Healthcare Designs: Can Modern Lighting Cure the ill's of Ailing Institutions. Presented by Karyn...

Whole-Human Approaches for Lighting That Cares

Karyn Gayle, MIES, EDAC

Vice-President – Healthcare, Acuity Brands

[email protected], Twitter: @karyngayle

mailto:[email protected]

Acuity Brands Lighting is a Registered Provider with The American Institute of Architects Continuing Education

Systems. Credit earned on completion of this program will be reported to CES Records for AIA members. Certificates

of Completion for non-AIA members are available on request.

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Light & Healthcare: Whole-Human Approaches

Learning Objectives

• Describe key trends impacting healthcare

• Discuss functional, physiological, and psychological aspects of lighting in

healthcare settings

• Review key design interventions in facility lighting design and the link to

health outcomes

• Examine current and future state of lighting technologies and their

application for care environments


Key Healthcare Trends

• Light + Health

• Demographic Shifts

• Evidence-Based Design


First things first…


Health ≠ Healthcare

Healthcare ≈ Sickcare

…would we be better off if we designed

for health as well as care?

The Realities:

Costs are high and expected to double in 10 years…


Source: OECD Health Data 2013, graphic by Huffington Post

Reimbursement Changes:

From volume to value…

• HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) developed by Center for Medicare & Medicaid Services (CMS) in 2006

• Scores capture patients’ perspectives on acute care hospital care experience

• Migration from optional data collection to pay for performance (October 2012)

• For acute care hospitals, performance will drive 2% of CMS reimbursements as part of Value-Based Purchasing

Patient Experience & Reimbursements

• Avoidance of hospital-acquired infections & shortened stays

• Readmissions can be 20% of inpatient volume, reimbursements for excess readmissions will be reduced, starting in Federal FY2013 (October 2012)

Patient Outcomes

• Fall prevention

• Hygiene, germ & dust management

Patient Safety


Sustainable Design & Energy Usage

• Based on 2008 data from the US

DOE’s Energy Information

Administration:

– Lighting accounts for 42 percent of

overall health care electricity use:

Inpatient: 42%

Outpatient: 40%

• Healthcare buildings account for 7

percent of electricity use by all

commercial and industrial buildings.

HVAC37%

Water Heating

2%

Lighting42%

Office Equipme

nt & Computer

s6%

Refrigeration2%

Other11%

US Electricity Consumption (kWh), 2003 - Inpatient Health

Care Facilities


Going back to our premise…


Health ≠ Healthcare

Healthcare ≈ Sickcare

…would we be better off if we designed

for health as well as care?

The root of the problem…what makes us so unhealthy?


Chronic Disease

• More than three-fourths of United

States healthcare costs are due to

chronic diseases (CDC)

• And, many preventable behaviors are

linked to chronic disease:

Tobacco use

Insufficient physical activity

Poor nutrition

Excessive alcohol consumption

(Also, unmanaged stress)


Source: Centers for Disease Control, 2009

“Everyone wants it, but nobody is

getting any...”

- Anonymous


The Importance of Sleep


Some Less-Obvious Implications of Sleep…

• People who get sufficient sleep have increased gray matter in their brains, which is connected

to psychological health. (Harvard Medical School Study)

• Brain clears out waste proteins between cells, and this waste product is linked to Alzheimer’s

disease, (Dr. Maiken Nedergaard, University of Rochester)

• People who are chronically sleep-deprived are 7 times more likely to feel helpless and 5x

more likely to feel alone (Great British Sleep Survey)


Source: http://www.greatbritishsleepsurvey.com/

http://www.greatbritishsleepsurvey.com/

Sleep deprivation is the “epidemic of the 21st century”.

Obesity• Higher BMI with insufficient sleep

• Disruption of appetite hormone secretion (leptin & ghrelin)

Diabetes • Slower processing of glucose

Hypertension• Elevated blood pressure

• Link to heart disease & stroke

Mood Disorders • Sadness, irritability, negative outlook, reduced sociability

Immunity • Increased susceptibility to infection

Self-Medication• Potential for increased alcohol consumption, dependence

on sleep aids

Life Expectancy • Sleeping 5 hours or less increases mortality risk by 15%


Source: Division of Sleep Medicine at Harvard Medical School

Sleep…the perfect storm.


The Role of the 3rd Photoreceptor

• Rods and cones are photoreceptors for our visual system

• Intrinsically photoreceptive retinal ganglion cells (IPRGCs) impact our circadian systems (seeks

blue light during the day)


What are Circadian Rhythms?


Photopic, Scotopic, and Circadian Spectral Functions


Regulating Circadian Rhythms

• Early morning exposure to higher light levels, especially in the short wavelength region of the

visible spectrum (460-490 nm)

• Early morning outdoor activities between 7 a.m. and 10 a.m., or indoors with daylight

• Maximum benefit in winter at high latitudes where it’s often dark going to work

• Warmer, long-wavelength light in late afternoon and evening

• Dark or amber light at night to allow for melatonin production


Circadian rhythms have gone mainstream…


Really mainstream…

• $10 million “WELL Certified” apartment in

Greenwich Village

• Includes “vitamin C-infused showers, heat

reflexology flooring, aromatherapy air supply, and

dawn-simulating circadian lighting design”

• The “Kardashian-ization” of circadian light?


Source: http://pagesix.com/2014/05/05/dicaprio-buys-10-million-greenwich-village-apartment/

http://pagesix.com/2014/05/05/dicaprio-buys-10-million-greenwich-village-apartment/

Light, Sleep, and Appetite

• Chronic and acute sleep deprivation results in

decreases in leptin (satiety hormone) and

ghrelin (hunger hormone)

• Prior studies established linkages between

timing of leptin & ghrelin secretions and the

circadian clock (i.e., hungrier during the day,

more sated at night)


Source: Mariana G. Figueiro, Barbara Plitnick, and Mark S. Rea, “Light Modulates Leptin and Ghrelin in Sleep-Restricted Adults,”

International Journal of Endocrinology, vol. 2012, Article ID 530726

Light, Sleep, and Appetite

• Subjects maintained a 5-hour sleep schedule for 5 days (as compared to an 8-hour baseline)

• Hypothesis that light could counteract the effects of sleep deprivation

• Subjects exposed to 4 lighting conditions via calibrated goggles:

60 lux of red light (633nm)

60 lux of green light (532nm)

60 lux of blue light (475nm)

Dim light (<0.5 lux at eye, 630nm)

• Morning red, green, and blue light significantly increased concentrations of leptin

(feeling of fullness); only red and green light exposure reduced ghrelin concentrations

(sensation of hunger).

• More studies need to be done to determine mechanism (likely not acute melatonin

suppression)


Source: Mariana G. Figueiro, Barbara Plitnick, and Mark S. Rea, “Light Modulates Leptin and Ghrelin in Sleep-Restricted Adults,”

International Journal of Endocrinology, vol. 2012, Article ID 530726

Light, Positive Distraction, and Mood


“The art of medicine consists of

amusing the patient while nature

cures the disease.”

- Voltaire



Credit: Clemson University Patient Room Prototype

Minimally Invasive Procedures & Treatments

• Interventional Radiology

• Cardiac Catheterization

• Oncology/Infusion

• In-Center Hemodialysis


In-Center Hemodialysis – Comfort, Positive Distraction


Credit: Queens-Long Island Renal Institute, Tobin & Parnes

Recommended Maintained Illuminance Targets

(In Footcandles, horizontal)

Visual Age of Observers (in years)

Applications & Tasks

<25 25-65 >65

Treatment Area

(Chair/Bed)

25 50 100

Treatment Room

(General)

10 20 40

Treatment Room

(Needle Insertion)

50 100 200

Dialysis Treatment – Example

How could lighting design make this procedure more

comfortable for the patient?Light & Healthcare: Whole-Human Approaches

Chemotherapy Infusion – Distraction, Comfort, Empowerment


Credit: Spellman Brady

Radiation Oncology


Credit: Fort Belvoir Community Hospital, Architecture/Lighting Design: HDR Architecture

Lighting in MRI Settings

• Illumination for preparation and procedure

• Lighting for patient relaxation and

distraction

–30% of patients experience some

distress during MRI examination

–Noise: MRI Sounds

–Claustrophobia: Some patients

need mild sedative; in some

cases, procedures must be

terminated prematurely

• Note: Non-ferromagnetic construction of

MRI lighting systems is of paramount

importance.


http://youtu.be/8oI9YnhPNcQ

Radiology: Visual Tasks




Applications &

Tasks<25 25-65 >65

Preparation 25 50 100

Procedure 2.5 5 10

Ceiling Art Introduce back-lighted murals or art panels on ceiling above

recumbent patient’s head position.


Which views are considered therapeutic?


Credit: Clemson Patient Room Prototype 2012/2013

• Balance of prospect & refuge, no perceived

threats

• Restorative nature images can reduce

stress, anxiety, and pain (Ulrich, 2009 and

Hathorn & Nanda, 2008)

• Studies have used both observation tools

as well as fMRI

• Applications in patient rooms, diagnostic &

treatment spaces, waiting rooms (ED and

general)

Enabling deeper connections to nature…


Image: Spaulding Rehabilitation Hospital

Incorporating biophilic design into ambulatory settings…


Exploration of increasing organic forms and materials…


De-institutionalization of the physical environment…


Using sparkle

and dimension to

connect with

people…


Shown: CS Mott Children’s Hospital, HKS Architects

Personal Expression

through Color & Light


• Current literature is inconclusive, in terms of linking specific colors of light with emotion,

health, and behavior (Edelstein et al., 2008)

• White walls and bright white light are the hallmark of institutional settings.

• Concern about use of light in certain spectra (460-480nm, blue) at night due to potential of

circadian disruption

• Project uses RGB LEDs to color space

Room Design Hypothesis: Giving patients the ability to define their color

environment will result in improved self-reported perceptions of mood.

Expression through Color and Light


Room as Color-Light Vessel


How easy can we make controls for healthcare?

DMX controller can be enabled via

“tethered” apps

Control color, intensity, speed of “show”from patient bed

Astronomical time clock can be used to

enable visual cues for activity schedule,

tunable white light for daylight simulation

Ease of use important for impaired, high

acuity, and pediatric patients


What if you could use color without “tinting” the space?


How do we make lighting more connected & immersive…more experiential?

What about our aging population?


People Are Getting Older, Living Longer…

• US: The “oldest” baby

boomers turned 65 in 2011

• Life expectancy:

– US is 78 years (76 for males,

81 for females)

– Canadians & Spaniards can

expect 81 years

– 80 years in the UK

– 76 years in Mexico


Healthcare & Aging Eyes

• Older adults make up a large percentage of healthcare facility occupants

(staff, patients, volunteers).

Patients 65 and up make up half of hospital visits, according to the CDC.

Over 50% of medical facility volunteers are >65.

Adults over age 65 visit a physician 7x a year (<4 visits/year for general population).

People over 65 can spend up to 4x longer in the hospital than younger population.

• Average age of patient in skilled nursing facility is 79

• Lighting requirements for aging eyes are different than for younger

populations.


Source: IESNA RP-29-06 (Lighting for Hospitals and Health Care Facilities); Mass General, The Graying American Patient, 2009

Changes in the Eye Occur With Aging…

• Less light is transmitted to the retina – from

100% at age 25, to roughly 25% at age 75

• Pupils become smaller, less able to adapt

• Lenses darken over time

• Increased prevalence of eye diseases

(aging and related to other chronic

conditions)


Prevalence of sensory impairments increases with age


Age Distribution of Registered Nurses


Eye Conditions and Care Environments

• Long-Term Care – Older population and

prevalence of vision impairments

• In-Center Hemodialysis – Diabetes &

hypertension are the two most common

causes of chronic kidney disease & end-

stage renal disease

• Stroke Patients – Hypertension, ocular

pressure, and glaucoma


Source: United States Renal Disease Statistics

Resources


NIBS – Lighting & Low Vision

IES – Lighting for Aging Eye

IES RP-28-07 (Lighting

– Senior Living) will

now be “Lighting for the

Aged & Partially

Sighted (revision in

progress)

http://c.ymcdn.com/sites/www.nibs.org/resource/resmgr/LVDC/lvdc2013_paper_guarnaccia.pdf

https://www.ies.org/PDF/Education/LightingForAgingEye.pdf

Evidence-Based Design &

Healing Environments

• Evidence-Based Design (EBD) –

“the deliberate attempt to base building decisions on the best available

research evidence with the goal of improving outcomes and of continuing

to monitor the success or failure for subsequent decision-making.”

• Focuses on patient stress and fatigue, staff stress, and facility operational efficiency &

productivity

Source: A Visual Reference for Evidence-Based Design, Jain Malkin 2008


Selected Evidence-Based Design Research Areas

Connection to nature

Control (choice and empowerment)

Social support

Positive distraction Elimination of environmental

stressors

Acceptance of complementary

therapies



Process of Evidence-Based Design

Measure and share

outcomes.

Hypothesize outcomes,

innovate, and implement

translational design.

• Design interventions & expected outcomes

• Mockups/Pilots for to test hypotheses prior to construction

Map strategic, cultural, and

research goals.

• Identify key strategic objectives & project vision, guiding principles

• Develop research agenda (baseline and benchmarking)

Gather qualitative and

quantitative intelligence in the pre-design

phase.

• Interdisciplinary team

• Existing facility data & information from similar projects

• Organizational goals

• Documented & peer-reviewed studies


Source: Evidence-Based Healthcare Design, Rosalyn Cama, 2009.

Research Area Conclusions/Findings

Safety – Infection

Control

Hand hygiene is the most important measure for preventing pathogen spread

(Boyce & Pittet, 2002), and hand-washing compliance is usually around 20-35%

(Malleret et al., 1998).

A few studies link an increase in number & accessibility of hand-hygiene sinks with

a rise in hand-washing compliance; however, results have been mixed.

Safety – Fall

Prevention

Most patient falls occur in the bedroom and bathroom, respectively, and transfers

to/from the bed are the source of most falls, at 42% (Brandis, 1999).

The location of the bathroom on patient headwall works to reduce walking distance;

however, studies indicate that bedrails, a popular fall prevention design feature, can

actually increase severity and injury of falls (Tan et al, 2005).

Higher ambient lighting levels, with effective glare control, is related to lower fall

risks. (Vu et al., 2004)

Research : Light + Safety



Circadian Systems &

Daylight

Exposure to light linked to length of stay (LOS); patients in cardiac ICU stayed one

day shorter when placed in the sunny room, versus the shaded one (Beauchemin &

Hays, 1998).

Patients staying on sunny side of hospital perceived less stress, reported lower

levels of pain, and took 22% less pain-relieving medication than those in the dim

rooms (Walch et al., 2005).

Communication &

Privacy

Lower lighting levels in patient rooms can foster enhanced communication between

patient and caregivers (Miwa & Hanyu, 2006).

Empowerment and

Control

Increasing patients’ control over their physical environment can result in a greater

sense of empowerment, which is linked to improved outcomes (Steptoe & Appels,

1989).

Views of Nature &

Biophilic Design

Views to nature may elicit positive emotions, distracting patients from pain and

anxiety (Malenbaum et al., 2008). Patients who viewed well-lit images of trees and

water needed fewer doses of pain relievers (Ulrich et al., 1993).

Research : Light + Wellbeing



Sleep Efficiency

Thirty minutes or more of daily sunlight exposure resulted in improved nighttime

sleep duration. (Alessi et al., 2005)

Higher daytime light levels (between 7am and 7pm) were associated with

improved sleep/wake cycles in skilled nursing residents. (Shochat et al., 2000;

Wallace-Guy et al., 2002)

Reduction of light levels at night and resultant reduction of peak noise level at

night were associated with improved sleep efficiency. (Schnelle et al., 1999)

Research : Light + Wellbeing


Evidence-Based Design Techniques

Patient Comfort

• Single patient rooms with access to natural light and views

• Use of daylight for visual and biological functions

• Dedicated spaces for family in patient care rooms

• Meditation rooms and positive diversions such as artwork, gardens, fountains, green spaces

• Noise-reduction and acoustic improvements

Caregiver Performance

• Acuity-adaptable rooms

• Decentralized nursing stations

• Enhanced physician lounges

• Same-handed versus “mirror” patient room design

• Ceiling lifts in patient rooms to prevent caregiver injury & fatigue (back injuries account for 44% of lost workdays for nursing staff*)



* Fragala & Bailey reported in Joseph & Fritz, 2006.

How do we manage patient/staff tradeoffs?



Patient Room: Space Considerations

• Room configuration and

intended purpose (Med/Surg,

ICU, Protective Environments,

Pediatric, etc.)

• Furniture layout

• Windows & room Orientation

• Location of medical equipment,

lift systems and tracks



Patient Room: Occupant Needs

Patient

• Reading/writing

• Watching TV

• Visiting with guests

• Sleeping

• Restroom

Caregiver Staff

• Routine nursing

• Observation of patients

• Night lighting

• Patient examination


Patient Room: Lighting Requirements




Applications & Tasks<25 25-65 >65

Examination 25 50 100

Reading 10 20 40

Television Viewing 2.5 5 10

Shower 5 10 20

Vanities 7.5 15 30

Night Lights 0.05 0.1 0.2

Reference: 10,000 footcandles = sunny day, 0.01 footcandles = full moonlight


Caregiver Activities

• “Time and Motion Study”, 2007

• Answered questions about how nurses spend

their time

– Primary activities: documentation, medication

administration, locating supplies, and

communication

– Median distance traveled by nurses in a 10-hour

shift is 3 miles

• Lean Design – Focuses on the elimination of

waste in processes to realize improvements in

quality, delivery, and cost

• Implications for decentralized nursing stations

and other layout changes

48%

28%

8%

16%

Percentage of Time – Nurse Activities

Indirect Care Direct Care

Waste Other

Source: “Time & Motion Study”, Ascension Health & Kaiser Permanente, presented 2007


Nursing Station: Illuminance Levels




Applications &

Tasks<25 25-65 >65

Work Station – Day

(Inpatient &

Intensive Care)

25 50 100

Work Station –

Night (Inpatient)

5 10 20

Work Station –

Night (Intensive

Care)

15 30 60

Corridors (Day) 5 10 20

Corridors (Night) 2.5 5 10


How do patients perceive their environment of care?


79 82

68 7164

73

61

85

0

10

20

30

40

50

60

70

80

90

Average "Top Box" HCAHPS ScoresOctober 2012 to September 2013 Discharges

How should corridors adapt throughout the 24-hour day?


Credit: Theda Care/HGA

Post-Anesthesia Care Units (PACU)/Recovery

• Used for patients coming out of anesthesia,

post-operative care

• Caregivers monitor vital signs of the patient,

inspect surgical site for tissue changes that

could be cause for concern

• Patients coming out of sedation may

experience nausea and vomiting, and

intense light may exacerbate these

conditions

• Visually comfortable, dimmable light for

observation (25-100fc) and rest (5-20fc)

recommended


Credit: Columbia Orthopedic Group, Christner, Inc.

What about shift work?

• Lighting Research Center at Rensselaer

Polytechnic Institute did a study with

subjects to see if red light could

increase their alertness

• Subjects were given either blue or red

LED glasses at night.

• Hypothesis: Blue glasses were the

control which would suppress

melatonin, and red would make them

alert

• Red light increased alertness, but the

exact mechanism is unclear

• (More study required)


Nursing Performance – Further Research

• Limited knowledge that is specific to nursing work and critical task performance

• Understanding of how nurses adapt when lighting is contradicts patient’s desires

• Impact of areas of respite on staff (some studies on staff retention)

• Need for inclusive design, mockups, and simulations


Closing Thoughts

• Technology will cease to

be the constraint

Wayfinding & positional

tracking

Connectivity & IoT

• We can design for

healthcare, but designing

for health will be the true

breakthrough



Thank you!!

Healthcare Designs: Can Modern Lighting Cure the ill's of Ailing Institutions. Presented by Karyn...

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Transcript of Healthcare Designs: Can Modern Lighting Cure the ill's of Ailing Institutions. Presented by Karyn...