WARNING: You are about to enter a facility that poses a threat to your hearing and your health—the hospital.
Better Medicine: Tame noise to better serve patients
Running to more than 135 articles, there is now a large body of research demonstrating that hospitals are loud environments. Enter the typical hospital and you will find noise levels far exceeding those recommended by the World Health Organization. WHO guidelines specify 35 decibels for continuous background noise in patient rooms with nighttime peaks not to exceed 40 decibels. Hospital background-noise levels far exceed those and peaks frequently exceed 90 decibels. Medical equipment and staff voices typically produce noise at 70-75 decibels levels. Other sources of noise include alarms, bedrails, telephones, ice machines, paging systems and pneumatic tube systems. The noise from portable X-ray machines can exceed 90 decibels. This is analogous to walking next to a highway when a large tractor-trailer passes.
Noise is not good for patients or healthcare providers. High background noise in patient-care areas has been associated with increases in blood pressure and heart rate and poor sleep patterns among patients. Noise in nurseries has been associated with higher oxygen-support therapy needs. Even more alarming and particularly relevant today is a study of a coronary-care unit that showed an increase in readmissions following discharge for patients who had poor room acoustics and noisy hospital stays. High noise levels have also been reported to be a source of patient dissatisfaction, according to Press Ganey, just as it is in restaurants. (Zagat includes noise levels in its restaurant rating system).
The prospects for healthcare workers in terms of health and hearing loss are just as grim. Work in high ambient-noise settings has been associated with hypertension and coronary artery disease. Noise-induced stress has been identified as a predictor of burnout in critical-care nurses. High noise levels in a hospital setting have been associated with high levels of hearing loss. The ambient noise level consistently experienced in emergency departments is particularly high and comparable to that experienced by rock stars who subsequently have demonstrated significant hearing loss.
Higher ambient noise makes oral communication difficult by making it hard to discern auditory cues from background noise. As people age (and certainly the healthcare workforce is aging) the capacity to decipher speech over high background noise is diminished. According to the Joint Commission, the majority of sentinel-event cases of patient death or permanent injuries can be traced back to communication errors. Noise then has the potential to reduce, prevent and/or distort interactions in settings where communication failures are well-documented. High ambient noise in healthcare settings is a patient-safety issue.
Reports of efforts at reducing noise in healthcare settings appear in the literature. During periods of reduced noise, speech intelligibility increased, nurses perceived their workloads as less, and social support among staff was better. A key component of quieting facilities is to eliminate noise sources. In one site the unit installed a noise-level monitor. As noise on the unit increased, the staff received a real-time signal. When levels were in range, the monitor showed a green light. When the sound exceeded the recommended levels, it went yellow; and when it was in a danger zone, the monitor showed red. Staff identified contributors to high noise levels. For instance, the lids on the rubbish bins were very noisy, so they were replaced; the X-ray machine was revised to be less noisy, and all alarms and phones were programmed to a lower decibel level. In another unit, the overhead paging was reduced and staff members were trained to speak more quietly. Insulating ice machines and pneumatic tube systems had a significant effect on reducing noise in clinical units. Even motion-sensing paper-towel dispensers have been shown to increase the decibel level in a clinical unit, so every element of the built environment must be considered in terms of its contribution to the noise level.
Design teams can help with noise reduction by bringing the latest evidence-based design strategies to clinicians and administrators. Single-patient rooms have been shown to be quieter than multiple-patient rooms. Noise concerns and concern about hospital-acquired infections are increasingly being taken into consideration in designs of single-patient rooms, even in the nursery. Another important and proven design intervention is to install high-performance, sound-absorbing ceiling tiles that reduce echoing and reverberation and sharply diminish sound propagation. Noise-reducing panels and wallpaper, strategically placed, were shown to significantly reduce noise in an oncology ward at Johns Hopkins Hospital in Baltimore. Decentralizing work stations on nursing units has been shown to reduce noise in inpatient settings. Those patient-care units that are built with large numbers of rooms operating out of a central station are particularly noisy and the need to involve architects and designers in these efforts is now apparent. As alluded to earlier, the environment can be designed in terms of layout and operations to facilitate communication and decrease noise.
The point is this: Physicians should lead the charge to reduce noise in healthcare settings. It will be to the benefit of patients, staff and all physicians. Let’s not wait too long to improve the acoustic environment that we work in. We just may run the risk of being too deaf to hear our own battle cry.
Dr. Shari WelchUtah Emergency PhysiciansSalt Lake CityPresidentQuality Matters Consulting
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