Please Stop the Racket!

The Hospitalist. 2006 July;2006(07):

July 1, 2006|The Hospitalist

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).