Journey to a Quiet Night Webinar Series

Webinar 2: June 15, 2018Noon – 1 pm

Presenters: • Aiaan Matthew Luciano, RN, BSN, 3C Unit Based Shared

Governance Chair, VA Palo Alto Health Care System• Aileen Naungayan, RN, BSN, CMSRN, WCC, 3C Nurse Manager,

VA Palo Alto Health Care System• Erik Miller-Klein, PE, INCE Bd. Cert., Founding Partner, A3

Acoustics, LLP• Kim Deynaka, RN, MBA, Director of NICU & NICU Operations,

CHI Franciscan Health at St. Joseph Medical Center, Tacoma, WA

This webinar will begin promptly at Noon!

2

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Please use the question box to type your questions.

Logistics

Speakers

Aiaan Matthew Luciano, RN, BSN 3C Unit Based Shared Governance Chair, VA Palo Alto Health Care System

Aileen Naungayan, RN, BSN, CMSRN, WCC3C Nurse Manager, VA Palo Alto Health Care System

Erik Miller-Klein, PE, INCE Bd Cert, Founding Partner, A3 Acoustics, LLP

Kim Deynaka, RN, MBA, Director of NICU & NICU Operations,CHI Franciscan Health at St. Joseph Medical Center, Tacoma, WA

Webinar Series: Journey to a Quiet Night

OBJECTIVES

• Understand how hospital soundscape impacts patients and staff.

• Understand “quiet” as an adjective that describes experience, and delineate between “good” and “bad” sounds.

• Describe effective mitigation strategies, including dedication of time for uninterrupted sleep, sound masking and better alarm management.

• Propose an approach for noise mitigation in their own hospitals.

Resources on HQI Website

Navigate to: “Programs” “Partnership for Patient Experience (P4PEx)” “Reducing Hospital Noise”

QuietNight AppToolkit

Summary of Webinar #1 (6/8/2018)

• Think of patients’ responses to “quiet at night” as a summary of their experiences with:– Sleep, their response is likely a summary of how disruption free and restful sleep their

sleep was during their stay– Noise and annoyances, their perceptions of quiet are more likely formed during waking

or napping hours– Control over sound, their experience of quiet can also be associated with their ability to

control the good noises in their room, and minimize bad noises from outside their room

• Analysis of millions of HCAHPS survey responses yielded following results:– For every 1.0 point improvement for “Quiet at Night” score– Other question scores improved by 0.75 points

• Strategies for Improvement:– Identify the types and frequency of sounds that could arousal someone from sleep– Track the number of nurse and staff disruptions during sleeping hours– Quantify the background noise within patient rooms and within common areas near

rooms– Develop strategies for limiting non-critical – Ask patients about their living and working conditions to understand the context of the

soundscapes patients are accustomed to optimize their sleeping environments.

Creating a Healing Environment: Collecting Real-Time Feedback to Improve Quiet at Night Scores

Veterans Affairs Palo Alto Healthcare System (VAPAHCS)Aiaan Matthew Luciano, RN, BSN (UBC Chair)

Aileen Naungayan, RN, BSN, CMSRN, WCC (NM)

Learning Objectives

Apply the basics of small cycles of change and rapid cycle improvement in order to improve and sustain patient experience

1

Engage staff in performance improvement at the front line

2

Implement key strategies to improve quiet at night scores

3

Content Overview

Demographics

Our Journey Towards Improvement

Rapid Cycle Change Using PDCA Model & Real-Time Feedback

Key Strategies to Hardwiring Process

A Comparison: Historical vs. Current Data Trends

Lessons Learned & Next Steps

Q&A Session

Demographics

Operates 800 beds

Includes 3 nursing homes and 100-bed Homeless Domiciliary

Home to a variety of Regional Treatment Centers:

Polytrauma Rehab Center, Spinal Cord Injury Center, Traumatic Brain Injury Center, Western Blind Rehabilitation Center, etc.

Teaching Hospital

21 Nursing Schools & Stanford University School of Medicine Affiliation

Unit 3C is a 34-bed Surgical Unit:

Post-procedural, Stepdown, Telemetry and Medicine Overflow

11 Surgical Services and 5 Medicine Teams

Creating a Healing Environment:Noise: The enemy to rest and relaxation

• Unit noise level during the night

• Inadequate rest & sleep during hospital stay

Patient Feedback

“Unnecessary noise is the most cruel abuse of care which can be inflicted on either the sick or the well”- Florence Nightingale 1859

Creating a Healing Environment:Impact of Noise on the Patient Experience

sleep disruption

agitation & anxiety

perception of pain

wound healing rate

HR and BP

chance of re-admission

length of stay

Patient

Creating a Healing Environment:Impact of Noise on the Patient Experience

Impairs communication

fatigue and exhaustion

burnout stress

irritability

Staff

Our Journey Towards Improvement

Our 2014 Quietness score baseline trend

Our Journey Towards Improvement

o Established initial Noise Reduction Program (2014)

o Interventions:

• Audio/Visual Noise Tracker

• Orange Quiet Zone Cones

• Project Rest (HUSH)

• Eye shades and Sleep kits provided during care rounds

Our Journey Towards Improvement

March 2015: Start of Noise Reduction Campaign

• Scores did not improve

• In response:

• Noise became a unit priority

• TruthPoint Coach weekly meetings

• Reviewed more literature and best practices

• Added interventions:

• Established Quiet hours from 10 pm – 5 am

• Installed sleep hygiene posters in every room

• Designated staff as noise reduction champions

• Assessed environment and fixed noise sources

Quiet Times Poster

Identifying the Root of the Problem

March 2015 – November 2015

Our Journey Towards Improvement

Our Journey Towards Improvement

From July 2016 to January 2017:

• Issues with sustainability

Our Journey Towards Improvement

o October 2016: Started creating Noise Reduction Program 3.0

o Unable to hardwire noise reduction program

o Unable to reach goal for TruthPoint quiet questions

How do we scale and sustain the program to gain

consistent, positive results?

Rapid Cycle Change using PDCAPLAN DO CHECK ACT

Utilize TruthPoint to identify root cause

Pilot noise reduction program with small group

Analyzed real-time feedback from evaluations, audits, and survey

Standardize noise reduction on unit

Research evidence-based articles

Data tracking via process evaluations, audits, and TruthPoint

Provided staff survey on noise reduction program

Provided 1-on-1 staff coaching to improve outcomes

Create plan, using rapid cycle improvement model

Brainstorm & test new adjustments to noise reduction program

Recognize staff who have been consistent top performers

Continue to analyze feedback from patients and staff

Utilizing Real-Time Feedback

• Process Evaluations• Identify barriers and obstacles in implementation

• Receive real-time staff feedback

• Audits• Measure unit compliance

• Receive real-time patient feedback

• Truthpoint Assessment• Measure overall unit performance

• Receive real-time patient feedback

• Provide real-time feedback to staff

Real-Time Feedback: Staff Coaching Ranked Percentage Report

Overview of Staff Assessment

Questions aimed to provide opportunity for staff to express their:

• Expectations on improving quietness at night

• Perception of effectiveness of current noise reduction interventions

• Suggestions on interventions and strategies to improve noise levels

Overview of Staff Survey

Main Take-aways:

• Standardize noise reduction interventions

• Communicate role expectations to staff

• Constant reminders, coaching, and feedback provided to staff

• Interdisciplinary plan to minimize interruptions at night

Making adjustments to address reoccurring problems

Vital Sign Monitoring

Consult MD’s to

minimize vital sign

monitoring at night

Bedside Alarms

Lowering volumes of non-critical

bedside alarms

Other Patients

Provide & reinforce

noise reduction education

Advocate for room change if situation

escalating

Staff Talking

Friendly Reminders

1-on-1 coaching using real

time feedback

from TruthPoint

Hallway Noise

Closing doors

Consult EMS on

collection schedule

Fix noisy equipment and doors

Resource Availability

Sleep kits & head-

phones in all

admission kits

Noise Reduction Reinforcement

Midnight Vital Sign Monitoring Sign

Quiet Time Reminder Announcement

“Good evening Staff,

Quiet Time will be starting soon at 10 pm. Please make sure patients are using their headphones, and offer to close their doors.

Also, please make sure Vital Sign Monitoring signs are up by midnight. Thank you!”

The secret to hardwiring:

Staff Engagement

PROMOTION

Noise reduction campaign to launch and spread awareness

of noise reduction program 3.0

RECOGNITION

Kudos during huddles and distributed awards to top

performers

INVOLVEMENT

Establish noise reduction champions & provide staff

assessment to receive feedback

EDUCATION

Sleep promotion and noise reduction in-service

COACHING

provide 1-on-1 feedback to staff

Lessons Learned:Key Strategies to Maintaining Consistency & Hardwiring Processes

• Make the program a unit priority

• Incorporate literature review during initial stage

• Leadership support

• Reinforce interdisciplinary and collaborative effort

• Continuous staff education, coaching and engagement

• Continuous monitoring of feedback and trends

• Be flexible and open-minded to changes

• Be resilient and never give up!

A Comparison: Historical & Current Trends

A Comparison: Historical & Current Trends

CurrentPerformance

Historical Performance

Next Steps

• Implement a Noise Reduction Program on other units

• Establish Quiet Hours during the daytime

• Implement the CARE Channel or GetWellNetwork

• Using Distraction, Guided Imagery and Music Therapy to promote rest and relaxation

• Continue process improvement cycle to sustain program

AcknowledgementsUnit 3C Nursing Team

Veteran and Family Advisory Council

Noise reduction Champion Leader:

• Inessa Zhernokleyeva, BSN, RN

TruthPoint Coaches:

• Tracie Clang

• Amy Vanderscheuren

• Sam Hansen

Chief of Specialty & Hospital-Based Services:

• David Renfro, MS, RN, NE-BC, VHA-CM

Assistant Chief of Specialty & Hospital-Based Services:

• Jennifer Ellman, MSN, RN, NE-BC, CEN

Director, EBP Program:

• Dr. Denise Fillipucci, PhD, RN-BC

Associate Director for Patient Care Service/Nursing Services

• Gloria N. Martinez, MS, RN, NEA-BC, VHA-CM

Deputy Associate Director/Patient Care Services

• Michelle R. Mountfort, MSN, MBA/HC, RN, VHA-CM

Patient Experience Services:

• Josh Cantillas

• Amin Eddebbarh (Patient Satisfaction Program Manager)

• Jane Rudolph Bloom, MS, RN (Director of Patient Experience)

VA Mission StatementTo fulfill President Lincoln's promise “To care for him who shall have

borne the battle, and for his widow, and his orphan” by serving and

honoring the men and women who are America’s Veterans

ReferencesMazer, S.E. (2012). Creating a culture of safety: reducing hospital noise. Advancing Safety in Medical Technology,

350-355. Retrieved from http://healinghealth.com/downloads/HospitalNoise_BIT_SeptOct2012.pdf

Su, X., & Wang, D.X. (2018). Improve postoperative sleep: what can we do? Current Opinion in Anesthesiology, 31(1), 84-88.

Wilson, C., Whiteman, K., Stephens, K., Swanson-Biearman, B., & LaBarba, J. (2017). Improving the patient’s experience with a multimodal quiet-at-night initiative. Journal of Nurssing Care Quality, 32(2), 134-140.

Fillary, J., Chapin, H., Jones, G., Thompson, A., Holme, A., & Wilson, P. (2015). Noise at night in hospital general wards: a mapping of the literature. British Journal of Nursing 24(10), 536-540.

Ackerman, J., Hsu, T., Ryherd, E., & Waye, K.P. (2012). Noise pollution in hospitals: impact on patients. Journal of Clinical Outcomes Management, 19(7), 301-309.

Barth, M.M., Dube, J.A.O., Cmiel, C.A., Cutshall, S.M., Olson, S.M., Sulla, S.J.,…Holland, D.E. (2008). Environmental noise sources and interventions to minimize them: a tale of 2 hospitals. Journal of Nursing Care Quality, 23(3), 216-224.

Chen, X.Y., Chen, J., Hu, R.F., Jiang, X.Y., Zeng, Z., Li, Y., Huining, X., & Evans, D.J.W. (2015). Non-pharmacological interventions for sleep promotion in the intensive care unit. Cochrane Database of Systematic Reviews, (10), 1-109.

Sandoval, C.P. (2017). Nonpharmacological interventions for sleep promotion in the intensive care unit. Critical Care Nurse, 37(2), 100-102.

Litton, E., Carnegie, V., Elliott, R., & Webb, S.A.R. (2016). The efficacy of earplugs as a sleep hygiene strategy for reducing delirium in the ICU: a systematic review and meta-analysis. Critical Care Medicine Journal, 44(5), 992-999.

Questions?

Aileen.Naungayan@va.gov

(650) 493-5000 ext. 64711

Aiaan.Luciano@va.gov

(650) 493-5000 ext. 64870

Kim Deynaka, MBA, BS, RNC

Director NICU & NICU Operations

CHI Franciscan Health at St. Joseph Medical Center

St. Joseph Medical Center

Neonatal Intensive Care Unit

Level II & Level III Renovation

Erik Miller-Klein, PE, INCE Bd. Cert.

A3 Acoustics, LLP

St. Joseph Medical Center Renovation

• Evaluated existing acoustic

performance compared to FGI 2010

Guidelines for Design and Construction

of Health Care Facilities

– Sections:• Special Design Elements section 2.2-2.10.9.3

Noise Control for Infant Rooms

• 1.2-6.1 Acoustic Design

Level II & Level III

Neonatal Intensive Care Unit (NICU)

NICU Specific FGI Health Care Guidelines

• Under 2.2-2.10 Newborn Intensive Care Unit is special section on Acoustic Performance.

– Design Guidelines:• Meet minimal background noise, sound transmission, and

sound absorption performances outlined in Section 1.2-6.1 (Acoustic Design)

• Infant Bedrooms or Sleeping Areas the background & operational sound cannot exceed:– Hourly Leq of 45 dB(A)

– Hourly L10 of 50 dB(A)

– Lmax of 65 dB(A)

Special Design Elements:

2.2-2.10.9.3 Noise Control

Original Design Conditions Evaluated

• Noise Impacts to infant sleeping areas from:– Security Systems, Door openings

– Equipment Alarms

– Curtain openings

• Room Conditions:– Background: NC 28 (36 dB(A))

– Average Absorption: 0.15 – 0.18

– Speech Privacy: SII 0.68 “No Privacy”

Sound Source Measured Lmax Guideline Lmax

Security Systems 66 dB(A) 65 dB(A)

Door Openings 82 dB(A) 65 dB(A)

Phones 58 dB(A) 65 dB(A)

Equipment Alarms 66 – 72 dB(A) 65 dB(A)

Curtain Openings 75 dB(A) 65 dB(A)

Challenges & Goals

• Short Timeline

• Streamlined Construction

• Acoustics identified as important design element

• Post-construction testing/verification

Impact Treatments: Door

• Recommended:– Disabling the security

door access alarm• Installed

– Use alternate door hardware• Adjusted, not replaced

– Door Seals per FGI• Pending, though this area

is isolated from other activities in the hospital

Sound Source Installed

Measured Lmax

Initial

Measured Lmax

Design

Guideline Lmax

Security Systems No Audible Alarm 66 dB(A) 65 dB(A)

Door Openings 63 – 67 dB(A) 87 dB(A) 65 dB(A)

Impact Treatments: Curtains

• Recommended:

– Change curtain rail to wheels or sliding clips• Installed for Level III, Level II

original

– Use Proprietary Sound Absorptive Medical Curtain• Installed to improve sound

absorption, and speech privacy

Sound Source Installed

Measured Lmax

Initial

Measured Lmax

Design

Guideline Lmax

Original Curtain 65 dB(A) 73 dB(A) 65 dB(A)

New Clip Track 52 dB(A) 73 dB(A) 65 dB(A)

Impact Treatments: Bassinet

• Recommended:

– Alternative bassinet with reduced noise during start-up and operation• Philips Intellivue MP50 with Atom Dual

Incu integrated bassinet, infant warmer, and incubator

– Change the alarm volume or start-up sequence• Pending coordination with equipment

manufacturers

Sound Source Philips Intellivue

Measured Lmax

Initial

Measured Lmax

Design

Guideline Lmax

Infant Warmer Alarm = 63 dB(A) 71 dB(A) 65 dB(A)

Incubator Closing = 50 dB(A) 60 dB(A) 65 dB(A)

Room Treatments

• Recommended & Installed:– 1-inch thick stretched fabric sound

absorption inside of Level III (most sensitive) Pods

– Proprietary Sound Absorptive Medical Curtain for Pods and open Level II sleeping areas

• Results:– 165% less sound reflective than

FGI standard• RT for double Pod area

Installed Measured Initial Measured Design Criteria

ത𝛼 = 0.39 – 0.42

RT < 0.25 secത𝛼 = 0.15 – 0.18

RT < 0.65 secത𝛼 = 0.15“Average”

Room Treatments • With additional 1,000 Sabins (ft2) of

sound absorption, and

• Improved sound transmission from the Proprietary Sound Absorptive Medical Curtain

• 6 to 8 dBA (30% to 40%) improvement over cloth curtain

Speech PrivacyMeasured Design Goal

AI SII AI SII

NICU Bed to Nurse Station(Estimated Initial Performance)

0.58 0.68 ≤0.20 ≤0.25

NICU Bed to Nurse Station(Measured with Acoustic Curtain)

0.18 0.30 ≤0.20 ≤0.25

Staff & Family Perception

The noise level in the NICU has changed 100%.

Families have some privacy.

The alarms don’t overwhelm the space and the staff, but they don’t want the alarms any quieter.

Feels like a soothing environment necessary for optimal healing and growing.

Described as calm environment away from the noise of normal hectic life.

The infants seem to be more relaxed and feeding and growing appropriately.

Questions & Comments

Contacts

Boris Kalanj, MSW

Hospital Quality Institute

bkalanj@hqinstitute.org

Jenna Fischer, CPPS

Hospital Quality Institute

jfischer@hqinstitute.org