Reducing hospital noise pollution gives QI staff something to shout about
Reducing hospital noise pollution gives QI staff something to shout about
EPA noise standards fall on deaf ears
Day and night, a pollutant is pumped into hospitals that increases errors, contributes to intensive care unit (ICU) psychosis, and wrecks patient satisfaction ratings. The pollutant is noise — and it comes from perfectly reasonable sources. Most health care workers are horrified when they learn of the harm noise can cause. But until it’s brought to their attention, they carry on, unwitting participants.
To comprehend the extent of the problem, consider that the Washington, DC-based Environmental Protection Agency’s (EPA) standards for hospitals are 45 decibels (dB) during the day and 35 dB at night. But most hospital noise levels average 50-70 dB over a 24-hour period.
Most harmful is the "impulsive noise" or spike, such as the dropped cleaning bucket or the alarm. "Noise spikes are the worst possible events for sleep deprivation. One-third of sleep-deprived patients suffer from ICU psychosis. Noise degrades health care workers’ performance. It reduces the ability to perform simple arithmetic and increases the risk of accidents," explains James Espinosa, MD, FACEP, FAAFP, chairman of the emergency department and co-chairman of the noise reduction task force at Overlook Hospital in Summit, NJ. Espinosa is also the quality advisor for the Quality Institute of the Atlantic Health System in Florham Park, NJ. Noise impairs memory and judgment among ICU staff and also contributes to burnout, he adds.
In the operating room, where suction pumps wheeze at 80 dB and a steel bowl clangs to the floor at 110 dB, the steady din combined with startle effects can impair concentration and interfere with reliable communication. Health care workers have grown so used to noise that they blithely exacerbate it by talking at 66 dB.
Compare that with the following framework of sound levels from the human voice. One-Jang Jeng, PhD, professor of human factors engineering for the Occupational Safety and Health Engineering Program at the New Jersey Institute of Technology in Newark, provides these facts:
• Conversation between two people standing five feet from each other is 60 dB.
• The sound level in a quiet office with a computer running is about 40 dB.
• A soft whisper heard from 15 feet away in a library is 30 dB.
• People notice changes in sound levels when they increase or decrease by 6 dB to 15 dB.
This is not a new issue. More than 25 years ago, a study1 found noise levels in typical recovery rooms and acute care units incompatible with normal sleep. "It’s no wonder that patients say how thankful they are when they can leave the hospital so they can go home and get some sleep," notes Linda Kosnik, RN, MSN, chief nursing officer and co-chairwoman of the noise reduction task force at Overlook Hospital in Summit, NJ. "A hundred years ago, Florence Nightingale understood that sick people need quiet environments," she adds, "but we’ve disregarded it." Or have people simply lost sight of the issue amid the staggering changes in health care during recent decades?
As technology becomes more sophisticated, it gets noisier. Alarms, bells, and beeps permeate the hospital environment. "Patient acuity has increased as well," Espinosa says. He attributes the noise increase to the synergistic effect of sicker patients who require more technological interventions and hospital workers who raise their voices to communicate over the sounds. "Besides, our society has gotten louder," he adds. "Hospitals are surrounded by traffic on busy streets. But our consciousness of the harm from noise has not increased."
Overall, hospitals are engineered to conduct sound. "The alarms and staff cues create noise," Kosnik says. While alarms are intended to protect patients, the constant sound reduces staff productivity, she contends. "People train themselves to ignore all but the alarms signaling lethal changes in a patient’s condition."
So don’t expect an easy sell when you raise the idea of quelling noise pollution. The harmful effects are still beyond most people’s awareness. And in-depth solutions often require more than behavioral changes from caregivers. They involve process engineering and equipment modifications. Even if process and equipment changes are slow to come, however, behavioral changes can make a remarkable difference.
Kosnik says that when the noise reduction task force placed two noise meters (costing about $60 apiece) on one of the hospital’s medical-surgical units for 24 hours, the impact was immediate and lasting. "Patient satisfaction went up, and the staff have been quieter ever since."
She suggests that your best chance of rallying support for noise abatement is through a "package deal":
• on-site noise measurements;
• education, including a review of the EPA standards for health care facilities and clinical evidence;
• solutions based on the following examples.
Architect Derek Parker, San Francisco-based principal at Anshen & Allen Architects and board chairman of the Center for Health Design in Martinez, CA, contends that while we can’t rebuild every hospital to separate patients and staff from obnoxious noise, courtesy and common sense can go a long way. "Every garbage truck in the world seems to come at 4 a.m., so it’s unconscionable to place patient rooms above the loading dock."
Noise-abatement strategies also can reach into the psychological realm, he adds. "You can play with people’s expectations a little. For example, they expect vacuum cleaners and floor buffers to run at hospitals. When they run during the day, most people accept that. But people don’t expect to hear them at 2 in the morning."
Here are additional solutions compiled from suggestions by Espinosa, Jeng, Kosnik, and Parker:
1. Use patient satisfaction data as a baseline for initial improvements. Do the data reveal trends such as sleep disturbances at night or intrusions by television sets or visitors?
2. Ask the nursing and support staff to identify improvement opportunities such as squeaky hinges and screws or rickety wheels on equipment carts.
3. Enlist the maintenance department to make rounds on loud air conditioning or heating ducts. Invite the maintenance staff to come in and identify noise-reduction opportunities. [At the Brockton (MA) Hospital, maintenance associates make rounds on each new patient and fix irritants, such as rattling fans, on the spot. See QI/TQM, August 2000.]
4. Remind your co-workers that voices carry even through closed doors. Softer voices and conducting patient-oriented conversations at the desk will calm the unit considerably.
5. Ask the housekeeping staff to run vacuum cleaners and floor buffers during the day shift. Invite their suggestions for reducing excess noise.
6. Establish a quiet hour during the afternoon when patients can rest undisturbed with their doors closed.
7. Turn pagers from beeper to vibration signals.
8. During the evening and night shifts, park the medication cart at one end of the hall to eliminate the disturbance when the alarm is set off by the open door. Hand-carry the meds to each patient’s room.
9. Locate the nurses’ lounge away from the patient rooms.
10. Adjust monitors to signal only significant warnings or emergencies.
11. Whenever feasible, switch the monitors from sound to light signals.
12. Install earphones for the TVs in patient rooms.
13. Offset the boxes for electrical outlets instead of placing them back to back on the wall between two rooms. When back to back, the boxes become sound tunnels conducting noise from voices and equipment.
14. Replace or cover hard, smooth surfaces with softer, textured materials. Acoustical wall and ceiling panels and biostatic carpets dampen sound. Wall hangings such as tapestries or fabric art soften noise. Parker notes that in one facility, when a nursery was retrofitted with sound-absorbing panels, the staff spontaneously lowered their voices, reducing sound levels by 15 dB to 20 dB.
15. Move pneumatic tube systems away from patient areas.
16. When you replace privacy curtains, consider ceiling-to-floor lengths. They prevent sound leaks.
17. When your facility is in the market for new equipment, ask vendors for noise specifications on items such as monitors or carts. Consider the relative noise levels as factors in purchasing decisions. Big health care groups have a certain leverage in persuading vendors to design quieter products.
Reference
1. Falk SA, Woods NF. Hospital noise — levels and potential health hazards. N Engl J Med 1973; 289(15):774-781.
Need More Information?
For more on noise abatement, contact:
James Espinosa, MD, Overlook Hospital, Summit, NJ. E-mail: [email protected].
Linda Kosnik, RN, MSN, Overlook Hospital, Summit, NJ. E-mail: [email protected].
One-Jang Jeng, PhD, Occupational Safety and Health Engineering Program, New Jersey Institute of Technology, Newark, NJ. Telephone: (973) 596-3659. E-mail: [email protected].
Derek Parker, Anshen & Allen Architects, San Francisco. E-mail: [email protected].
For more on noise regulations for health care institutions, contact:
Environmental Protection Agency, Washington, DC. Web site: www.epa.gov.
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