES RP-28-07 (Lighting – Senior Living) will now be “Lighting for the Aged & Partially Sighted (revision in progress)
  • 54. Evidence-Based Design & Healing Environments • Evidence-Based Design (EBD) –  “the deliberate attempt to base building decisions on the best available research evidence with the goal of improving outcomes and of continuing to monitor the success or failure for subsequent decision-making.” • Focuses on patient stress and fatigue, staff stress, and facility operational efficiency & productivity Source: A Visual Reference for Evidence-Based Design, Jain Malkin 2008 Light & Healthcare: Whole-Human Approaches
  • 55. Selected Evidence-Based Design Research Areas Connection to nature Control (choice and empowerment) Social support Positive distraction Elimination of environmental stressors Acceptance of complementary therapies Source: A Visual Reference for Evidence-Based Design, Jain Malkin 2008 Light & Healthcare: Whole-Human Approaches
  • 56. Process of Evidence-Based Design Measure and share outcomes. Hypothesize outcomes, innovate, and implement translational design. • Design interventions & expected outcomes • Mockups/Pilots for to test hypotheses prior to construction Map strategic, cultural, and research goals. • Identify key strategic objectives & project vision, guiding principles • Develop research agenda (baseline and benchmarking) Gather qualitative and quantitative intelligence in the pre-design phase. • Interdisciplinary team • Existing facility data & information from similar projects • Organizational goals • Documented & peer- reviewed studies Light & Healthcare: Whole-Human Approaches Source: Evidence-Based Healthcare Design, Rosalyn Cama, 2009.
  • 57. Research Area Conclusions/Findings Safety – Infection Control Hand hygiene is the most important measure for preventing pathogen spread (Boyce & Pittet, 2002), and hand-washing compliance is usually around 20-35% (Malleret et al., 1998). A few studies link an increase in number & accessibility of hand-hygiene sinks with a rise in hand-washing compliance; however, results have been mixed. Safety – Fall Prevention Most patient falls occur in the bedroom and bathroom, respectively, and transfers to/from the bed are the source of most falls, at 42% (Brandis, 1999). The location of the bathroom on patient headwall works to reduce walking distance; however, studies indicate that bedrails, a popular fall prevention design feature, can actually increase severity and injury of falls (Tan et al, 2005). Higher ambient lighting levels, with effective glare control, is related to lower fall risks. (Vu et al., 2004) Research : Light + Safety Light & Healthcare: Whole-Human Approaches
  • 58. Research Area Conclusions/Findings Circadian Systems & Daylight Exposure to light linked to length of stay (LOS); patients in cardiac ICU stayed one day shorter when placed in the sunny room, versus the shaded one (Beauchemin & Hays, 1998). Patients staying on sunny side of hospital perceived less stress, reported lower levels of pain, and took 22% less pain-relieving medication than those in the dim rooms (Walch et al., 2005). Communication & Privacy Lower lighting levels in patient rooms can foster enhanced communication between patient and caregivers (Miwa & Hanyu, 2006). Empowerment and Control Increasing patients’ control over their physical environment can result in a greater sense of empowerment, which is linked to improved outcomes (Steptoe & Appels, 1989). Views of Nature & Biophilic Design Views to nature may elicit positive emotions, distracting patients from pain and anxiety (Malenbaum et al., 2008). Patients who viewed well-lit images of trees and water needed fewer doses of pain relievers (Ulrich et al., 1993). Research : Light + Wellbeing Light & Healthcare: Whole-Human Approaches
  • 59. Research Area Conclusions/Findings Sleep Efficiency Thirty minutes or more of daily sunlight exposure resulted in improved nighttime sleep duration. (Alessi et al., 2005) Higher daytime light levels (between 7am and 7pm) were associated with improved sleep/wake cycles in skilled nursing residents. (Shochat et al., 2000; Wallace-Guy et al., 2002) Reduction of light levels at night and resultant reduction of peak noise level at night were associated with improved sleep efficiency. (Schnelle et al., 1999) Research : Light + Wellbeing Light & Healthcare: Whole-Human Approaches
  • 60. Evidence-Based Design Techniques Patient Comfort • Single patient rooms with access to natural light and views • Use of daylight for visual and biological functions • Dedicated spaces for family in patient care rooms • Meditation rooms and positive diversions such as artwork, gardens, fountains, green spaces • Noise-reduction and acoustic improvements Caregiver Performance • Acuity-adaptable rooms • Decentralized nursing stations • Enhanced physician lounges • Same-handed versus “mirror” patient room design • Ceiling lifts in patient rooms to prevent caregiver injury & fatigue (back injuries account for 44% of lost workdays for nursing staff*) Light & Healthcare: Whole-Human Approaches Source: A Visual Reference for Evidence-Based Design, Jain Malkin 2008 * Fragala & Bailey reported in Joseph & Fritz, 2006.
  • 61. How do we manage patient/staff tradeoffs? Light & Healthcare: Whole-Human Approaches Credit: Fort Belvoir Community Hospital, Architecture/Lighting Design: HDR Architecture
  • 62. Patient Room: Space Considerations • Room configuration and intended purpose (Med/Surg, ICU, Protective Environments, Pediatric, etc.) • Furniture layout • Windows & room Orientation • Location of medical equipment, lift systems and tracks Light & Healthcare: Whole-Human Approaches Credit: Fort Belvoir Community Hospital, Architecture/Lighting Design: HDR Architecture
  • 63. Patient Room: Occupant Needs Patient • Reading/writing • Watching TV • Visiting with guests • Sleeping • Restroom Caregiver Staff • Routine nursing • Observation of patients • Night lighting • Patient examination Light & Healthcare: Whole-Human Approaches
  • 64. Patient Room: Lighting Requirements Recommended Maintained Illuminance Targets (In Footcandles, horizontal) Visual Age of Observers (in years) Applications & Tasks <25 25-65 >65 Examination 25 50 100 Reading 10 20 40 Television Viewing 2.5 5 10 Shower 5 10 20 Vanities 7.5 15 30 Night Lights 0.05 0.1 0.2 Reference: 10,000 footcandles = sunny day, 0.01 footcandles = full moonlight Light & Healthcare: Whole-Human Approaches
  • 65. Caregiver Activities • “Time and Motion Study”, 2007 • Answered questions about how nurses spend their time – Primary activities: documentation, medication administration, locating supplies, and communication – Median distance traveled by nurses in a 10-hour shift is 3 miles • Lean Design – Focuses on the elimination of waste in processes to realize improvements in quality, delivery, and cost • Implications for decentralized nursing stations and other layout changes 48% 28% 8% 16% Percentage of Time – Nurse Activities Indirect Care Direct Care Waste Other Source: “Time & Motion Study”, Ascension Health & Kaiser Permanente, presented 2007 Light & Healthcare: Whole-Human Approaches
  • 66. Nursing Station: Illuminance Levels Recommended Maintained Illuminance Targets (In Footcandles, horizontal) Visual Age of Observers (in years) Applications & Tasks <25 25-65 >65 Work Station – Day (Inpatient & Intensive Care) 25 50 100 Work Station – Night (Inpatient) 5 10 20 Work Station – Night (Intensive Care) 15 30 60 Corridors (Day) 5 10 20 Corridors (Night) 2.5 5 10 Light & Healthcare: Whole-Human Approaches
  • 67. How do patients perceive their environment of care? Light & Healthcare: Whole-Human Approaches 79 82 68 71 64 73 61 85 0 10 20 30 40 50 60 70 80 90 Average "Top Box" HCAHPS Scores October 2012 to September 2013 Discharges
  • 68. How should corridors adapt throughout the 24-hour day? Light & Healthcare: Whole-Human Approaches Credit: Theda Care/HGA
  • 69. Post-Anesthesia Care Units (PACU)/Recovery • Used for patients coming out of anesthesia, post-operative care • Caregivers monitor vital signs of the patient, inspect surgical site for tissue changes that could be cause for concern • Patients coming out of sedation may experience nausea and vomiting, and intense light may exacerbate these conditions • Visually comfortable, dimmable light for observation (25-100fc) and rest (5-20fc) recommended Light & Healthcare: Whole-Human Approaches Credit: Columbia Orthopedic Group, Christner, Inc.
  • 70. What about shift work? • Lighting Research Center at Rensselaer Polytechnic Institute did a study with subjects to see if red light could increase their alertness • Subjects were given either blue or red LED glasses at night. • Hypothesis: Blue glasses were the control which would suppress melatonin, and red would make them alert • Red light increased alertness, but the exact mechanism is unclear • (More study required) Light & Healthcare: Whole-Human Approaches
  • 71. Nursing Performance – Further Research • Limited knowledge that is specific to nursing work and critical task performance • Understanding of how nurses adapt when lighting is contradicts patient’s desires • Impact of areas of respite on staff (some studies on staff retention) • Need for inclusive design, mockups, and simulations Light & Healthcare: Whole-Human Approaches
  • 72. Closing Thoughts • Technology will cease to be the constraint  Wayfinding & positional tracking  Connectivity & IoT • We can design for healthcare, but designing for health will be the true breakthrough Light & Healthcare: Whole-Human Approaches Credit: Fort Belvoir Community Hospital, Architecture/Lighting Design: HDR Architecture