SILENT OPS

This is what the hospital of the future sounds like

Nothing sounds like a hospital. The incessant beep of monitors. The squeak of clogs on the tile floor. The whir of automatic doors and rolling cots. The moan of suffering patients and the drone of families huddled in a waiting room.

Anyone who’s spent a night in a hospital knows it’s hard to find a few moments of quiet—let alone sleep through the night. And when patients don’t sleep, they don’t heal.

There is now a small but diverse group of experts—electronic musicians, acousticians, researchers, and healthcare providers—devoted to improving the sound experience of hospitals. Already, they have begun to change the soundscape of the hospital.

Based largely on patient feedback, these experts are working to create environments that will be less cacophonous and more harmonious. Wearables could silently alert nurses to a change in patient vitals instead of the beep of monitors; patients would wait for surgery in their own private rooms; and the vexing din of voices and TVs playing talk shows are replaced by ambient music.

 Some hospitals were found to have noise over 100 decibels at night, which is as loud as a chainsaw. 

Hospitals have always been noisy places. In 1859, Florence Nightingale wrote a section devoted to noise and its hazard to patients in her Notes on Nursing. But in the US the noise problem has been getting worse and worse.

A 2005 study of global hospitals found that compared to 1960, daytime noise levels rose from 57 decibels to 72 and nighttime levels from 42 to 60. The World Health Organization says nighttime noise levels above 55 decibels (pdf) can routinely cause sleep disturbance and increase risk for heart disease. It recommends decibel levels of 30 or less for sleeping. In the 2005 study, some hospitals were found to have noise over 100 decibels at night, which is as loud as a chainsaw.

The 2008 Hospital Consumer Assessment of Healthcare Providers and Systems (HCAPHPS) patient survey, administered by the Centers for Medicare and Medicaid Services, highlighted the problem. The survey asked patients to grade their hospital experiences on a number of factors, ranging from cleanliness to communication with nurses; each one was given a score out of 100. The average US hospital received a quietness score of 54—the lowest of all 10 survey traits.

Smart design goes a long way

Today, America’s hospitals are going through a design renaissance. The confluence of a few factors—portions of the Affordable Care Act that reward outcomes and reposition patients as consumers, combined with the infusion of design-thinking, with attention paid to the end user (in this case, the patient), into various industries—are leading to facilities that focus on patient experience.

“It’s not any one particular thing” driving the shift in hospital design, says Nick Dawson, executive director of the Johns Hopkins Sibley Innovation Hub. “Some organizations are motivated by revenue streams from intellectual property. Some are looking at it as a way to mitigate HCAPHPS. And some are looking at it and saying, ‘There’s this untapped voice of the patient out there and we need to re-tailor our business toward them.’”

Yoko Kamitani Sen is an electronic musician and founder of Sen Sound, a startup reimagining the sound environment in hospitals. She proposes that in the future nurses might use wearables to alert them to a patient in need rather than an alarm. For years now, many healthcare experts and reports have been predicting that wearables will revamp the clinical setting. That’s yet to fully come into practice. But eliminating the ubiquitous beeps of the hospital floor might be what finally brings wearables to the clinic.

A 2013 report by the Joint Commission, a healthcare non-profit, found that an estimated 85 to 99% of all hospital (pdf) alarms did not require clinical intervention. That same year, Boston Medical Center set out to tackle “alarm fatigue,” a phenomenon that occurs in hospitals where there is so much beeping, nurses and support staff become desensitized to it. The excess of alarms not only contributes to the jarring environmental soundscape, but can also result in death when nurses fail to respond to alarms that are actually urgent. In a 24-bed cardiac care unit, the hospital was able to reduce alarms from 88,000 a week to 10,000 essential beeps.

Eliminating alarms is a good start, but it won’t solve everything. A recent survey asked 40 patients and 10 nurses and administrators at Johns Hopkins to explain the most annoying sound they regularly experienced at the hospital.

“Oftentimes we assume it’s the sound of alarms, which is actually the sound that really got me interested in this noise issue as a whole,” says Sen. “But repeatedly the answer we got [from patients] was the voice of somebody who is suffering in pain. Lots of patients expressed that across the hallway they can hear others in pain moaning, screaming.”

No single technology will fix that, though design changes, like private rooms, can help. And a lot of newly built or recently designed hospitals have recognized that. The Josie Robertson Surgery Center, an outpatient facility of Memorial Sloan Kettering Cancer Center in New York, opened earlier this year and completely upends traditional hospital design. For example, patients, family, and staff are given badges that are connected to a real-time locating system. That facilitates quieter and more efficient communication—instead of calling on an overhead pager, a nurse can go directly to the family when a patient is out of surgery.

Third floor waiting area at the Josie Robertson Surgery Center in New York. (Karsten Moran)

But perhaps even more importantly, patients at Josie Robertson also have their own private rooms. Combined with the tracking system, this means that they don’t have to be herded from group pre-op rooms to operating rooms to group post-op rooms—they can actually get some peace and quiet throughout treatment.

Others are following suit: Cleveland Clinic is in the process of building a new cancer center due to open in March of next year, which will have a private room for each patient receiving chemotherapy. Shannon Faulhaber, director of strategic growth for Cleveland Clinic Taussig Cancer Institute says, “We tried really hard to separate the medical from the patient space in all of our rooms.”

Silence isn’t the sound you actually want

Individualization extends beyond the physical room to how the actual soundscape of those patient spaces are designed. Everyone’s perception of what constitutes “noise” is different. The sound of your own baby crying is an important signal—to others, it’s an irksome racket that disturbs their sense of peace and wellbeing. In other words, it’s noise.

 “You can’t go to Home Depot and buy some magic acoustic paint and paint your walls.” 

“People’s preferences are very, very different,” says Sen. “On the same floor, on the exact day we have one patient say, ‘Oh it’s very quiet, nothing bothered me,’ and this other patient in the next room who says ‘It’s so loud I can’t stand it.’ Everybody is really different in terms of their perception of noise and their perception of sound.”

Ideally you could give patients the ability to choose how they want their room to sound.

Susan Mazer, the president and CEO of Healing HealthCare Systems, points out that we don’t want complete silence where accidental noise—a dropped cup, for example— becomes amplified. We don’t want to “merely mask other sounds, [but] add positive, therapeutic sounds where there are none.”

Mazer has helped to makeover the range of sounds available to patients through development of the C.A.R.E channel, an option on TVs in over 900 hospitals and care facilities around the world with relaxing imagery and soothing and ambient sounds.

The hospital people problem

While many hospitals have added white noise machines or other soundscapes to rooms, made improvements in construction to help with the acoustics, and even invested in more private rooms, there’s still one thing missing: Specialists have realized that changing behaviors in hospitals is fundamental to fixing the sound problem.

Gary Madaras, founder of the consultancy Making Hospitals Quiet, says we need to work on the “physical environment, the culture and the behavior, and hospital policies and procedures. We tell [clients] that all three of these need to be addressed. You can’t go to Home Depot and buy some magic acoustic paint and paint your walls.”

“For the most part I think the design world is further ahead in the environment than anybody is in the culture/behavior or the policies and procedures,” Madaras says.

You can’t completely control patients and their families. But you can direct the behavior of the health care workers in a hospital. In her treatise Nightingale wrote: “Never to allow a patient to be waked, intentionally or accidentally, is a sine qua non of all good nursing. If he is roused out of his first sleep, he is almost certain to have no more sleep.”

Through his consulting work, Madaras has put sound monitors in patient rooms and hallways and found that in some hospitals throughout the night there are very few 45 minutes segments where someone isn’t going into the patient room.

 We don’t like the sights and sounds of the sick because they presage our own eventual decline. 

He teaches hospital clients that there’s active care and there’s passive care—and the latter is just as important as the drugs and procedures patients receive. Passive care is basically: “leave me alone to sleep so I can heal.” Madaras works to rearrange care routines across the myriad schedules and departments—phlebotomists, nurses, doctors—so that there’s less need to go into patients’ rooms while they sleep.

While the promise of wearables and other forms of technology present potential to reduce sound, simple behaviors could have the greatest impact. Currently, typical practice is to keep doors open so that health care providers can easily access patients. But, says Madaras, “something so simple as closing the patient room door does a tremendous amount for the ability for that patient to sleep and not be disrupted. There’s a strong reluctance to do that.”

He’s working with a few institutions to implement technology that remotely monitor vitals so that nurses would be comfortable having the door closed all night long. “The next move in technology I see is not just remote monitoring of vital signs but actually remote monitoring of sleep,” he says. Systems could tell nurses what stage of sleep a patient is in—if they’ve reached stage three or four, deep sleep, they shouldn’t be bothered.

The things beyond our control

Underneath much of the anxiety and discomfort most of us feel about hospitals is the specter of death. We don’t like the sights and sounds of the sick because they presage our own eventual decline.

Between hospitals and nursing homes, the majority of Americans are still dying in institutions where the environment, and its sounds, is traditionally beyond our control.

Slowly, discussion of death is becoming less taboo, and patients and advocacy groups are pushing for more than just advance directives to plan what their finals days and hours will be like. Sound may soon be a part of that, too. For example, Sen’s Sound Will Project was selected by OpenIDEO as one of their “challenge” projects, where the site hosts innovative ideas for a few months so that community members can collaborate on solutions to pressing world issues. She’s now asking people what sounds they’d like to hear during their final days; the responses will serve as inspiration for a composition that Sen will present at an interactive performance during Stanford Medicine X conference in September. So far, answers include the sounds of crashing waves and thunder, song and songs like Radiohead’s “Nice Dream” and hearing “I love you” from family members.

The point isn’t to use sound to hide the reality that eventually, all of us die. Rather, it is to emphasize the meaning and even the potential beauty of an end-of-life experience that has been thoughtfully composed. Similarly, the goal of changing the soundscape of hospitals isn’t to cover up suffering, but rather to make them more healing environments for those who work and receive treatment there. We may never get to a place where a hospital has the full comfort of home, but this is sounding like a start.

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