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Please Stop the Racket!


 

Machines hum and alarms beep. Televisions squawk and telephones ring; overhead pagers blare out names. Equipment travels on squeaking, groaning carts, and people shout their conversations so they can be heard above the din.

Welcome to the hospital.

Noise has been a problem in hospitals at least since the 19th century, when Florence Nightingale described it as a “cruel absence of care.” In the nearly 150 years since she wrote that statement, the problem has only gotten worse, reflecting the increasing reliance on technology and an older and sicker patient population.

A Growing Problem

The average level of daytime hospital noise has risen from 57 decibels in 1960 to 72 decibels in 2005. Night-time noise increased from 42 to 60 decibels in the same time period. These levels are well above World Health Organization recommendations of no more than 40 decibels during the day and 30 to 35 decibels at night.

“It’s like being about 100 meters from a busy highway,” says Ilene Busch-Vishniac, PhD, professor of mechanical engineering at Johns Hopkins University (Baltimore) and a co-investigator in an ongoing study on hospital noise.

Despite the longstanding complaints of patients and hospital staff, little formal documentation of the problem existed until three years ago, when Stephanie L. Reel, vice president and chief information officer for Johns Hopkins Medicine learned from nurses that the noise level in the pediatric intensive care unit was a major source of complaints. To assess the problem she turned to two acoustical engineers: Busch-Vishniac, and James E. West, PhD, research professor in electrical and computer engineering.

One research team spent an informative—and sleepless—night in a patient room as part of a sleep-promotion study. They found a portable chest X-ray unit to be the biggest single problem, especially because the technician wheeled it in at 3:15 a.m.

Over the next year, they and their associates measured the noise at five wards on several floors in the hospital, including the PICU. The average sound levels in all five units ranged from 50 to 60 decibels, with the PICU being the loudest.

These findings reflect the pattern of a general rise in the sound level in hospitals worldwide, the investigators wrote (Busch-Vishniac IJ, West JE, Barnhill C, et al. Noise levels in Johns Hopkins Hospital. J Acoust Soc Am. 2005;118(6):3629-3645).

Since then, West and Busch-Vishniac have performed similar measurements in the emergency department and virtually all of the operating rooms at Johns Hopkins Hospital, with similar results. West recounts anecdotes of nurses retreating into the bathroom to have a quiet place to think, and taking patient records home so they can prepare them in peace.

Perhaps the biggest reason for concern is the potential impact on patient safety. “If instructions are misunderstood because of the high noise levels, it can lead to all sorts of safety problems,” adds West. “What’s most disturbing to me is that the noise level will continue to rise if something isn’t done about it.”

Sound Solutions:

Innovative Ways to Reduce Noise

Noise-abatement strategies need not be expensive or high-tech. “We asked, ‘what kinds of changes can we make without going through a lot of red tape?’” says Cmiel. Among the solutions that St. Mary’s came up with:

  • Make people aware of the problem. Post signs reminding them to keep their voices down and close the doors to patients’ rooms;
  • Hold training sessions on noise abatement for ancillary staff members including the cleaning crew.
  • Put foam padding on the bottom of chart holders.
  • Identify patients who don’t need nighttime care—and don’t disturb them.
  • Replace paper towel rolls in or near patient rooms with quieter, folded-towel dispensers.
  • Eliminate the use of overhead paging systems—at least during nighttime hours. Consider equipping doctors and nurses with tiny individual pagers that can be worn around the neck.*
  • Lower the volume of telephone ringers and other equipment wherever possible.
  • Gain the cooperation of other departments. The St. Mary’s team finally persuaded the surgical department to revise its schedule so it could stop ordering X-rays at 3 a.m.

At Montefiore Hospital in New York City, the Silent Hospitals Help Healing (SHHH) program is employing many of these techniques. Signs reading “SHHH” decorate the hallways, and patients, staff, and even visitors sport buttons showing a nurse holding a finger to her lips. Intercoms are turned down, and staff members are asked to keep their beepers on vibrate mode. Equipment is kept lubricated and in good repair to minimize squeaks and rattles.

It’s all paying off: Noise levels have decreased markedly since the program’s inception in March. Elodia Mercier, RN, the administrative nurse manager who developed the program, reports that patients tell her they are sleeping better, and the house staff finds the environment less stressful.—NM

For more information, contact Vocera Communications Inc. in Cupertino, Calif. (www.vocera.com).

None of this is a surprise to hospitalists. “I’ve discussed this with at least 30 employees in hospitals—especially nurses—and they all agree it’s a problem,” says Douglas Cutler, MD, regional medical director, Phoenix and Tucson, for IPC The Hospitalist Company.

Indeed, Dr. Cutler could hardly be heard during a telephone interview. In the background phones rang, announcements blared, and people talked and laughed loudly. He was calling from the nurses’ station, an area he estimated at about five feet square and which contained—at that moment—at least seven people.

“I think it’s a terrible problem, but so far it’s been pretty much ignored,” says Burke Kealey, MD, chief of professional services for hospital medicine at Regions Hospital in St. Paul, Minn.

Regions is now building a new hospital (see The Hospitalist March 2006, p. 30), and Dr. Kealey has raised the issue in design sessions, so far with little success. Money is tight, and noise-reducing materials and designs are seen as expendable. “It’s way down on the list of priorities,” he notes.

Worst Offenders

In the Johns Hopkins study, the air-conditioning and overhead paging systems were among the biggest culprits. Human speech was also at the top of the list.

Lakshmi Halasyamani, MD, chair of the Hospital Quality and Patient Safety Committee for SHM, recalls one instance in which she and a resident couldn’t talk to a patient because of a loud conversation about another patient that occurred in the hallway just outside the room. In fact, the incident made her take a new look at patient privacy and confidentiality issues. She now makes a point of including patients in all such conferences whenever possible.

These may be the worst offenders, but anything that hums, rattles, vibrates, squeaks, beeps, ticks, or otherwise makes itself heard contributes to the general racket. Even something as innocuous as placing a chart in its holder can be disruptive, says Cheryl Ann Cmiel, BAN, RN, a staff nurse on the surgical thoracic intermediate care nursing unit at St. Mary’s Hospital, a Mayo Clinic-affiliated hospital in Rochester, Minn.

Cmiel and another team member, Dawn Marie Gasser, ASN, RN, spent an informative—and sleepless—night in a patient room as part of a sleep-promotion study. She found a portable chest X-ray unit to be the biggest single problem, especially because the technician wheeled it in at 3:15 a.m. In general, the noise was loudest during shift changes (AJN. 2004;104(2):40-48).

Squeaky Wheels

Perhaps the best way to start a noise-reduction program is by asking patients what bothers them the most. “Staff members kind of filter out the noise, so we don’t hear it all the time,” Cmiel tells The Hospitalist.

The next step is to remain vigilant and use common sense. “As we move forward with team-based care, noise will become more of a problem,” says Dr. Halasyamani. At night, “we must remember that the patient’s goal is to sleep, unless they’re having an acute problem.”

Remind staff members to keep their voices down. On wards, keep all conversations patient-centered and include the patients in them whenever you can. If possible, designate certain areas away from patient rooms as areas for collegial staff chats.

Simply remembering to close a patient’s door can make a difference, adds Dr. Kealey. Whenever it’s appropriate, he also orders that a patient not have her vital signs checked or receive medication at night. If a patient requires particularly close watching or is at risk of wandering or falling, he recommends video monitors, centralized alarms that sound at the nurses’ station rather than the bedside, and low beds that minimize the risk of falls. He and his colleagues are also trying to emphasize to residents the importance of keeping the noise level down.

Administrators require data before they’ll consider major, system-wide changes, Dr. Cutler warns. Noise-reducing strategies that involve significant sums of money are viewed as a capital expense, “and [administrators] have to balance that against other capital expenses. If there was evidence that it affected patient outcomes, the trend would be for hospitals to improve [their efforts at noise control],” he explains.

Dr. Busch-Vishniac agrees that more research is needed. “That there aren’t more people working in this area is disturbing,” she observes. “We were really surprised at our findings. We thought it would be a quick fix and walk away.” TH

Norra MacReady is based in Southern California.

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