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2007 International Conference and Exhibition on Planning, Design and

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Welcome to the 2007 PDC ConferenceTuesday, February 27, 2007

• Don’t forget to attend the ASHE and AIA Updates on Wednesday, February 28, at 8:00am.


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David M. Sykes, panel organizerKurt Rockstroh, AIA, ACHA

Gregory C.Tocci, FASA, INCE Bd Cert Jo M.Solet, PhD, Harvard Medical School

February 26 – 27, 2007

San Antonio, TX

New Guidelines on Acoustical Design in Healthcare


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1. Overview of the session

David M. Sykes, ASA, INCE• Co-chairman, ANSI S12 Workgroup 441

• Co-chairman, ASA/INCE/NCAC Joint Subcommittee (TC-AA.NS.SC2)

• Liaison to GGHC & LEED HC - Acoustics EQ

• Managing Partner, Remington Partners

• [email protected],2 Workgroup 44 – Healthcare Acoustics & Speech Privacy; TC-AA.NS.SC – Technical Sub-committee of the Committees on Architectural Acoustics, Noise, and Speech Communications


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Frequently asked questions

• What is it & what’s in it?• Who authorized it?• Who wrote it?• Why is it needed—now?• Is it practical, actionable information?• Who to contact for more information?


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The panelists

• Kurt Rockstroh, AIA, ACHA

• Gregory C.Tocci, FASA, INCE Bd. Cert.

• Jo M. Solet, PhD, Harvard Medical School

• D. Sykes - Solving acoustical problems


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Why an ‘interim guideline on acoustics’ exists

Reason #1: Noise in healthcare facilities stimulated growing inquiries from HCOs, regulators, lawyers & patient groups to the professional organizations in acoustics (ASA*, INCE, NCAC). The professions needed to respond comprehensively. Our group was organized for this purpose & met with FGI two years ago to explore a response.*Acoustical Society of America; Institute of Noise Control Engineering;, National Council of Acoustical Consultants


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Reason #2: Two separate issues—healthcare facility noise and privacy—stimulated members of Congress, WEDI-SNIP1, AIA, ACHA, ASHE, FGI, AHLA2, CHD3, AIS4 & others to learn about standards and best practices in the 100-year-old profession of scientific acoustics. This led to requests for conference papers, articles & advice by our members.*WEDI-SNIP - Workgroup on Electronic Data Integration-Strategic National Implementation Process; AHLA - American Healthcare Lawyers Association; CHD - Center for Health Design; AIS - Atlantic Information Systems.


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Reason #3: The Facility Guidelines Institute responded to the growing interest in noise, privacy & acoustics and other specialized topics by authorizing several “interim guidelines/white papers” as a step toward including new information in the 2010 FGI/AIA Guidelines for the Design and Construction of Healthcare Facilities.


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Who wrote it?

• ANSI S12 Workgroup 44 formed in 10/04 as ASA Joint TC-AA.NS.SC focused on healthcare acoustics & speech privacy

• Group applied to ANSI in ’05 for recognition which was awarded in 3/06

• See: www.healthcareacoustics.org


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Committee scope

• Membership is ~350 professionals from nine constituencies including: legislators; regulatory agency heads in several countries; leaders of large healthcare organizations; lawyers; clinical research professionals; planners, architects & designers; facilities managers; researchers & practitioners in acoustical science; acoustics professionals at leading manufacturing organizations in acoustics.


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When was it written?

• 8/31/05: co-chairman met in Washington DC with FGI board & board of the 2010 edition to urge recognition of importance of healthcare acoustics

• 9/2/05: FGI approved this group as drafting party for the interim guideline on acoustics

• 3/06: ANSI recognized the committee as ANSI S12 Workgroup 44

• 11/06: committee leaders met with Core Committee members of the Green Guide for Healthcare, v.2.2


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A short summary

See Healthcare Design, 09.06 issue -

“Evidence-Based Design: The New AIA Guidelines on Noise and Privacy” by

D. Sykes, K. Rockstroh, J. Solet & O. Buxton

www.hcdmagazine.com


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2. The need for ‘interim guidelines’

Kurt Rockstroh, AIA, ACHA• President/CEO, Steffian Bradley Architects• Board of Directors, Facilities Guidelines Institute• Co-chairman, 2010 Healthcare Guidelines

Revision Committee• Board of Directors, AAH Foundation• [email protected]


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Why ‘interim guidelines’ have been instituted

• Guidance clearly needed on several topics

• Guidance is needed now, not four years from now…

• “Interim” phase allows time for research, testing, validation, revision, development of new standards, etc.


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Four subjects covered in the first group

• Acoustics – completed 10/28/06 • Oncology – in process*• Bariatrics – in process*• Imaging – in process

*will be reviewed by FGI/HGRC in April ‘07


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What is their status before the 2010 edition?

• Significant need now for expert, authoritative guidance

• Never before codified for HCO’s--so information is highly useful as a digest of expertise & professional best practices

• Interim guidelines set benchmarks that can be tested through research & field trials


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Why did the acoustical document appear first?

• Noise/privacy are big, growing concerns• Paucity of organized guidance available • Large group of qualified, willing &

well-organized professionals • They completed this one first


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Next steps in approval process

• ASA/INCE peer review (6/06–10/06) • HCO peer review (11/06–8/07)• Appointment of HGRC Workgroup (4/07)• April HGRC “all hands” meeting (4/17-20/07)• Proposal to HGRC (8/07)• Public review period (11/06–8/07 & 1/08–8/08)• Integration into 2010 edition• Send comments to: www.fgi-guidelines.org


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3. Overview of the ‘Interim Guideline on Acoustics’

Gregory C. Tocci, PE, FASA, INCE Bd Cert• President, Cavanaugh Tocci Associates, Boston MA*• Co-chairman, ASA/INCE/NCAC Joint Subcommittee• Co-chairman, ANSI S12 Workgroup 44 – Speech Privacy• [email protected]

*Consultants in sound and vibration


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Document parameters

• Title: Interim Sound and Vibration Design Guidelines for Hospital and Healthcare Facilities – Public Draft 1 (Nov. 1, 2006)

• Practical approach covers retrofit & new construction in 36 pages

• Drafting group - 34 professionals actively participated in drafting with review by the full 350 members of both committees


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Document parameters• Intended to be comprehensive• Completed peer review by engineering

community 10/28/06• Peer review by healthcare profession began

11/1/06• Obtain a copy: www.healthcareacoustics.org

» See “Documents” » $30 – credit card orders» (view-only on FGI website)


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Six topics covered

1. Site exterior noise* (5 pages)2. Acoustical finishes and details* (3 pages)3. Room noise levels (2 pages)4. Sound isolation performance of constructions*

including speech privacy (4 pages)5. Paging & call systems, clinical alarms, masking

systems & sound reinforcement (2 pages)6. Building vibration (2 pages)


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1. Site exterior noise

Exterior Site Noise Exposure

AMinimal

BModerate

CSignificant

DExtreme

STC* >35 > 40 >45 >50

Exterior Equipment Goal

45 dBA 50 dBA 55 dBA 60 dBA

*sound transmission loss (STC) rating


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Site exterior noise


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Example 2: Acoustical Finishes

Space designSubjective description

Private room 0.15 “Average”

Corridor 0.15 “Average”

Waiting 0.25 “Medium-dry”

Atrium 0.10 “Medium-live”

Office 0.15 “Average”

Treatment 0.15 “Average”

Average absorption coefficient ( )


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Ex.2: Acoustical Finishes & Ex.4: Sound Isolation


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Example 4: Speech privacy

Privacy GoalArticulation

Index(AI)

Privacy Index(PI)

Sound Transmission

Index(STI)

Speech Intelligibility

Index (SII)

Closed Plan

NormalConfidentialSecure

<0.15<0.05

>85%>95%

<0.19<0.12

<0.20<0.10

Open Plan

NormalConfidential

<0.20 >80% <0.23 <0.25

Special consideration required

Special consideration required


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4. Speech Privacy


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Regulatory compliance

• ‘Interim Guideline’ is based on existing standards from recognized standards authorities & on widely accepted professional best practices

• Certification?—standard analyses & tests can be performed in design & tested in-situ to show general conformance to the established criteria specified in the Interim Guideline

• For HCO’s, this may be useful & desirable for inspections (e.g., JCAHO, FDA, etc.)


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Goal: common sense

“The character and magnitude of the sounds in a building should be compatible with the intended use of the space.”

William CavanaughArchitect, FASA, INCE Bd. Cert.,

& 2006 recipient of the Wallace Clement Sabine Medal


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4. The medical perspective:Acoustics matter

Jo M. Solet, Ph.D.• Clinical Instructor, Harvard Medical School

• Cambridge Health Alliance, Behavioral Medicine

• Member, 2010 Healthcare Guidelines Revision Committee

• Commissioner, Cambridge Historical Commission

• [email protected]


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Evidence-based design meets evidence-based medicine


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The stakeholders

• Patients and Families• Caregivers and Staff• Federal and State Governments• Hospital Boards and Management• 3rd party payers


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Acoustics & clinical outcomes: mechanisms of

influence• Stress response• Lost privacy• Sleep disruption• Impaired communication• Clinician “burnout”


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Stress response

• Arousal

• Trauma

• Pain

• Lack of control

• Inability to interpret experience


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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• Lower weight gain• Impaired sleep


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Influence of ICC Acoustics on the Quality of Care and

Physiological State of Patients2004 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


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Sleep disruption

• Physiological Changes

• Memory and Cognition

• Epidemiological Evidence


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Consequences of poor sleep

Risk of Injuries, Falls

Incidence of Pain

Weight Gain

DiabetesIncreased Consumption of

Healthcare Resources

Impaired Attention

and Reaction Time

Decreased Memory

and Concentration

Impaired Task Completion

Psychosocial difficulties

Insufficient or

Disordered Sleep

Worse Mood; depression

Cardiovascular Disease


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Significance of sleep for US obesity?

SOURCESObesity: CDC (NHES, NHANES)Sleep: Roffwarg Science 1966, NHIS (unpublisheddata), National Sleep Foundation polls, Hale J PublicHealth 2005

1960 1970 1980 1990 200040

50

60

70

Overweight and obesein the U.S. (%)

1960 1970 1980 1990 20006.5

7.0

7.5

8.0

8.5

9.0

year

mean sleep duration (hrs)


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Privacy protection and speech intelligibility

• HIPAA 1996 Health Information Portability and Accountability Act

• PHI= Protected Health Information • Patients with families & friends• Caregivers with each other


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Interactions among patients, families & friends


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Purpose dedicated environments


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Scanners

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Examination rooms

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Accurate communication: nurses’ stations


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Pharmaceutical “homonyms”

• Celexa anti-depressant• Lamicil anti-fungal• Propecia hair growth stimulator• Klonipin anxiolytic

• Celebrex anti-inflammatory• Lamictal anti-convulsant• Precose glucosidase inhibitor• Clozapine anti-psychotic


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Avoiding medical errors


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Quieter work environment

• Lower stress levels/decreased sympathetic activation

• Greater control in high demand situations• Increase in speech intelligibility• More sustained attention for careful decision-

making = fewer errors• Respectful of workers and their mission• Less burnout/staff turn-over


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Clinical evidence

• 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, JASA, 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


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Where do we go from here?


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Intervention outcome studies

Compare guideline-compliant with standard rooms:• Sleep quantity/quality• Patient comfort and satisfaction• Pain perception• Staff and caregiver experience• Privacy/speech intelligibility


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The challenge

• Evidence-based• Inter-disciplinary• IRB approved• COI free• Promptly reported• Practical

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5. Practical solutions

David M. Sykes, ASA, INCE• Co-chairman, ANSI S12 Workgroup 44

• Co-chairman, ASA/INCE/NCAC Joint Subcommittee (TC-AA.NS.SC)

• Liaison to GGHC & LEED HC - Acoustics EQ

• Managing Partner, Remington Partners

• [email protected]


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Can acoustical problems be solved?

• Yes, most solutions already exist…• So do licensed professionals• What holds up implementation?

– Assumptions about cost– FUD (fear, uncertainty & doubt)– Quality issues like noise & privacy often get

lost in value-engineering


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A “revolution” in building materials

• Has already brought new products to market• Many are well-suited for healthcare

• energy efficient• anti-microbial• cost-effective• durable & color-fast


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Examples

– Fabrics (anti-microbial, color-fast)– Insulation (thermo/acoustic & translucent) – Paints & surface coatings– Flooring & carpeting (anti-microbial)– Filtration methods (air & water)– Lighting


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Specify performance

Crucial for administrators, planners & facilities managers to charge architects, designers & engineers to consider the full range of solutions (including newer materials) because conventional solutions may raise problems


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What about GGHC &LEED?

The Green Guide for Healthcare Version 2.2 (released 1/31/07) contains two new credits for acoustics

• See “Environmental Quality - Acoustics Credit 9”

• The Interim Guideline on Sound and Vibration is the sole reference standard cited in GGHC,V2.2

• Download from: www.gghc.org


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Ongoing efforts• Organizing clinical research• Further development of “Interim

Guideline” based on input from healthcare professionals

• Outreach & advocacy programs (e.g., ICA/Madrid, ASJ, UIA-PHG, etc.)

• Progress presentations at future ASHE meetings


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Questions?

Please contact us directly with questions & comments. The ‘Interim Guideline on Acoustics’ can be obtained

for $30. from www.healthcareacoustics.org

Contact information:– David Sykes: [email protected]– Kurt Rockstroh: [email protected]– Greg Tocci: [email protected]– Dr. Jo M. Solet: [email protected]


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AppreciationANSI S12 Workgroup 44 and the ASA/INCE/NCAC Joint

Subcommittee are supported in part by contributions from the following organizations. Supporters do not exert influence over

the deliberations and decisions of the committee

Armstrong

BPB/Certaineed

Cabot Corporation

Logison

Owens Corning

Sonare Technologies

Speech Privacy Systems

USG


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Estimating costs per GGHC V2.2 Acoustic credit 9, Jan. 31, 2007

Estimated

construction cost for

a healthcare facility

Approximate

design cost for

both acoustic points

(combined)

Approximate construction cost for both acoustic points

(combined)

<$5 Million $30k <$50k

<$10 Million <$45k <$100k

<$50 Million <$55k <$500k

>$50 Million $70k - $100k $500k-$1M

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Documents

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