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Hospital, Heal Thyself

Clamor is hazardous to your health. Designers have the Rx.

Imagine bright lights, beeping monitors, crowds of strangers and workers filling the corridors. Now add large equipment on wheeled carts, computer screens everywhere, and the voice of overhead paging speakers. When you complete the picture with the shuffle of partially clothed bodies, today’s hospitals are more akin to 24-hour Las Vegas casinos than the home-like spa settings that are conducive to recuperation.

Mix in the pervasive sense of personal vulnerability and drama, and the need to get things done quickly, with no tolerance for error, and the hospital — a place most of us will encounter at some point in our lives — is far from the peaceful environment needed to support healing.

In fact, the clamor impedes recovery: Rising blood pressure, increased respiratory rates, sleep deprivation and anxiety are well documented in adults overexposed to noise. The World Health Organization recommends that noise in hospital rooms shouldn’t be above 30 to 40 decibels. (For comparison, the rustling of leaves is 20 decibels, and highway traffic is 75 decibels.) A study published in 2012 by University of Chicago assistant dean Dr. Veneet Arora found that average patient-room noise level was closer to 50 decibels and sometimes spiked to 80. This is like sleeping next to a running dishwasher all night. No wonder standard hospital satisfaction surveys report patients complaining about noise twice as often as about the food.

Architects working in healthcare settings strive to create an ordered, tranquil environment: part meditative chapel and part babbling forest brook. But this essence of calm is far from total silence. Susan E. Mazer, president of the consulting firm Healing Healthcare Systems (and a former jazz harpist), has it right when she describes the need to create an exemplary standard of caring that is “heard as well as seen.’’

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As early as 1859, Florence Nightingale believed that noise delayed healing. In Notes on Nursing, Nightingale writes, “Unnecessary noise, then, is the most cruel absence of care which can be inflicted either on sick or well.” In 1918, one of the foremost American architects in healthcare design, Edward Fletcher Stevens, called for new technologies to reduce noise; he advocated the removal of “nurse call electric bells” and worried about vacuum cleaner racket. Even Mark Twain was recruited to join The Society for the Suppression of Unnecessary Noise, in an early-20th-century effort to minimize steamboat whistles in the East River as they passed though hospital zones.

The first comprehensive acoustic regulations for hospitals in the modern era appeared in the 2010 edition of Guidelines for Design and Construction of Health Care Facilities, published by the nonprofit Facility Guidelines Institute. The institute brought together an interdisciplinary group of architects, engineers, human behaviorists, acousticians, and others to set standards for healing environments. The guidelines cover a wide range of issues, from internal noise isolation of a patient’s room to vibration isolation of mechanical equipment to dampening exterior noise impacts on the surrounding community.

The Acoustical Society of America has been vital in developing numerical ratings to measure interior walls, ceilings, floors, doors, windows, and exterior wall configurations. The larger the number the more successful the material is at preventing noise from passing through. Establishing such standards is a step in the right direction. But merely focusing on compliance with a single numerical rating risks losing the potential for more highly informed acoustical design decisions. More important than trying to solve the problem with a number is finding the cause of the problem and addressing it at the source.

A quieter approach. At this typical intensive-care patient room on the 6th floor of the new Lunder Building at Massachusetts General Hospital, the architects minimized visual clutter along with aural noise and created calming views.<br>Photo by Frank Oudeman.<br>Architecture by NBBJ.

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The hospital experience is dominated by equipment noise. From the monitor next to the patient’s bed to the neighbor’s television, from pagers and alarms to mechanical equipment noise, there is no end to the cacophony found in a patient room. Other than the obvious need for regular equipment maintenance, options to keep unwanted noise down could include locating TV speakers close to a patient’s bed, using headphones, or providing speakers integrated into pillows.

Hospitals are making progress. To minimize overhead paging, many are now incorporating integrated pagers, texting, and synchronized internal communication among staff. Sound-level monitors at nursing stations also help keep staff aware of their behavior. A device called the “Yacker Tracker” has been installed at Veterans Administration hospitals in Florida and at Roger Williams Hospital in Providence. It is similar to a stoplight, turning from green to yellow to red to alert people in the vicinity when sound levels reach an uncomfortable level.

Hospitals are also visually cluttered places, requiring designers to keep in mind the important relationship of visual and auditory senses. Providing a view and connection to nature can have a positive effect on the mind. At the recently completed Lunder Building at Massachusetts General Hospital, every patient room and the staff lounges have been designed with calming views. Open gardens of all varieties and sizes, whether on ground level or atop a roof, have the power to heal. At Hershey Medical Center in Pennsylvania, multiple healing gardens provide respite from a busy and noisy clinical environment for patients, family and staff alike.

Even at a distance, patients are more apt to be negatively affected by noise when they can see the corresponding unpleasant source. Like covering your eyes or ears in a scary movie, reducing the number of sensory inputs is calming. Similarly, lowering light levels tends to cause people to tone down their voices. Lighting, then, is an invaluable tool in reducing noise.

Good design is sometimes limited by regulation. Infection control obviously is critical. But as Erica Ryherd, an acoustical specialist at the Georgia Institute of Technology, writes in her 2010 article “Too Noisy to Heal,” poor sound environments are a result of reflections from numerous hard surfaces that hospitals favor because they are easy to clean. As a result, noise mitigation solutions mainly have been confined to ceiling materials.

Although infection-control measures must be followed, marquee cancer centers such as Memorial Sloan-Kettering in New York City and MD Anderson in Houston, and community hospitals such as St. Joseph’s in Wisconsin are going against norms by using carpet in the hallways of their patient-care spaces. Carpets have meant quieter corridors and greater patient satisfaction. St. Joseph’s reports evidence that carpeting reduces staff fatigue as well. The hospitals have also acknowledged the need for higher levels of maintenance for carpeting and have adopted a rigorous program that supports such maintenance.

Another regulatory imperative for sound control is HIPAA — the Health Insurance Portability and Accountability Act — which establishes national rules for patient privacy. Hospitals understand that poorly designed acoustical environments can pose a serious threat to confidentiality if private conversations between doctor and patient or among clinical staff can be overheard. Still, privacy should not be the only goal for designers. Human presence perhaps creates some unwanted noise, but it should be weighed against the positive influence of human connection. Sounds of water, music, and other calming sounds from nature have proven to be therapeutic as well.

It is not just patients who are affected by noise. Hospital staffers consistently report exhaustion and burnout due to the continued exposure. The Boston Globe’s coverage of “alarm fatigue” found medical errors, delayed care, and even deaths could be attributed to staff becoming desensitized to the constant bleating of alarms. On one 15-bed unit at Johns Hopkins Hospital in Baltimore, staffers documented an average of 942 alarms per day — about one every 90 seconds.

Some owners are taking charge. A 2011 article in the St. Louis Post-Dispatch described how Memorial Hospital in Belleville, Illinois, adopted the national Silent Hospitals Help Healing, or SHHH, campaign. “The hospital’s maintenance staff replaced squeaky wheels, installed noise-absorbing ceiling tiles, and flattened the thresholds at the entrances to patient rooms,” the article read. Beyond those structural improvements, Memorial Hospital staff began sending text messages to doctors, reducing noisy overhead paging announcements “from an average of 100 pages per day to only three.” A tangible act such as this from the owner’s side sends a strong message about the importance of acoustic comfort, and it certainly is a strong booster for both patient and staff satisfaction.

Acoustics in healthcare is a relatively new area of specialization. Merely mitigating noise through sound-absorbing materials is not enough. We need to be thinking actively of hospitals as multicultural, multi-layered environments.

After all, our ears are “on” 24 hours a day. Some of us sleep through everything at night and yet hear the baby stirring. We can hear noises from a very soft whisper to an airplane engine and everything in between. Acoustic transmission and perception of noise is complex, and to create the right balance, a holistic approach is needed: one that considers use of advanced technology, connection between the senses, and behavioral and cultural education for everyone involved.