Reducing Length of Stays in VA Critical Care Through Noise Reduction

Problem Statement and Background

The Department of Veterans Affairs (VA) operates the nation's largest healthcare system and provides training for more than half of all physicians practicing in the United States. Based on its mission, drawn 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 highest quality medical care to veteran patients. One significant issue affecting patient care quality is sleep disruption on critical care wards due to high levels of environmental noise. Noise levels on many critical care wards are equivalent to those produced by a lawnmower or blender, and many patients report difficulties obtaining sufficient sleep while recovering from surgical procedures or medical interventions. In response, the Oklahoma City VA Medical Center, along with a growing number of hospitals across the country, has implemented a noise-reduction initiative designed to reduce noise levels on its critical care wards and improve patient outcomes.

Hospitals are notoriously noisy environments, particularly on critical care wards where patients cannot obtain adequate sleep due to constant disturbances from staff conversations, fluorescent lighting hums, roommates, equipment buzzers, pagers, telemetry machinery beeping, carts rolling in hallways, and countless other sources of environmental noise. Many patients, especially older individuals, struggle to rest in an unfamiliar hospital environment, and this challenge is severely exacerbated during medical crises in noisy intensive care settings. According to Sheldan and Belan (2009), "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). Research indicates that patient lengths of stay in critical care wards can be extended unnecessarily because of inadequate rest and sleep. As Lambie (2007) reports, "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).

Change Investigation Process

Patients requiring rest and sleep the most may be those most adversely affected 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 noise sources are unavoidable in healthcare settings, many can be eliminated or mitigated to provide patients with the restful environment necessary for recovery and discharge.

An interview was conducted with an advanced practice nurse and director of nursing at the Oklahoma City VA Medical Center (hereinafter referred to as "OKC VAMC") to formulate an investigation process. The nurse indicated that she had received numerous reports from nursing staff and complaints from patients in recent months concerning high noise levels on the intensive care units that prevented restful sleep. Because measuring patient satisfaction levels is mandated by the Joint Commission, improvement of care quality through noise reduction was identified as a priority.

Solving this problem required collaboration with all stakeholders in the medical center. While many sources of noise are environmental and difficult to address, others involve the multidisciplinary staff working in intensive care units, including support and custodial staff. Meaningful changes required identifying opportunities for noise reduction across all personnel and departments. According to the director of nursing, old habits die hard and effecting changes in healthcare routines proves more challenging than many observers might anticipate. Despite these constraints, eliminating unnecessary noise sources was recognized as simply good patient care. The initiative has succeeded in reducing length of stays for critical care patients by an average of 28 hours compared to the previous year's levels.

Organizational Change and Patient Population

To develop the plan, the director of nursing conducted a comprehensive review of relevant literature to identify comparable interventions at other healthcare facilities and personally inspected each critical care ward under her supervision to identify potential noise sources that could be eliminated or mitigated. She also solicited feedback from nursing and housekeeping staff to identify additional potential noise sources that could be addressed cost-effectively. Data collection methods include empirical observations of noise sources, sound level measurements using decibel meters, and interviews with patients who have experienced sleep disruptions due to noise. Key stakeholders for ongoing improvement include patients who have experienced sleep disruptions, building management professionals, and nursing and support staff with direct experience on critical care wards.

A comparable program at Stanford Hospital, called "SHHH" (Silent Hospitals Help Healing), included posters placed at nursing stations with a stylized finger-on-lips graphic encouraging staff to keep noise at minimal levels. At the OKC VAMC, the graphic arts department prepared inexpensive posters for all critical care ward nursing stations, reminding staff and patients of the need to minimize noise and highlighting the intervention's purpose. Additionally, nursing staff distribute earplugs to patients complaining about noise, and all nursing staff were instructed to routinely remind patients and visitors about maintaining minimal noise levels.

This intervention is important to practitioners and patients because it can improve care quality and many noise sources on hospital critical care wards are amenable to mitigation. As noted in the literature, the clinical implications of high noise levels on critical care wards can be severe. 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 organizational culture that prioritize noise reduction.

Two main quantifiable measures were established for this intervention: the average length of stay on each critical care ward and noise levels measured in decibels. Historic data was used for benchmarking with a goal of reducing average length of stay by 24 hours. For noise level measurement, the baseline benchmark was established using sound level meters, with a goal of achieving 50 percent reduction in noise levels within one year. For average length of stay, the benchmark was established using historic data from medical center quality assurance staff, with the goal of reducing lengths of stay by 24 hours within one year.

Data sources for this intervention include medical and treatment records, administrative data, and patient complaints. The data collection methodology includes medical record abstraction, personal interviews, and the use of noise level meters, current and past patient satisfaction surveys, and informal patient interviews. Measurements occur monthly, covering noise levels on all OKC VAMC critical care wards using noise level meters, and the number of days spent on each critical care ward expressed in hours.

Barriers and Literature Review

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

Sound levels in healthcare environments significantly exceed recommended standards. According to comparative data, peak sound levels on medical-surgical floors reach 96 decibels, while intensive care units peak at 80 decibels. Post-anesthetic care units experience peak levels of 130 decibels. For context, these levels approximate a thunderclap (130 dB), a heavy truck or lawnmower (90 dB), and an alarm clock (80 dB). The typical medical-surgical ward has peak sound levels higher than a lawnmower, heavy truck, or blender. Therefore, even completely healthy people would have difficulty sleeping normally when exposed to such inordinately high sound levels.

According to research titled "The Inhospitable Hospital" (2011), healthcare environments are becoming progressively noisier. "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" (p. 1). Surveys of critical care wards in recent years confirm that noise levels exceed the levels recommended by the World Health Organization. Sources of noise in tertiary healthcare facilities are diverse and complex. As Rogers (2009) reports from Stanford Hospital's investigation, "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 identified include healthcare providers typing on computer keyboards, IV alarms, and sounds from various monitors.

Some environmental sources of noise in tertiary healthcare facility settings are difficult to mitigate. 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). Some hospitals have installed acoustic tiles to mitigate noise levels, but primary noise sources often persist. Furthermore, innovations in healthcare that have provided improved patient care have simultaneously introduced additional noise sources. As Bijwadia and Ejaz note, "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).

However, some noise sources can be readily identified and resolved in cost-effective ways. The University Hospital of Wales, Cardiff, recently purchased new trash cans that do not make noise when opened and closed, addressing a major source of patient irritation on critical care wards, particularly during evening hours. 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). Sound levels generated by previous trash cans were louder than ringing telephones, monitor alarms, and staff conversations around patient beds.

While some noise sources are readily apparent and remedies are available, others are inherent to healthcare settings themselves. As one authority notes, "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, identifying all noise sources to determine which can be addressed through cost-effective interventions is vitally important.

One healthcare facility modeling effective noise reduction strategies is Montefiore Medical Center in Bronx, New York. This innovative facility has embraced quietness as a matter of course in critical care delivery. 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).

To ensure accurate noise level monitoring, specific protocols must be followed. A sound level meter is a versatile device used to measure sound intensity in acoustic environments by measuring sound pressure levels, which read as decibels (dB) on the meter. Although no specific training or expertise is required to operate sound level meters, accurate and faithful recording by nursing staff is essential to provide data needed for informed evaluation of intervention efficacy. Steps to ensure accurate monitoring include measuring sounds at least 10 dB louder than background noise to ensure meaningful readings, avoiding meter positioning that causes needle pegging (which can damage the instrument), and positioning the meter perpendicular to the sound source to avoid body reflections that can result in errors of several decibels in frequency ranges above 100 hertz (Hz).