Evidence-based design: The new AIA guidelines on noise and privacy
Noise all night, couldn't sleep”; “Roommate drove me crazy”; “There's no privacy”—all are familiar complaints from hospital patients who can't wait to go home for some peace and quiet. Confirming the importance of these complaints, medical professionals acknowledge that noise-induced stress and sleep interruption—as well as inadequate privacy and the resulting reduced communication—contribute to a wide range of potentially serious health consequences in hospitals. Nevertheless, according to recent research from Johns Hopkins Medical Institutions, noise in healthcare facilities continues to escalate, and has done so for three decades.
Sleep is that golden chain that ties health and our bodies together.
Why all the problems? Could it be that noise prevention and the assurance of conversational privacy are just too expensive for hospitals to deliver? Widespread assumptions do persist that the acoustic context in which healthcare is delivered either “doesn't matter” or that nothing practical can be done to improve it.
The American Institute of Architects’ (AIA) 2006 Guidelines for the Design and Construction of Healthcare Facilities, available from www.aia.org/books.
The patient intake and interview area in the Endoscopy Suite at Beverly Hospital in Beverly, Massachusetts.
These assumptions have now been challenged. This past July, the American Institute of Architects (AIA) published its 2006 Guidelines for Design and Construction of Health Care Facilities (figure 1). The Guidelines contain new material of vital interest to healthcare architects and designers. The latest edition of this “bible of healthcare design” is the place to look for the most current minimum design standards that matter to federal agencies, JCAHO, 42 states, and the countless municipalities that routinely adopt the entire document as code.
There are four reasons that this publication is of particular concern to anyone involved with healthcare design:
1. The 2006 edition is completely reorganized and no longer parallels earlier editions. Since, as indicated, many municipalities typically adopt the latest edition as de facto code, it's time to replace your earlier editions for that reason alone.
2. The Facilities Guidelines Institute is considering publication of supplemental white papers after release of the 2006 edition, but ahead of the 2010 edition. Several white papers are already being prepared for public review, including papers on noise and acoustical privacy (completed last June and available at http://www.speechprivacy.org until November 1), bariatric care, and medical oncology.
3. Work on the 2010 edition is under way, and the new material will be considered for the next edition using the AIA's six-month public review process to begin in the spring of 2007. The AIA group sees an urgent interest in acoustical guidelines now, however, and is therefore releasing the interim guideline and supplemental material for review, discussion, and testing prior to final publication in 2010.
4. Specific topics, such as the privacy policies embodied in HIPAA (Health Insurance Portability and Accountability Act of 1996), are now being enforced. The 2006 Guidelines acknowledge this and instruct architects to address specifically how these regulations will impact healthcare design.
Validating the guidelines
Why do noise and sound in a hospital matter clinically? Ours and other clinical teams will be investigating this (see sidebar). We know that noise can disrupt sleep, thus impairing and delaying healing, and that sound levels can impact privacy in ways that diminish healthcare quality. By what mechanisms do these occur?
Patients may already have their sleep compromised by pain, anxiety, and adjustment to new environments. Excess noise exacerbates these factors and contributes to transient insomnia, stress, and increased physiologic changes, such as elevated heart rate and blood pressure. Known adverse outcomes of impaired sleep also include falls (particularly in the elderly), mood changes, and diminished learning capacity/decision-making.
Noisy hospital environments are believed to slow rates of recovery among hospitalized patients, as well as delay brain development among infants in the neonatal intensive care unit (NICU). Medical error rates are also higher in noisier hospital environments. Taken together, these noise-related disruptions can lead to significantly increased healthcare costs.
Occupants of long-term care facilities could be even worse off—patients could suffer chronic sleep disruption. Sleep loss in adults has been associated in various studies with obesity, diabetes, cardiovascular disease, and earlier mortality.
High noise levels disrupt patient-provider and patient-family communications necessary for making informed decisions about care. Conversely, a lack of privacy because of voices carrying beyond the radius of those meant to hear them tends to reduce the forthrightness of communication between patient and doctor. Unhindered but protected communication is essential to effective healthcare, and is a legal requirement of HIPAA compliance that all healthcare facilities must meet.
Cases in Point
Following are five settings in which noise and lack of privacy are problems that, unaddressed, can lead to compromised healthcare delivery, demanding that attention be paid to the Interim Guideline:
NICU. Clinical research in Italy has demonstrated that distractions such as noise can delay infant brain development and result in significant long-term social costs in response to learning disorders, behavioral difficulties and social decrements. Even though many NICUs are being redesigned, incubators themselves have been shown to produce significant noise that is disruptive to their occupants, as measured in recent studies.
Healthcare facilities project noise into surrounding communities and by the same token suffer themselves from intruding noise from traffic and helicopters passing nearby.
ICU with curtain dividers versus central nursing station. The needs of patients and caregivers in ICUs conflict. While patients need rest and freedom from distractions, medical professionals rely on batteries of instruments and alarms, as well as continual visualization, for monitoring. Adverse acoustical conditions in ICUs can be endemic as a result and therefore need to be resolved.
Patient intake/interview areas. As mentioned, patients and families who fear a lack of privacy can inadequately disclose or withhold information crucial to diagnosis and treatment, which can lead to errors. In line with this, the new proposed draft “Interim Guideline on Acoustics” deals extensively with HIPAA and spells out standards and best practices for measuring, monitoring, and certifying privacy in the healthcare environment (figure 2).
Helipad/emergency room. Healthcare facilities project noise into surrounding communities and by the same token suffer themselves from intruding noise from traffic and helicopters passing nearby (figure 3). The proposed “Interim Guideline on Acoustics” addresses these situations in ways that owners, planners and architects will find useful—for example, describing measured noise and vibration levels appropriate for each setting and practical methods of mitigation.
Cooling towers. These are another source of noise emanating from healthcare facilities into the community that design planners need to address before the problem becomes a serious issue.
There are several interesting questions for current research—for example, does auditory disruption increase length of hospital stay? Will acoustical design countermeasures improve patient outcomes? At Harvard Medical School, two of our authors (Solet and Buxton) have been reviewing, through the lenses of behavioral medicine and sleep research, evidence regarding decrements in health and health outcomes that can be improved by design and use of materials and systems to manage acoustics in healthcare facilities. In short, use of evidence-based design to improve patient outcomes from an auditory standpoint is here. The new supplemental guideline on acoustics, in keeping with this, is intended to provide the medical community with a much-improved context for guiding this process. HD
Part two of this article will summarize relevant research and propose goals for research on the effects of noise on patients and staff in the context of the new Interim Guideline on Acoustics.
David Sykes, ASA, INCE, is cochairman, ANSI S12/WG44 and the ASA/INCE/NCAC Joint Subcommittee on Healthcare Acoustics & Speech Privacy. Kurt Rockstroh, AIA, ACHA, is President and CEO of Steffian Bradley Architects, Board Member of the Facility Guidelines Institute, and Vice-Chairman of the 2010 Health Guidelines Revision Committee; Jo Solet, PhD, is Clinical Instructor, Harvard Medical School, member of Cambridge Hospital and Cambridge Health Alliance, Behavioral Medicine Program, and Commissioner of the Cambridge Historical Commission; Orfeu Buxton, PhD, is Instructor, Division of Sleep Medicine, Harvard Medical School, and Associate Neuroscientist, Brigham and Women's Hospital, Boston.
Drafting of the new AIA interim guideline on acoustics was led by the distinguished acoustical scientist William Cavanaugh, FASA, and carried out by members of a 315-member interdisciplinary group that performs duties under two identities: First, as ANSI S12/WG44, the group works on new standards related to noise and privacy in healthcare. Second, the same group is also known as the Joint ASA/INCE/NCAC* Subcommittee on Speech Privacy and Healthcare Acoustics. Under this name, they are developing uniform professional guidelines for use by engineering professionals. The group is open to all and encourages visits to its Web site: http://www.speechprivacy.org.
ASA—Acoustical Society of America, a professional society affiliated with the American Institute of Physics; INCE—Institute of Noise Control Engineering, a professional society; NCAC—National Council of Acoustical Consultants, a professional society. The collective membership of these three professional societies is 8,500 professionals worldwide.