journey to a quiet night webinar series · 15/06/2018 · journey to a quiet night webinar series...
TRANSCRIPT
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?
(650) 493-5000 ext. 64711
(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
Jenna Fischer, CPPS
Hospital Quality Institute