Reducing length of stays in VA critical care wards through noise reduction

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

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).

Impact of interventions

There remains a paucity of timely and relevant studies concerning the impact of noise-reduction interventions in hospitals in general and critical care wards in particular. In this regard, Hardin (2009) reports that, "High-level evidence regarding the effect of sleep deprivation on recovery from acute illness or the morbidity and mortality in ICU patients remains to be described" (p. 284). What is known for certain is that sleep disturbances due to environmental noise sources represent a serious problem for healthcare providers and patients alike. In this regard, Hultman and Coakley (2012) advise that, "Sleep is a complex physiologic process that is not fully understood. However, the effects of sleep disturbance in the hospitalized population are well documented" (p. 135).

It is also well documented that the delivery of critical care can be highly disruptive to normal sleeping patterns. For example, Stanzak (2006) reports that, "Sleep deprivation is often a direct result of the need for intensive care, continuous surveillance and monitoring which affords very little opportunity for uninterrupted sleep" (p. 94). Likewise, Freedman, Gazendam and Levan (2001) also cite the dearth of relevant studies in this area but point out that, "Environmental stimuli are proposed to be the most disruptive factors to achieving sleep in the ICU. The environmental stimulus most often cited in the literature to disturb sleep is noise" (p. 451).

Although there is a growing body of evidence concerning the impact of noisy environments on patient care, it remains less clear which sources of noise are most responsible for disturbing the sleep of critical care patients. For instance, according to Neergaard (2012b), "Patient satisfaction surveys are packed with complaints that the clamor makes it hard to sleep. Yet remarkably little is known about exactly how that affects patients' bodies -- and which types of noises are the most disruptive to shut-eye" (p. 3). As noted above, though, any type of noise can be highly disruptive to rest and sleep for critical care ward patients. The definition of noise provided by Wenham and Pittard (2009) confirms that it is "any unwanted or undesirable sound which is subjectively annoying or disrupts performance and is physiologically and psychologically stressful" (p. 178).

Further complicating the evaluation of the effectiveness of noise-reduction strategies on critical care wards is the fact that noise sources are inextricably interrelated to patient care protocols as well as a general lack of awareness on the part of staff and visitors concerning the need for quiet in these healthcare settings. As a result, there is a need for a reshaping of the organizational culture in critical care units to embrace noise reduction as a priority. In this regard, Friese (2008) points out that, "Physicians and ICU directors must develop and put into practice protocols for sleep promotion. Nursing staff and other bedside care providers must carefully follow these protocols. ICU monitoring practices must change" (p. 146).

The impact of interventions that are designed to reduce noise levels on critical care wards can be reasonably expected to have a corresponding impact on the quality of patient care that is being provided and the ability of patients to convalesce. For example, Wenham and Pittard (2009) report that:

In general, patients in critical care units may spend 30 -- 40% of their sleep time awake, sleep may be highly fragmented and distributed throughout the day and night, and there is a reduction in slow wave and REM sleep. There may even be a complete absence of definable sleep or wake states in septic patients (emphasis added). (p. 180)

Taken together, it is clear that the impact of interventions targeted at noise reduction on critical care wards can have a highly positive effect on patient care and can be effective in reducing patient lengths of stay. Indeed, according to Lambie (2007), "Noise is a major problem. Anything which reduces noise levels is good as it is intense in hospitals. It is like being in a factory and when you are trapped in a bed feeling ill, it must be terrible" (p. 23).

Section IV: Interventions Table

The interventions that have been taken for improvement as a result of the analysis of the collected data at the OKC VAMC are set forth in Table 2 below.

Table 2

Interventions implemented at the OKC VAMC for noise abatement

Intervention

Date Implemented

Status

Purchased six sound level meters and distributed to all nursing stations on critical care wards

November 15, 2014

Ongoing (daily by shift)

Designed posters and distributed to all critical care nursing stations; new posters are currently being designed.

December 1, 2014

Ongoing (periodic)

Informal patient interviews are being conducted to assess patient perceptions of noise levels

December 15, 2014

Ongoing

Noise reduction strategies are discussed at nursing staff meetings

December 15, 2014

Ongoing (monthly)

Environmental design specialists consulted to identify potential building design modifications that can be implemented to reduce noise levels (carpeting was considered but eliminated due to difficulties in cleaning but different window blinds in patient rooms are being considered).

January 5, 2015

TBD