Monday, July 16, 2012

All’s Quiet on the Lunder Floors

One of the best parts of the Lunder Building is something that's missing

Hanging plants have helped enhance the Lunder Building's peaceful atmosphere

Hanging plants have helped enhance the Lunder Building's peaceful atmosphere. Read more at

Three p.m. on the patient floor of a hospital is typically a noisy time. Nurses are changing shifts, physicians are arriving to see patients, pages are continually heard overhead, and alarms are beeping.

But on Lunder 9 — one of five floors dedicated to patient care in Massachusetts General Hospital’s new Lunder Building— there is a peaceful background hum of the heating unit. Nurses’ stations are dispersed so there is no congregated clamor. The floors are made of rubber and so is the coating on the wheels of food and supply carts. Glass doors on the private patient rooms are closed and patients are resting, visible to nurses but insulated from the sound of hospital activities. The corridor walls and the visitors’ lounges, sequestered to the four corners of the floor, are also soundproof.

“I’ve never seen so many patients sleeping as when I visit patient floors in the Lunder Building,” says Susan Cronin-Jenkins, RN, senior project manager for clinical planning. She helped oversee the design and construction of the Lunder Building, which opened last summer. “A great deal of thinking and planning went into the acoustical aspects of the building’s design,” she explains. “We and the architects were very focused on the needs of  patients, their families and staff.”

A large body of research points to the healing effects of quiet. Studies have shown that hospital noise can raise blood pressure, interrupt sleep necessary for healing, increase sensitivity to pain, and raise the stress levels of both patients and the staff there to care for them. Noise is one of the top complaints of hospitalized patients throughout the country. Hospitals like Mass General are listening.

Achieving quieter units was the goal from the start, says Ms. Cronin-Jenkins, who adds that “the architects were chosen for their expertise in this area.”

Building for Noise Reduction

Hospital noise levels have been rising since the 1960s. The average daytime decibel level inside hospitals worldwide is 72 decibels — about the loudness of a vacuum cleaner. This far exceeds the 35 decibels recommended by the World Health Organization — approximately the level of a quiet bedroom at night. Beeping equipment, staff voices, ice machines, paging, food and supply carts all contribute to the cacophony. So does noise related to hospital roommates and the hard surfaces in hospital buildings that bounce noise around.

Most new hospital buildings and renovations must follow the Facility Guidelines Institute’s “Guidelines for Design and Construction of Health Care Facilities,” which includes acoustic related requirements that are now also the basis of regulatory code in at least 42 states. For reasons involving both noise and infection control, the recommendation is to move to all private rooms. Using sound-absorbing materials to finish walls, ceilings and floors was another major way the Lunder Building’s architect met these criteria to reduce noise. For example, the

Lunder Building features:

  • Noise-reducing acoustical ceiling tiles
  • Rubber flooring throughout, which provides cushioning and quietness comparable to carpeting
  • Full-glass sliding doors on the patient rooms to allow natural light and visibility, but keep out noise
  • Acoustic wall panels wrapped in an anti-microbial fabric with soothing pastel-colored graphics
  • Laminated glass around the triage booths in the Emergency Department and the staff areas of the patient floors with high acoustical ratings

“What makes the Lunder Building distinctive is the combination of strategies we used to reduce noise,” says Sarah Markovitz, senior architect from the healthcare architecture firm NBBJ. The sliding glass doors on all the patient rooms, for example, are typically only used in intensive care units. “Not only are they great acoustically,” Ms. Markovitz points out, “but you can adjust how far open or closed you want them.”

If an environment is noisy, people tend to talk louder. So Ms. Markovitz and her team also created what they call dispersed “interaction zones” instead of one main nursing station where everyone congregates. They designed the floors to keep the elevators, food delivery, supply rooms and other high-traffic areas away from the patient rooms.

“We also made sure there would be no doors opening and closing across from patient rooms,” adds Ms. Markovitz, who estimates that it took interactions with 200 to 300 Mass General clinicians, facilities and planning staff over the course of two years on the whole design of the building, including the planning for solutions to noise control.

Improving the Patient Experience

Construction of a new hospital building is a prime opportunity to employ what are now known to be the best ways to meet patient needs. “I see things on the Lunder patient units that I could only have dreamed of at other places I’ve worked,” comments Rick Evans, senior director in the Service Improvement Department, who has only been at Mass General for relatively short time but has worked in the hospital industry for 15 years. “Private rooms, comforting colors, more light, floor-to-ceiling glass. It’s great to see something new that embodies a lot of the concepts we’re looking for.”

The observations made by Florence Nightingale in her 1898 book, “Notes on Nursing,” include two related tidbits: “Unnecessary noise, or noise that creates an expectation in the mind, is that which hurts a patient” and “Never to allow a patient to be waked, intentionally or accidentally is a sine qua non of all good nursing.”

Private rooms are key to reducing noise and enhancing rest. “With the private rooms, now we don’t have to wake up two patients when we only need to help one of them,” says Barbara Cashavelly, RN, nurse director of one of the two cancer unit floors, as she slides open the door to one room.

Quieter Bells and Whistles

Pages are almost synonymous with hospitals, but may not be for long. One goal from the start of Lunder planning was to eliminate overhead paging and reduce the confusion and constant ringing of machine alarms.

Nurses typically spent a great deal of time locating other people and waiting for responses to pages to get answers and supplies. Using new communications software from a company called Voalté, Lunder nurses, operation associates, case managers and patient care associates all now use iPhones to communicate directly and quickly with each other.

“We log into the Voalté system when we begin our shift and can see everyone else who is logged in,” says Ms. Cashavelly, demonstrating on her iPhone. “We just click on someone’s name to call or text her and there’s no need to use a pager or overhead page system.”

Before the building officially opened, nursing staff spent a great deal of time rethinking the alarm systems that alert them when their patients’ physiological responses fall out of a normal range. Many devices have alarms: cardiac monitors that can signal dangerous drops in blood pressure or heart rate, respiratory equipment monitoring breathing, infusion pumps, feeding pumps, bed and chair alarms. There is no standardization of alarm sounds among manufacturers, so caregivers must be able to distinguish among them and react based on perceived importance.

“We listened to all the various alarms and found some we couldn’t distinguish,” says Ann Kennedy, RN, the nurse director for one of the neurosciences units. “We worked with the company to select tones and levels of loudness that made it easier for us to discern.”

In addition, Lunder patient floors have ambient noise sensors. They measure the amount of noise in the environment and recalibrate the critical physiological alarms. If it is louder at one time of day, alarm volume increases, then readjusts when the environment becomes quieter. Automatic display boards on the walls of the patient units provide visual information when an alarm sounds.

Healing Environment

Natural light floods the patient rooms and common areas. There are two sets of shades and panels that allow natural light in the rooms, but create privacy when desired. There are nightlights to read by and in the bathroom that patients can control. Most rooms also have their own thermostat and a pull-out couch if family members wish to stay over. Creating a healing environment has always been a Mass General goal, say the Lunder nursing directors. That effort has been enhanced by the quiet of the Lunder. “We often have head-injured patients who don’t do well if there is too much stimulation,” comments Ms. Kennedy about the neurosciences units. “Now, if we’re trying to calm down an agitated patient, the environment supports us.”

In terms of patient satisfaction, being able to put all the known best practices for noise reduction together in one building is already paying off in terms of patient satisfaction. Patients at Mass General are routinely questioned after discharge about their hospital experience, using a standardized Hospital Consumer Assessment survey. It includes questions about how quiet the areas around their rooms are.

“We have seen increases of six percentage points and higher on the quietness questions for the Lunder patient units, which is a huge improvement,” says Mr. Evans. “Patients are telling us it’s much quieter and they’re happy about it.”

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