Acoustics

Towards achieving
the ‘quiet hospital’
Alex Krasnic BEng MSc MIOA, senior acoustician at ZBP Acoustics, the
acoustics division of consulting engineer, Zisman Bowyer & Partners, explores
practical steps towards achieving ‘the quiet hospital’ without compromising
other design elements, while also recognising that acoustic design features
can sometimes be seen to conflict with certain healthcare protocols.

T
he ‘quiet hospital’ is a concept
which has long rung true in many a
healthcare designer’s mind, with
current acoustic design guidance, and the
implications of noisy premises on patients
and staff, already well documented. How,
though, can this concept be achieved in
reality, and what steps should the industry
as a whole be taking towards reaching
this goal? As for any major infrastructure
project, healthcare premises design is an
holistic process, that requires considerable
multidisciplinary input. As such, there are

Courtesy of Saint-Gobain Ecophon

numerous elements to consider early on
in the design stage, each of which must
comply with the regimes and protocols
of the healthcare operator.
Early acoustic input on a project is a
generally recommended approach, but,
beyond this, multidisciplinary designers
need to work closely to better understand
how their respective design features could The circulation area at Crumlin Children’s Hospital, Dublin, and below left,
impact on both others, and operational the reception area at the Walkergate Hospital, Newcastle upon Tyne, both
regimes, and how best to overcome incorporating acoustic ceiling systems from Saint-Gobain Ecophon.
potential conflicts. It should be noted, at
this juncture, that there have been several Manual. Through each edition and new invaluable information for the design
changes to healthcare design guidance guidance publication, the common team, in terms of guiding the specification
in recent times, with acoustic guidance objective has remained – to minimise of appropriate design measures to
having seen a gradual evolution from the noise wherever possible, in both critical minimise the ingress of environmental
days of HTM 2045: Acoustics design and non-critical areas of healthcare noise. In the case of refurbished
considerations, to HTM 08-01: Acoustics, premises. healthcare premises, there is often a more
and now to the current designation – restricted scope in terms of practical
TDM 4032: 0.6 Acoustics Technical Design Building fabric acoustic measures (especially those
The physics of sound are such that one subject to Listed Building status), but one
must consider how it is generated in commonality with new-build developments
the first place (i.e. understand the is the option of optimising glazing
Courtesy of Saint-Gobain Ecophon

characteristics of the sound sources), configurations. The acoustic designer will

and which methods can be adopted to
attenuate it to within acceptable limits.
Noise ingress into healthcare premises
has long been considered an important
consideration for acoustic designers. For
this reason, acoustic data collected during
pre-design ambient surveys can provide
usually have, at his or her disposal, a raft
of test data for a number of common and
specialist glazing configurations. With
sufficient acoustic knowledge of the
prevailing ambient conditions, and
information on the proposed external
building fabric, glazing test data can be

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September 2012 57
Acoustics
assessed against internal design targets
to yield optimal ingress noise levels.
Internal partitions
Where internal acoustic partitions are
proposed, TDM 8941:0.6 (superseding
HTM 56) can be referenced to assist
designers in achieving Department of
Health design objectives. As before,
selection of these must be balanced
against the need for structural integrity
and ventilation requirements. Clearly, the
greater the mass per unit area of acoustic
partitions, and the more partitions there
are spread across the floor span, the more
far-reaching the structural implications on
the floor system’s design and construction
type. Similarly, where more acoustic
partitions are required, this will affect
room shapes, and, in turn, the design of
either mechanical or passive ventilation
systems, due to considerations with air
movements, and the need for thermal
control.
Air transfer between spaces has also
posed acoustic problems in the past.
For example, where undercuts have been
designed under doors in critical care
areas subject to an air pressure regime,
this has usually led to a severe
degradation in acoustic privacy. Clearly,
the implications of any of these processes
must be considered alongside those for
(among others) lighting, thermal,
structural, ventilation, and facade
engineering requirements.
Impact of internal finishes
Regardless of the nature and characteristic
of internal noise sources within healthcare
premises, the design of room acoustics is
paramount to ensure that the level of
reverberant noise is minimised throughout.
The degree of reverberant build-up is
determined by the so-called ‘Reverberation
Time’, defined as the time taken for noise
in a room to decay by a certain amount
(usually by 60 decibels). Section 4079 of
the Technical Design Manual advises on
methods of appropriate room acoustic
treatment to minimise the reverberant
influence on noise levels. Specifically, it
states: ‘Acoustically absorbent materials
should have a minimum absorption
area equivalent to a Class C absorber
(as defined in BS EN ISO 11654:1997),
covering at least 80% of the area of the
floor, in addition to the absorption that
may be provided by the building materials
normally used. If a Class A or B absorbent
material is used, less surface area is
needed’.
To meet this requirement, there are a
number of commercially available systems
capable of achieving reasonably high
levels of acoustic absorption for use in
healthcare premises. The Class of the
system defines how effective it is at
absorbing sound in the frequency range
between 250 Hz and 4 kHz. A Class E
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58 September 2012
The ease-of-use, and low maintenance and installation costs, of modern patient
paging systems have appealed to many healthcare operators.
absorber is categorised as being the least
effective, and a Class A absorber the most.
For example, a Class B system (or better)
could be recommended in a neo-natal unit
to provide additional protection from noise
to the immature hearing system.
An alternative parameter which defines
the effectiveness of an acoustic absorber
is the Noise Reduction Coefficient (NRC),
as defined in North American standards.
An NRC of 0.0 indicates total reflection of
the incident sound, and an NRC of 1.0
indicates total absorption.
Ceilings’ effect
UK-based acoustic research into noise
levels in hospitals conducted by Dr. Nicola
Shiers at the London South Bank
University1 reveals that replacing an
existing suspended ceiling (NRC = 0.15)
with a mineral fibre-based acoustic variant
(NRC = 0.60) in a four-bedroom ward
yielded a reduction in the reverberation
time from 0.7 seconds to 0.3 seconds (in
the 1 kHz octave band). This resulted in a
reduction in the average continuous noise
level by 2.4 dB during the daytime, and
by 3.4 dB at night. Furthermore, notable
reductions in the number of high-level
noise events coinciding with patient
visiting times, ward procedures,
conversations, and cleaning activities,
were also observed. To put these
reductions into perspective, consider that
a 3 dB reduction in room noise level is
roughly equivalent to halving the number
of noise sources in the room (assuming
that each noise source generated an
equal magnitude of noise initially).
As before, the type, quantity, and
performance, of acoustic absorbers must
be compatible with other elements such
as architectural requirements, including
aesthetics, and positioning of acoustic
panels alongside lighting and building
services fittings. TDM 8941:0.6 also
specifies performance requirements for
building elements used in healthcare
developments, Element 3 of which is
specific for ceilings. Glass fibre ceiling
Courtesy of Call Systems Technology
tiles are generally regarded as having the
best acoustic absorption performance,
and can be encapsulated in a thin anti-
microbial film for specific hygiene
applications. Some specialist tiles have
also been coated in a thin anti-microbial
and hygrophobic film, which has been
shown to not significantly degrade the
acoustic performance.
The ‘cleanability’ factor
Standard tiles for healthcare applications
are best suited to general circulation areas
and waiting rooms. In critical care areas,
cleanability is an important factor when
selecting a suitable acoustic system.
Reputable manufacturers of mineral fibre
systems can provide accredited test data
confirming compatibility with hard
cleaning regimes such as formaldehyde
or hydrogen peroxide gas methods. This
aspect is often a shortcoming of older
healthcare premises, which still contain
older ceiling tiles pre-dating more modern
systems, and may need replacing during
refurbishment works.
Solutions for intensive
care units
If a ceiling tile is required to achieve a
sound transmission function (in addition
to sound absorption), then these can be
backed with encapsulated gypsum board
or treated steel plates, thereby making this
a good solution for intensive care units
(e.g.-natal intensive care units), where
improved sound insulation through the
ceiling can also be important. However,
a misconception persists in healthcare
design that acoustic ceilings will adversely
impact on infection control regimes.
Professor Brian Duerden, Inspector of
Microbiology and Infection Control at the
Department of Health,2 responsible for
monitoring the quality and consistency of
clinical and public health microbiology
services, advises that: “As far as ceilings
are concerned, they are probably the least
significant of surfaces in the clinical
environment in terms of transmission of
 Acoustics
infection. Most surfaces that become a degree that residual levels should not
contaminated do so as a result of hand only lie within design criteria, but are
contact (touching) or by skin scales usually masked by general background
(squames) that we all shed in large noise, thereby rendering them all but
numbers landing on a horizontal surface. imperceptible. There are many ways of
Ceilings are generally not within touching introducing noise control, measures to
distance for most of us, and squames are attenuate services noise in buildings, but
subject to gravity, so they fall downwards. healthcare premises, with their greater

Courtesy of Call Systems Technology

As well as the route to contamination, need for infection control and compliance
the other important factor in a surface with specific performance criteria, provide
contributing to the spread of infection is designers with a greater challenge.
whether the bacteria can be dislodged For example, regardless of the type of air-
from the surface, either by directly handling device serving a clinical area,
touching the surface, or by contact the choice of system filtration is critical
with clothing, shoes etc. Neither of these to ensure economical and energy-efficient
apply to ceilings”. operation of the fan. High Efficiency
Particulate Air (HEPA) filters are often
Wall panels Clinical headset systems have been adopted for such applications, and
In addition, wall panels of varying acoustic developed for use by clinical staff provide a high degree of particulate
performance are available which can working in noise-sensitive areas. retention, whilst minimising the flow
complement acoustic ceiling systems, resistance against which the fan is
and are usually positioned at high level properties (e.g. cabinets, curtains, working. This, in turn, satisfies infection
to reduce the risk of impact-associated bedding, rubber flooring vs. carpets etc.) control requirements, while maintaining
damage, but also to minimise the effect no matter how small, the consideration of a quiet, energy-efficient system.
of sound reflections from acoustically these must be balanced against the need
hard, parallel surfaces (so-called ‘Flutter to comply with infection control regimes, HVAC noise attenuation
Echoes’). In clinical areas, wall panels can in particular for critical care areas. More generally deployed are noise
be encapsulated in a Mylar or polyvinyl attenuators inside ventilation ductwork,
fluoride material to provide a degree of Building services which serve to absorb excess noise in the
cleanability, but the degree of reduction noise/vibration ductwork generated by the air-handling
to the acoustic absorption will need to be One of the most significant sources of unit and other devices in the airflow
factored in. It should be noted that, while noise in healthcare premises can be (e.g. dampers). These attenuators usually
other surface finishes may be considered building services. In practice, the noise contain mineral fibre infills, over which the
to have some degree of acoustic from these services is attenuated to such airflow passes. The noise in the airflow is

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September 2012 59
Acoustics
absorbed by the infills, but, depending on
the type and positioning of the filtration
devices (and the attenuator relative to
these), the infills can be encapsulated in
a Melinex lining to prevent mineral fibres
migrating into the airflow. Such systems
have been used to good effect with critical
care areas such as NICUs. Melinex-
Courtesy of Emcel Filters
bagged acoustic media are well known
to exhibit a degradation in acoustic
performance, in particular at mid- and
high frequencies. Therefore, an acoustic
factor needs to be taken into account
when specifying these systems. Where
crosstalk attenuation is required in
ductwork serving sensitive adjacencies,
such as for maternity care facilities (the
requirements of which are detailed in
Planning and Design Manual 72:0.8),
these must be designed in such a way
as to avoid harbouring pathogens, and
to be easily maintained.
VAV boxes
Space-permitting in plant rooms, service
risers, and ceiling voids, larger duct areas
are preferable, because they exhibit lower
friction rates than smaller ducts, thereby
resulting in reduced fan duties, greater
energy efficiency, and lower noise.
Some terminal devices, such as supply
grilles and variable air volume (VAV)
boxes, can also pose acoustical
challenges. Airflow noise data from supply
grille manufacturers should be assessed
to ensure that that terminal noise levels
do not increase above design targets.
Similarly, discharge noise from VAVs is
usually dealt with by a short run of lined
duct, which may not be suitable for
healthcare applications. In these cases,
the sound-absorptive lining can be
covered in a film which, again, degrades
the attenuation performance. This can be
overcome by using parallel-baffle duct
silencers, also known as ‘labyrinth’
silencers, which, while also being film-
lined, provide a more onerous path for
the noise to pass through.
Airflow in ventilation ductwork
The airflow in ventilation ductwork should
be also considered at the design stage.
Mechanical system designers will aim to
reduce duct airflows, especially at final
run-outs, to within design tolerances,
using careful duct runs, or damping
devices where appropriate. If additional
regenerated noise from such devices is
deemed problematic, the introduction of
secondary silencers downstream of the
airflow can also be considered. Lastly,
larger reciprocating plant usually housed
in a dedicated plant room, or on the roof
of the building, can sometimes lead to
higher levels of structure-borne vibration.
This can be dealt with at source – by
specifying anti-vibration mounts such as
springs or rubber mounts, or concrete-
filled inertia bases for much larger plant.
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60 September 2012
Regardless of the type of air-handling
device being used, system filtration
choice is critical to ensure economical
and energy-efficient fan operation.
HEPA filters ‘provide a high degree
of particulate retention, while
minimising flow resistance’, in turn
both satisfying infection control
requirements, and maintaining a
quiet, energy-efficient, system.
Spatial design considerations
The transfer of operational noise to
sensitive areas within healthcare premises
can be mitigated by careful spatial design.
This is when the healthcare operator,
architect, and acoustician, should gather
to discuss the most appropriate ways of
designing the building layout. One
common issue has been the positioning of
bulk storage rooms. Place them too close
to sensitive areas and noise becomes an
issue, but if you place them too far, and
you may impede staff procedures. The
design team should consider the likely
noise sources, the path that the noise
takes to reach sensitive spaces, and how
best to mitigate its transmission. A simple
solution is to consider noise barriers in, or
around, the interconnecting corridor to
attenuate the noise, or position the
storage door access away from the
sensitive space. Guidance within Planning
and Design Manual 9935:0.4, details the
requirements for Adult Acute Mental
Health Units. Section 9985 of this manual
advises on providing the correct acoustic
environment through spatial planning of
bedrooms, use of silent fire alarms, and
maintaining high levels of speech privacy
between patient areas.
General ‘office noise’
Staff administrative duties have always
been a source of noise in premises.
Nurses, physicians, and consultants, are
sometimes required to undertake office-
type activities alongside their clinical
duties (although there has been a drive to
reduce the amount of administrative work
that clinical staff are required to do over
recent years). This, in turn, forces the
design team to consider how staff are
conducting their administrative duties
in and around patient areas. It may not
always be possible to attenuate noise
from printers, telephones, and other
communication devices at source, so
careful layout arrangement of
administrative or office areas, as well as
organisation of staff activities at, or close
to, patient bedsides, is paramount.
Room adjacencies
Other design features to consider include
room adjacencies and traffic control. This
is an important aspect of acoustic design
of healthcare premises, as it offers an
opportunity for the operator to outline their
protocol requirements early on, which
serves to guide the positioning of adjacent
spaces. Dirty utilities, staff areas
(changing rooms and staff rooms), stores,
and WCs, can all contribute significant
noise levels which, if not attenuated
through early design, can adversely affect
sensitive spaces. Minimising human
traffic noise through careful design is also
important. In such cases, is there a way to
‘short-cut’ staff circulation between areas
without passing by sensitive spaces?
If not, can the use of partitions or other
acoustic barriers be used to minimise the
transmission of traffic noise? All these
considerations can be reviewed during
the design stage to optimise the reduction
of noise transmitting to sensitive areas.
Communication and
operational noise
Operational noise generated in patient
areas, critical care, and other clinical
areas, has long been a problem in
healthcare premises. Many papers and
articles have been written about the ill-
effects which excessive noise can cause
to staff operation, patient welfare, and
hospital discharge rates. Rather than
revisiting these well-documented issues,
here we aim to propose some outline
design and operational considerations
which may go some way to mitigating
excessive noise. The larger, busy hospitals
nationwide must handle and
accommodate the greatest numbers of
patients and staff at any one time, which
can result in significant noise levels
being generated in any 24-hour period.
Everything from general circulation noise,
people chatting, listening to televisions,
and talking on mobile phones, to medical
equipment alarms and communication
systems, contribute to ever-increasing
noise levels.
Neo-natal units, in particular, require
careful acoustic attention. Planning and
Design Manual 8720:0.6 details these
requirements, and advises on the use of
quiet paging systems, soft-close bins, soft
floorcoverings, and quiet door closers
where appropriate.
Patient paging systems
Over the last few years, patient paging
systems have proliferated in healthcare
premises, with their ease-of-use, and low

Courtesy of Allaway Acoustics
Noise attenuators inside ventilation
ductwork serve to absorb excess noise
in the ductwork generated by the air-
handling unit and other devices in the
airflow (e.g. dampers).
maintenance and installation costs,
appealing to many healthcare operators.
For example, the Whittington Hospital
NHS Trust3 in North London chose to
install a patient paging system which
yielded significant benefits to both staff
and patients. A notable by-product was far
fewer announcements over the public
address system, as well as greatly reduced
circulation noise, as patients tended to
de-congregate away from the central
waiting areas, thereby reducing the
number of noise sources in one space.
The paging system’s installation also
improved clinical staff productivity and
re-circulation, as staff could dedicate more
time to their duties, and spend less time
on administrative activities.
Telemetry equipment
Staff communication is critical in fulfilling
demanding clinical roles, but the by-
product of noise can be problematic.
Advanced nurse call systems and, more
recently, telemetry and headset systems,
have been developed for use by clinical
staff working in noise-sensitive areas.
Telemetry systems in particular allow staff
to communicate effectively at distance,
whilst minimising noise transmission
to sensitive areas. In the UK, several
healthcare operators have been employing
this technology – especially for critical
care staff – with significant success,
and indeed many office personnel have
commented on how much quieter their
working areas have become.
Aside from staff and patient
communication, nurse call systems have
long been a source of noise consternation,
and this is an area where more research
would benefit in terms of designing
quieter systems. In the short term, nurse
call systems should be located in areas
where the noise transmission path is well
attenuated, either by careful doorway
positioning, or adoption of other partitions
or barriers in the design. TDM 130:0.5
details the design of Bedhead Services,
with Section 1943, in particular, focusing
on the acoustic requirements of nurse call
systems. Overhead paging systems in
patient areas have also been a source of
noise. As for nurse call systems, these
devices should also feature volume
controls and user-selectable functions
which limit their operation during noise-
sensitive times (e.g. at night).
‘Overhauling’ the
noisiest equipment
Again, for premises undergoing
refurbishment, the aim is to overhaul the
noisiest equipment, replacing it with more
developed technologies which offer the
same level of functionality, but with better
noise control features. In patient rooms,
speaker pillows for use with TV sets,
radios, and other communication devices,
should be encouraged where possible,
without affecting operational protocols.
Finally, although critical within any
healthcare operation, clinical alarms again
offer an opportunity for designers and end-
users to better understand the source of
noise, and how to limit patient disturbance
without compromising operational
protocols.
As patient monitoring systems become
more advanced, the need to raise clinical
alarms diminishes, but, in the short term,
operators should consider directing
alarms away from patients as much
as possible. Here, clinical alarm
manufacturers also have an opportunity to
develop user-selectable volume controls,
and more directional sounders, to further
reduce unwanted noise. Ultimately, there
is an opportunity for clinical engineers and
the medical technology industry to better
understand the use and functionality of
such devices with the aim of minimising
the degree of noise disturbance.
The future of healthcare
acoustics
This article has touched upon both some
well-known, and some perhaps less-
considered, acoustic design and
management features for healthcare
premises. While acoustic design guidance
in the UK has seen a gradual evolution
over the years, the guiding principles have
remained the same. In so far as many
healthcare premises in the UK are well
operated, and aim to generate as low
a level of noise disturbance as possible,
here we have explored some practical
design and operational considerations
with regard to achieving ‘the quiet
hospital’. However, there is much more
that can be done, and there is ample
evidence of the patient, staff, and visitor
health benefits that lower noise levels
can yield.
It is on this note that some conclusions
can be drawn, because, as healthcare
establishments grow in size, this will lead
to a far greater turnover of both patients
(in and out) and staff numbers, thereby
Acoustics
necessitating the installation of more
building services components and clinical
equipment to support effectively the
healthcare facilities’ operation.
Clearly, the equipment manufacturers
have a role to play, for instance in
designing more standardised alarm
systems that incorporate more efficient
patient monitoring systems. My message
is that we should not stop here in
reducing healthcare noise levels, but
should instead use the knowledge already
garnered to date to improve future
healthcare delivery by promoting a
considerably more restorative environment
for patients and staff alike. ✚
References
1 Shiers N. 2008. Acoustic design for
inpatient facilities in hospitals. Thesis,
(PhD), London South Bank University.
2 Anthony Thomas, concept developer –
Healthcare), Saint-Gobain Ecophon.
3 Case Study: The London Whittington
Hospital NHS Trust (Client testimonial),
Call Systems Technology.
Alex Krasnic
Alex Krasnic BEng MSc MIOA
has been involved in numerous
infrastructure and built environment
projects since gaining a Masters
degree in Environmental and
Architectural Acoustics from the
London South Bank University in 1999.
Having initially successfully worked
on large-scale transportation and land
use development schemes, he moved
to specialise in the field of building
acoustics, where he has applied his
noise and vibration engineering
expertise to building design across
sectors including healthcare,
residential, education, commercial, and
research. Now senior acoustician at
ZBP Acoustics, he has considerable
multi-disciplinary experience, having
worked for clients including the
Institute for Animal Health; Cancer
Research UK, the Veterinary Laboratory
Agency; Homerton Hospital, London;
Bronglais District General Hospital,
Aberystwyth; Heartlands Hospital,
Solihull, and the John Radcliffe
Hospital, Oxford.
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