Noise-Abatement Strategies for Tertiary Healthcare Facilities

Reducing Length of Stays on Critical Care Wards in a Department of Veterans Affairs Medical Center

Today, the Department of Veterans Affairs (VA) operates the nation's largest healthcare system and provides training for more than half of all of the physicians that practice in the United States today. Based on its mission, taken from President Lincoln's Second Inaugural Address, to "care for him who has borne the battle, his widow and his orphans," the VA Medical Center in Oklahoma City is committed to providing the best quality medical care possible for its veteran patients. One issue that has emerged in recent months that has been shown to adversely affect the quality of this patient care is sleep disruption on critical care wards due to the high levels of noise that are generated in these healthcare environments. In fact, the noise levels on many critical care wards as the same as a lawnmower or blender, and many patients report difficulties getting enough sleep while they are trying to recover from a surgical procedure or medical intervention. In response to this problem, this medical center, along with a growing number of other hospitals across the country, has implemented a noise-reduction initiative designed to reduce the noise levels on its critical care wards. This paper reviews this initiative and provides an overview of an analytical approach to evaluate its effectiveness.

Part A: Change Investigation Proposal Form

A brief description of the organizational change planned for investigation

Hospitals are notoriously noisy environments, and many patients, especially on critical care wards, are unable to obtain a normal amount of sleep due to constant awakenings due to staff talking, lights humming, roommates, buzzers buzzing, pagers and telemetry machinery beeping, carts rolling in the hallways, and countless other sources of environmental noise. Indeed, many patients, especially older individuals, have trouble resting and sleeping in a strange environment in the first place, and this constraint is severely exacerbated during periods of medical crisis, especially in noisy hospital wards. In this regard, Sheldan and Belan (2009) emphasize that, "Complaints from patients about disrupted and unrefreshed sleep in the noisy hospital setting at night, may be expected by nurses. Physical, environmental and psychological factors [cause] sleep disturbances in older adults in hospital environments" (p. 20). In fact, patient lengths of stay in critical care wards can be extended unnecessarily because of a lack of rest and sleep (Sheldan & Belan, 2009).

The VA Medical Center in Oklahoma City is a tertiary healthcare facility that is no exception to the pattern of noisy critical care wards that exists across the country. This healthcare facility has medical and surgical intensive care units that are constantly filled with patients who are experiencing a wide range of healthcare issues. When patients convalescing from surgical procedures or medical interventions do not receive sufficient rest, their recovery can be delayed, their hospitalization extended and their clinical outcomes can be adversely affected. For example, Lambie (2007) reports that, "Peace and quiet and sleep are essential in the healing process and those who do not get enough sleep take longer to recover. They need more drugs and in the long run it could cost more for the hospital" (p. 23). Moreover, patients that need their rest and sleep the most may be the most adversely impacted by noisy hospital wards. As Neergaard (2012a) points out:

The beeping monitors, the pagers and phones, the hallway chatter, the roommate, and even the squeaky laundry carts all make for a not-so-restful place to heal. In fact, the wards with the sickest patients - the intensive care units - can be the loudest. (p. 8)

Although some sources of noise in the healthcare setting are unavoidable, many of these sources of noise can be eliminated or mitigated to provide patients with the restful environment they need to recuperate and be discharged. For example, a noise-reduction team at Stanford Hospital evaluated the sources of noise in their facility and determined that although some environmental sources of noise could not be realistically eliminated, there were some straightforward steps they could take to reduce noise levels on critical care wards.

Among the steps taken at Stanford Hospital to reduce noise levels were posters placed at all nursing stations and patient unit doors with a classic stylized finger-on-lips graphic encouraging everyone to be as quiet as possible (see Figure 1 below) (Rogers, 2009).

Figure 1. Sample "Shhh!" poster at Stanford Hospital

Source: http://news.stanford.edu/news/2009/may27/gifs/noise_600web.jpg

Because resources at the VA are limited, the intervention developed by Ms. West and her team (described further below) was required to be as cost-effective as possible. To this end, a comparable program was implemented at the OKC VAMC where the graphic arts department prepared inexpensive posters for posting at all critical care ward nursing stations reminding staff and patients of the need to keep noise at absolute minimum levels and highlighting the purpose of the intervention. In addition, the nursing staff at the OKC VAMC distributes earplugs for patients who complained about noise levels to help them get the rest they need to convalesce. In addition, all nursing staff was instructed to routinely remind patients and visitors about the need to keep noise levels at absolute minimums.

A process for conducting the investigation

An interview with Jennie West, an advanced practice nurse with the Department of Veterans Affairs Medical Center in Oklahoma City (hereinafter alternatively "the medical center" or "OKC VAMC") and director of nursing was conducted to formulate a process for conducting this investigation, and the results were as follows.

How was the problem identified? Ms. West indicated that she had received numerous reports from her nursing staff as well as complaints from patients in recent months concerning the high level of noise on the medical center's intensive care units that was preventing restful sleep. Because measuring patient satisfaction levels is mandated by the Joint Commission, Ms. West emphasized the need to improve the quality of care being provided by reducing the amount of noise being generated on the hospital's critical care wards.

What collaborations were needed to solve the problem? Although many sources of noise are environmental and are intractable to easy resolutions, other sources of noise include the multidisciplinary staff that work in intensive care units, including support and custodial staff. Therefore, collaboration with all stakeholders in the medical center was required to effect meaningful changes in the manner in which healthcare professionals and support staff performed their duties in order to identify opportunities to noise reduction on critical care wards.

What was the impact of the solution on the organization and what would the impact have been if the problem had not been resolved? According to Ms. West, old habits die hard and effecting changes in healthcare routine are more challenging than many observers might believe. Despite these constraints, Ms. West emphasized that eliminating unnecessary sources of noise was just good patient care and the initiative had succeeded in reducing length of stays for critical care patients by an average of 28 hours compared to the previous year's levels. It is reasonable to suggest, Ms. West stated, that absent the intervention to reduce noise levels, this reduction in length of stays would not have been achieved and the rate might have actually increased.

What was the plan and what was the thought process that went into constructing the plan to resolve the problem? Besides conducting a review of the relevant literature to identify comparable interventions in other healthcare facilities, Ms. West indicated that she inspected each critical care ward under her supervision to identify potential noise sources that could be eliminated or mitigated. In addition, she solicited feedback from nursing and housekeeping staff to identify other potential noise sources that could be addressed in a cost-effective fashion.

What resources can I seek out to help me gather data? Empirical observations can provide valuable data concerning potential noise sources on hospital wards, and respective noise levels on different wards can be measured using sound level meters that accurately gauge decibel levels. In addition, interviews with patients who have complained about noise on their wards can help identify specific noise sources.

How can I participate in or observe implementation team meetings? Besides Ms. Smith, other key stakeholders that can provide valuable data for improving the effectiveness of this intervention include patients who have experienced disruptions in their sleep due to noise, building management professionals who can provide guidance concerning mitigating noise sources, as well as nursing and support staff who have personal experience with the working conditions on the various critical care wards.

Part B: Summary of Identified Organizational Change and Affected Patient Population

Section I: Activity Selection and Methodology

A. Rationale. This intervention is important to practitioners and patients because it can improve the quality of patient care and many of the sources of noise on hospital critical care wards are amenable to mitigation (Sheldan & Belan, 2009). An initiative at Stanford Hospital entitled "SHHH" ("Silent Hospitals Help Healing") was designed to eliminate as many sources of noise on critical care wards as possible. Nursing staff surveyed each ward with a decibel meter to identify noise levels and sources. According to Rogers (2009), "The causes of noise at the hospital were legion. Service carts rattled over threshold strips, HVAC units wheezed, water pipes burped, helicopters landed and took off, telephones rang, voices rose at nursing stations" (para. 3). Other sources of noise identified in this intervention included healthcare providers typing on computer keyboards, IV alarms and the sounds produced by various monitors (Rogers, 2009).

The clinical implications of high noise levels on critical care wards can be severe. For example, Patel, Chipman, Carlin and Shade (2008) emphasize that, "All body systems require an adequate amount of sleep to maintain proper function and any disruption in the sleep cycle can dramatically impair any or all of the body systems" (p. 309). For critical care patients, this issue can become life-threatening and demands the development of hospital policies and an organizational culture that place a high value on noise reduction wherever possible (Patel et al., 2008).

B. Quantifiable Measures. There are two main quantifiable measures of interest in this intervention as follows:

1. The average length of stay on each critical care ward. Historic data was used for benchmarking with a goal of reducing the average length of stay by 24 hours.

Quantifiable Measure #1:

Numerator: Targeted noise levels on each critical care ward as measured in decibels.

Denominator: Actual noise levels on each critical car ward as measured in decibels.

First measurement period dates: An initial noise level for each ward will be established and measured on a monthly basis thereafter.

Baseline Benchmark: A benchmark for each critical care ward was established

Source of benchmark: This benchmark was established using sound level meters.

Baseline goal: A 50% reduction in noise levels within a one-year period.

Quantifiable Measure #2:

Numerator: Targeted average length of stays on critical care wards.

Denominator: Actual average lengths of stays on critical care wards.

First measurement period dates: One month post-implementation and on a monthly basis thereafter.

Benchmark: Historic data concerning average length of stays on critical care wards.

Source of benchmark: Medical center quality assurance staff

Baseline goal: Reduction of lengths of stay on critical care wards by 24 hours within a one-year period.

C. Baseline Methodology.

C.1 Data Sources. Data sources for this intervention include the following:

Medical/treatment records

Administrative data:

Patient complaints

C.2 Data Collection Methodology. The data collection methodology for this intervention includes the following elements:

Medical/treatment record abstraction

Personal interviews

Internet

Other: (1) noise level meters; (2) current and past patient satisfaction surveys; (3) informal interviews with patients.

C.3 Data Collection Cycle.

Section II: Data / Results Table

#1 Quantifiable Measure:

Time Period: Monthly.

Measurement Covers: Noise levels on all OKC VAMC critical care wards.

Measurement: Noise levels using noise level meters.

Numerator: Targeted noise levels.

Denominator Rate or Results Comparison Benchmark Comparison: Actual noise levels measured on the respective wards.

#2 Quantifiable Measure:

Time Period: Monthly average lengths of stay on critical care wards.

Measurement Covers: The number of days spent on each critical care ward.

Measurement: The number of days spent on each critical care ward expressed in number of hours.

Numerator: Targeted lengths of stay on critical care wards.

Denominator Rate or Results Comparison Benchmark Comparison: Actual lengths of stays on critical care wards.

Section III: Analysis Cycle

A. Time Period and Measures That Analysis Covers.

Implemented in November 2014, the intervention at the OKC VAMC has not collected sufficient data to determine its effectiveness with any degree of reliability, but anecdotal accounts from nursing staff and interviews with patients confirm that "things seem quieter." A monthly evaluation of noise levels on each critical care ward and the average lengths of stay for each ward will be aggregated and compared to determine the efficacy of the intervention and additional opportunities for cost-effective remedies formulated.

B. Analysis and Identification of Opportunities for Improvement.

B.1 Quantitative analysis:

Comparison with the goal/benchmark

Each month's results were compared to benchmarks to determine progress, if any, towards the achievement of the respective goals of a 50% reduction in noise levels on OKC VAMC critical care wards and the reduction of patient lengths of stay by 24 hours.

Comparison with previous measurements

Each month's results are compared to previous measurements to determine if progress towards goal achievement is being made.

Impact of any methodological changes that could impact the results

B.2 Qualitative analysis

Techniques and data (if used) in the analysis

Noise levels on each critical care ward are measured by assigned nursing staff members using sound level meters on each shift each day. For instance, according to Powitz and Balsamo (1999), "A sound level meter is an extremely versatile device used to measure sound intensity in almost any acoustic environment. The device measures levels of sound pressure, which read as decibels (dB) on the meter" (p. 27). In addition, data concerning the patient lengths of stay on the various critical care wards was also used in the analysis to determine if the intervention had the desired effect on reducing the length of hospital stays on these nursing units.

Expertise (e.g., titles; knowledge of subject matter) of the work group or committees conducting the analysis

Although no specific training or expertise is required to use sound level meters, it was important for nursing staff members to record sound levels accurately and faithfully to provide the data needed to make an informed evaluated of the efficacy of the intervention. The following steps are used to ensure accurate noise level monitoring for each OKC VAMC critical care ward:

Sounds that are at least 10 dB louder than the background noise level are measured to ensure meaningful readings.

Nurses avoid operating the meter at a range setting that causes "pegging" of the needle (which can damage the movement) and always start monitoring at the highest setting and. work down the range selector until the needle begins to move.

When measuring sounds that come mainly from one direction, the reading may be significantly affected by reflections from the nurse's body so they avoid holding the meter close to their body and directly between them and the sound source because doing so can result in an error of several decibels in the frequency range above 100 hertz (Hz)). The meter is positioned so that an imaginary line between the nurse and the meter is perpendicular (90 degrees) to a line between the meter and the sound source and by pointing the microphone toward the sound source whenever possible (Powitz & Balsamo, 1999, p. 27).

Citations from literature identifying barriers

As noted throughout, some environmental sources of noise in tertiary healthcare facility settings are difficult to mitigate and in some instances, one source of noise can exacerbate other sources of noise. For example, Rogers (2009) points out that, "The alarms can't be turned off, and the noise can escalate from there. People talk more loudly to be heard over the alarms, and when a phone rings, you have to talk over that" (para. 5). In response, some hospitals have installed acoustic tiles to mitigate noise levels on critical care wards, but the primary sources of noise remain despite these efforts (Sheldan & Belan, 2009). Furthermore, the same innovations in healthcare that have provided improved patient care have introduced yet additional sources of noise in many tertiary healthcare settings. For instance, Bijwadia and Ejaz note that, "The ICU is geared towards specifically treating organ failures and providing a higher level of nursing care. However, these benefits come at substantial physiological and psychological discomfort to the patient" (p. 25). Moreover, the problem appears to be getting worse instead of better in many healthcare settings. According to the study, "The Inhospitable Hospital," "Healthcare just keeps getting noisier. The average daytime sound level in acute care hospitals grew from 57 decibels (dB) in 1960 to 72 dB in 2005. Nighttime noise is just as severe as daytime noise, and weekends are no quieter than weekdays" (2011, p. 1).

Irrespective of the country or specialty, surveys of critical care wards in recent years all confirm that noise levels exceed the levels recommended by the World Health Organization (Brindley, 2009). As shown in Table 1 and depicted graphically in Figure 2 below, the peak levels experienced in various settings can be significant:

Table 1

Sound levels in patient care environments

Patient Care Area

Average Sound Level

dB

Peak Sound Level

dB

Medical-surgical floor

56

96

Intensive care

56

80

Emergency department

61-69

Operating rooms

58-67

> 120

PACU

67

Pediatric intensive care

60-70

Neonatal intensive care

58-62

80

Source: The Inhospitable Hospital, 2011, p. 2

Figure 2. Sound levels in patient care environments

Source: Based on tabular data in The Inhospitable Hospital, 2011, p. 2

For comparison purposes, the sounds and approximate sound levels from other sources are provided in Table 2 below.

Table 2

Representative sounds and approximate sound levels

Sounds

dB (A)

Rocket launching

Jet engine, gunshot

Thunderclap

Jet takeoff (threshold of pain)

Rock concert, car horn

Firecracker, subway train

Heavy truck, lawnmower, blender

90

Alarm clock, hair dryer

80

Noisy restaurant, business office

70

Normal conversation

60

Light traffic, average home

50

Living room, quiet office

40

Library, soft whisper

30

Rustling leaves

20

Threshold of hearing

0

Source: The Inhospitable Hospital, 2011, p. 2

As can be seen from the data in Tables 1 and 2 above, the typical medical/surgical ward has peak sound levels higher than a lawnmower, heavy truck or blender, and peak sound levels on critical care wards are equivalent to an alarm clock. Furthermore, the peak sound level in post-anesthetic care units is the same as a thunderclap. Therefore, it is reasonable to suggest that even completely healthy people would have difficulty sleeping normally when exposed to these inordinately high sound levels.

In other cases, though, the sources of noise on critical care wards can be easily identified and resolved in a relatively straightforward and cost-effective fashion. For example, the University Hospital of Wales, Cardiff, recently purchased new trash cans that do not make noise when they are opened and closed which was a major source of irritation for patients on critical care wards, particular during the evening hours when they were accustomed to sleeping. In this regard, Brindley (2009) reports that, "The introduction of bins that do not make a noise when they close follows a research project in the critical care unit [that found] the noise created by bins constantly disturbed patients, especially in the night when they were trying to sleep" (p. 9). In fact, the sound levels that were generated by the previous trash cans were louder than ringing telephones, monitor alarms and conversations between staff around patient beds (Brindley, 2009).

Barriers/opportunities identified through the analysis

While some sources of noise are readily apparent and remedies are available, other sources of noise are an unfortunate concomitant of the healthcare setting itself. For instance, according to one authority, "The problem is all of the hard surfaces and right angles that reverberate, or reflect sound, and few surfaces that absorb it. Soft or sound-absorbent surfaces are not hospital friendly because they can harbor micro-organisms and are difficult to clean" (The Inhospitable Hospital, 2011, p. 2). Consequently, it is vitally important for nursing staff to identify all of the sources of noise to determine which ones can be addressed through cost-effective interventions.

One healthcare facility that is modeling the way for others in promoting noise reduction strategies for its critical care wards is Montefiore Medical Center in Bronx, New York (Walker, 2007). This iinnovative healthcare facility has embraced quietness as a matter of course in its delivery of critical care services. For instance, Walker (2007) reports that, "It is not uncommon to hear, well, hardly anything. Doctors, nurses, technicians and other workers shuffle back and forth with nearly silent carts, and conversations among the staff are held at almost whisper levels" (para. 2).