Between 2011 and 2013, ambient electronic musician Yoko K. Sen spent time in a local hospital receiving treatment. She didn’t like what she heard. The incessant stream of jarring noises—slamming doors, beeping medical equipment, blaring televisions in neighboring rooms—wasn’t exactly conducive to a restful recovery. When she learned that some believe hearing to be the last sense we lose before death, Sen began wondering: Is this really what terminal patients should hear during their last moments on Earth?
Now, Sen is on a mission to use sound design to make hospitals calmer, more soothing places to stay. Conducting extensive research on the needs of health care providers and alarm fatigue—a condition that occurs when people become desensitized after being exposed to too many alerts—Sen is currently prototyping sound environments that help patients and providers cut through the clamor, potentially improving both patient health and medical care in the process.
One Alarm Every 11 Minutes
“The incredible thing we’re learning, and the very beginning of the dawn of human-centered design in health care, is how little attention we’ve paid to most things that aren’t clinical,” says Nick Dawson, executive director of the Johns Hopkins Sibley Innovation Hub, a group that’s working with Sen and other partners to use design to improve patient experiences at Sibley Memorial Hospital in Washington, D.C. “It’s not just that [medical sound design] has been done poorly, it’s that it’s never been done.”
Hospital cacophony is so constant, doctors and patients stop noticing it’s there. Just a few days in a hospital means hearing thousands of alarms. Research presented at the Acoustical Society of America’s 2016 spring meeting found that the average hospital racks up 135 alarms per patient per day, about one every 11 minutes. There are blood pressure and cardiac monitors that beep in tandem with patients’ heartbeats, ventilators that sound when patients cough or shift in bed, and IV machines that trip every time medication is delivered, just to name a few.
But none of these are critical alarms, and neither are many of the other alerts patients hear on a constant basis. The Joint Commission, a nonprofit health care accreditation and certification organization, estimates that 85% to 99% of hospital alarms don’t require any clinical intervention, leaving patients nervous that there’s something wrong and health care providers scrambling to sort false alarms from real ones.
“One of the things that we know from the literature is if a clinician believes an alarm to be valid 90% of the time, they’ll answer it 90% of the time,” says JoAnne Phillips, co-chair of the Alarm Safety Committee at the Hospital of the University of Pennsylvania in Philadelphia.
The reverse is true, too. When clinicians know that false alarms are common, they’re substantially less likely to answer, raising the risk of missing a major medical emergency. The Joint Commission found that between 2010 and June of 2015, 138 people died in events related to alarm system failures. Even when life or death isn’t on the line, alarms still take a toll. For patients, hospital noise has been linked to sleep difficulties, higher stress levels, increased blood pressure, and longer healing times and hospital stays.
From Silence To Dissonance
It wasn’t always this way. Back in the 1800s, silence was considered crucial to a patient’s recovery. Hospitals were considered public quiet zones. A speed limit was imposed in the surrounding area and straw was put down on nearby streets to prevent patients from hearing noise from horse-drawn carts and pedestrians. Early nurses went so far as to wear moccasins to quiet their footsteps to help patients get the maximum amount of rest. That changed with technology. With the advent of devices ranging from intercoms to the steadily growing barrage of monitoring systems, hospitals became louder, more dissonant places with patients and health care providers dealing with the consequences.
In an effort to keep as close an eye on patients as possible, monitoring devices have proliferated, and, as they’ve grown more sophisticated and increasingly automated, they’ve also become more sensitive and include more and more alert-heavy features. Many are designed for the average person, JoAnne Phillips says, which means that cardiac monitors will often continually go off if a patient naturally has a slightly irregular heartbeat, even if nothing is truly wrong. Health care practitioners can turn these alarms off, but many don’t.
“The fear for clinicians that are potentially less knowledgeable is that they’ll miss something. ‘I can’t touch that, I’ll miss something,’” Phillips says. “One of the biggest initiatives right now is how do we teach nurses to customize the alarms so that they feel they’re safe, so they feel that they’re going to get called to the monitor for the right things?”
As part of her work to calm the cacophony of the hospital environment, Sen converted one of Sibley Memorial’s patient rooms into a tranquility area to provide a place for hospital staff to escape the noise and mentally reset. After entering an antechamber where Sen herself brewed and served green tea, weary staff were greeted with reclining chairs, soothing music, lavender scents, and moving projections on the walls, which Dawson describes as reminiscent of the northern lights. The project was originally intended to be temporary, but it proved so popular that Sibley’s executive board has approved making a permanent tranquility room. Members of the Sibley Innovation Hub are also investigating bringing the concept to patients through “tranquility boxes” stocked with a noise machine and a small projector that health care staff could use to quickly transform a patient’s room into a simulated forest or beach scene.
One challenge to creating purposeful sound design that works in shared patient rooms and communal hospital spaces is that hearing perception varies between people, says Sen. What sounds soothing to one person isn’t always to the next.
“We always ask what kind of sound environment might be ideal for a patient, and not everyone said ‘I like quiet and silence,’” Sen says. “We are actually hearing complaints from patients that it’s too quiet and I feel lonely and I’m scared.”
Sen is experimenting with sound design options that can be individually tailored, such as sensors that adjust sounds and volume according to a patient’s heart rate. Her work goes hand-in-hand with steps health care providers are taking to turn down the volume. Some, like Hospital for Special Care in New Britain, Connecticut, have invested in software that separates alarms requiring an immediate response from those that don’t. In the facility’s respiratory wing—a place where 19,000 alarms from ventilators go off in an average day—only the most critical alarms to patient safety are sent to staff computers, personal pagers, and over the unit’s loudspeaker. Those include alerts letting providers know when patients are experiencing dangerous changes in lung pressure or if they’re not exhaling enough air, as well as when patients are disconnected from the ventilator or the machine has lost connectivity with the hospital’s alarm monitoring software.
Alarms, for things like high respiratory rate, which is often a temporary condition that isn’t life-threatening, only sound at the patient’s bedside. The system has reduced the number of ambient overhead alarms and alarms requiring immediate staff response by 80%, says respiratory practice manager Connie Dills, adding that the facility is planning to expand the system into all hospital units in the near future.
“Discordant Cacophony Of Beeps And Blurps”
A 2014 mandate by the Joint Commission required hospitals to implement alarm management systems by January 2016, but how and which alarms are addressed was left up to the individual institutions. While some care facilities have focused on reducing specific types of alarms—cardiac monitors or ventilators for instance—others have focused more on sending alerts to individual health care providers rather than anyone on the floor. Even with these management systems, there’s still a lot of beeping and buzzing. One way to tone it down is to get medical equipment vendors and health care facilities on the same page, says Dawson.
“If you’re the vendor of IV pumps, it probably never occurred to you to coordinate with people who make the ventilator that your tones should be in the same scale,” Dawson says. “It sounds like a preposterous idea,” but without that coordination, right now “it’s just this discordant cacophony of beeps and blurps,” he adds. “At some point you stop being able to tell what’s what.”
The Association for the Advancement of Medical Instrumentation’s National Coalition for Alarm Safety—a collection of representatives from roughly 25 hospitals and 15 vendors—is working to bridge the gap between health care workers and equipment designers. The group is “probably the first time that practitioners and vendors have been at the same table” says JoAnne Phillips, the coalition’s representative from the Hospital of the University of Pennsylvania, and getting everyone on the same page requires significant coordination and cooperation from the vendors.
In the mean time, Sen is thinking of ways to expand her work throughout the health care system. Last September, Sen asked people throughout Iceland about sounds they would like to hear at the end of their lives, and created a composition based on their responses. She is currently working with a neuroscientist at another institution to create research-backed sound environments designed to soothe babies.
“We are really spending time to understand,” she says. “You don’t come here with the solution first.”