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...

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…