The Seventh Annual Quality Colloquium

Transcription

1 The Seventh Annual Quality Colloquium August 2008, Track IIC: The Role Sleep and Acoustics Play in Creating Safe/Healing Environments of Care Jo M. Solet, PhD Harvard Medical School and Cambridge Health Alliance, Member HGRC Orfeu M. Buxton, PhD Harvard Medical School and Brigham and Women s Hospital

2 Sponsors AAHF American Architects Healthcare Foundation FGI/HGRC Facilities Guidelines Institute: Healthcare Guidelines Review Committee CHER/CHD Coalition for Health Environments Research/ Center for Health Design

3 Rising concern for acoustics in US healthcare facilities Mechanisms of influence on clinical outcomes Sleep disruption, health and memory Acoustic Guideline validation study: Hospital noise and sleep disruption Additional resources Overview

4 Increasing Hospital Night (Nighttime) 80 Sound Level Leq in db(a) re 20 micropa Year A-weighted equivalent sound pressure levels measured in hospitals during nighttime hours as a function of the year of study publication Redrawn from: Busch-Vishniac, J. West, C. Barnhill, T. Hunter, D. Orellana, R. Chivukula, "Noise levels in Johns Hopkins Hospital," JASA 118 (6), December 2005.

5 The Stakeholders Patients and Families Caregivers and Staff Government Regulators Hospital Boards and Management Employers and Insurers

6 Acoustics and Clinical Outcome: Mechanisms of Influence Lost Privacy Clinician Burnout Medical Errors Stress Response Sleep Disruption

7 Adapting the Neonatal Intensive Care Environment to Decrease Noise Johnson in J. of Perinatal & Neonatal Nursing 2003 Noise Effects: Lower oxygen saturation Higher respiratory rate Higher blood pressure Faster heart rate Slower weight gain Impaired sleep Photo: Jo M. Solet, PhD

8 Influence of ICC Acoustics on the Quality of Care and Physiological State of Patients 2004 Hagerman, Rasmanis, Blomkvist, Ulrich, Erikson, Theorell, in Internatl. J. of Cardiology Poorer acoustic environment: higher re-hospitalization rates Sickest patients showed the most reaction: Acute MI and unstable angina patients had raised pulse amplitudes, greater sympathetic arousal Quieter environment elicited higher patient quality of care ratings

9 The Quieter Work Environment Greater control in high demand situations Increase in speech intelligibility Respectful of workers and their mission Less burnout/staff turnover Fewer medical errors

10 Pharmaceutical Homonyms Jo M Solet 2008 Celexa anti-depressant Lamicil anti-fungal Propecia hair growth stimulator Klonipin anxiolytic Celebrex anti-inflammatory Lamictal anti-convulsant Precose glucosidase inhibitor Clozapine anti-psychotic

11 Arousal Trauma Pain Lack of Control Inability to Interpret Experience Stress Response Original pen and ink drawing: M. Rusciano virtualeasel.com

12 . a sustained quiescence in a species-specific posture accompanied by reduced responsiveness to external stimuli Sleep zzzzzz

13 Sleep Cycles Across the Night: Hypnogram

14 Sleep: Less and Lighter With Aging Minutes of sleep stage per night versus age. WASO: Wake after Sleep Onset (increases with age) REM: Rapid Eye Movement Sleep. (decreases with age) SWS: Slow wave sleep (non-rem), deepest stages 3 and 4 combined. (decreases with age) from: Ohayon MM et al, Sleep 27(7):

15 Sleep Disruption Physiological changes Altered memory and cognition Epidemiological evidence Original pastel drawing by M. Rusciano Virtualeasel.com

16 Consequences of Poor Sleep Impaired Attention and Reaction Time Risk of Injuries, Falls Decreased Memory and Concentration Worse Mood; depression Impaired Task Completion Insufficient or Disordered Sleep Incidence of Pain Weight Gain Diabetes Psychosocial difficulties Cardiovascular Disease Increased Consumption of Healthcare Resources

17 Restricting Sleep Impairs Vigilance Actual performance Self-rated performance 8 hrs/night 6 hrs/night Better performance 8 hrs/night 6 hrs/night 4 hrs/night 4 hrs/night Worse performance baseline Week 1 Week 2 baseline Week 1 Week 2 Van Dongen et al., SLEEP Redrawn by and courtesy of Orfeu Buxton

18 Sleep and Memory Sleep enhances many aspects of memory (Ellenbogen et al 2006) Disruption impairs memory-boosting influence of sleep Memory is critical for treatment adherence and decision-making

19 Significance of Sleep for US Obesity? 70 Overweight and obese in the U.S. (%) mean sleep duration (hrs) SOURCES Obesity: CDC (NHES, NHANES) year Sleep: Roffwarg Science 1966, NHIS (unpublished data), National Sleep Foundation polls, Hale J Public Health

20 The Challenge: Evidence-based Medicine Meets Evidence-based Design Evidence-based Inter-disciplinary Conflict of Interest free Promptly reported Actionable

21 Validating the Interim Guideline Select hospital sounds from categories addressed in the AIA Draft Interim Guideline on Sound and Vibration in Healthcare Facilities Draw conclusions about arousal and physiological effects of hospital noise on sleeping subjects Confirm or modify Guideline to improve environment of care

22 Goals and Methodology Record real hospital sounds to develop a virtual hospital soundscape Expose subjects during all sleep stages to soundscape components as experienced in patient rooms Quantify physiologic and cognitive responses Quantify sleep arousal thresholds Organize outcome data to inform Interim Acoustic Guidelines Contribute to operational, behavioral, design solutions

23 Familiarity/Source Salience Conveyance of Threat Motion/Variability Persistence/Intermittency Spectrum Volume Co-occurrence Original pen and ink drawing by M. Rusciano Virtualeasel.com Sound Qualities

24 Sample Sound Monitor Data Gathered During One Overnight Subject Exposure Subject 2853-E /18-11 PM 3/19-12 AM 3/19-1 AM 3/19-2 AM 3/19-3 AM 3/19-4 AM 3/19-5 AM 3/19-6 AM 3/19-7 AM 3/19-8 AM 11PM 12AM 1AM 2 AM 3AM Leq Leq 4AM 5AM 6AM 7AM 8AM

25 Arousal Thresholds During Sleep Solet et al unpublished

26 Site exterior noise Design/configurations Interventions: Acoustical surfaces & materials-infection control Paging & call systems Clinical alarms, equipment Behavioral protocols

27 Summary: Noise and Quality of Care Sleep disruption Medication use Patient satisfaction Staff and caregiver experience HIPAA, Privacy/speech intelligibility

28 GOT SLEEP? UnderstandingSleep.org Presented by: Harvard Medical School Division of Sleep Medicine & WGBH Educational Foundation

29 Further Readings ULRICH The Role of the Physical Environment in the Hospital of the 21st Century: A once-in-a-lifetime opportunity (2004). Ulrich and Quan, Center for Health Systems and Design at Texas A&M; Zimring, Anjali and Choudery, Georgia Institute of Technology BUSCH-VISHNIAC Noise Levels in Johns Hopkins Hospital (2005) Busch-Vishniac, West, Barnhill, Hunter, Orellana, Chivakula, J. Acoust. Soc. Am. RUBIN Status Report (1998) : An investigation to determine whether the built environment affects patients medical outcomes. Rubin, Owens, and Golden, Center for Health Design at Johns Hopkins

30 Research Collaborators Jo M. Solet, PhD Clinical Instructor, Harvard Medical School, Cambridge Health Alliance Orfeu Buxton, PhD Instructor, Harvard Medical School, Brigham and Women s Hospital Orfeu@HMS.Harvard.edu Andrew Carballeira, BM Acoustics Consultant, Cavanaugh Tocci Associates, Inc. acarballeira@cavtocci.com Jeffrey M. Ellenbogen, MD Instructor in Neurology, Harvard Medical School, Mass. General Hospital jeffrey_ellenbogen@hms.harvard.edu

31 The Role Sleep and Acoustics Play in Creating Safe/Healing Environments of Care