Hospital noise can affect patients adversely, largely because it keeps them from sleeping. Controlling hospital noise is an integral part of the Joint Commission’s Environment of Care (EC) standards. Standard EC.8.10 (in EPs 5–7) addresses lighting, temperature, and odors, strongly implying the full range of sensory elements. Standard EC.8.30, EP 3, which deals with maintaining the health care environment during construction, specifically mentions noise and vibration.
“One of our major goals is to make the healing environment less intrusive for the patient,” says Bruce Morgan, an environment of care consultant for Joint Commission Resources. “Noise is certainly part of the EC standards.”
Pinpointing Noise Sources
Recently, caregivers at Saint Marys Hospital, a 1,100-bed facility in Rochester, Minnesota, demonstrated an effective approach to identifying and reducing sources of hospital noise. Noise reduction efforts at Saint Marys, which is affiliated with the Mayo Clinic, started about five years ago. At that time, nurses in the surgical thoracic intermediate care unit began to focus on the issue of patient sleep. Inability to sleep at night, they noticed, made it hard for patients to take part in rehabilitation activities during the day. “Breathing exercises, coughing exercises, simply walking around—patients weren’t feeling like they had the energy to do this,” says Cheryl Cmiel, B.A.N., R.N., a thoracic care staff nurse. In response, the unit formed a continuous improvement team aimed at helping patients get more rest.
The project team, which consisted of several nurses from the thoracic care unit, began by identifying sources of sleep-disrupting noise. Using a noise dosimeter, team members measured nighttime sound levels in the unit. In addition, two nurses from the team spent a night in one of the unit’s semiprivate rooms to experience hospital noise first-hand. The team also talked to patients themselves, asking them what noises made it hard to fall asleep and stay asleep. Cmiel says some of their answers were surprising: “We learned things we would not necessarily have found out on our own.”
After gathering data, the team generated a list of several sources of nighttime noise. At the top of the list was bedside monitors. Cmiel notes that although monitor alarms in the thoracic care unit were equipped with volume control, this option had been deactivated. To address the problem, team members had technical staff activate the volume control capability, giving nurses the choice of setting monitor alarms at high, medium, or low. “We still had alarms outside patient rooms in multiple locations,” says Cmiel. “But now we could set the in-room alarms quieter if we needed to.”
The team also encouraged staff nurses to individualize alarm settings for different patients. “For example, if a patient has a normally fast heart rate, you can adjust the monitor setting so that the alarm is not constantly going off,” says Cmiel.
Hospital carts were another source of disruptive noise. The project team’s strategy was to enlist a group of troubleshooters from Mayo’s division of engineering. Step one for the engineering group was identifying all the types of carts used in the hospital. “In two hours, our people cataloged 44 different types of carts and did noise measurements,” says Kevin Bennet, division chairman. The investigators found that the noisiest units were the dietetics carts, which were also the ones on the floor most often.
“We then came up with some modifications, costing about $200 per cart, that reduced the sound you hear by 75%,” says Bennet. The engineering team also created a preventive maintenance plan for the dietetics carts and developed a proposal for identifying noise problems with other cart types.
Not every intervention required technical support. For example, the project team identified simple fixes for several noise sources, including the following:
- Pneumatic tube delivery canisters—Maintenance staff installed foam padding to muffle the impact of canisters arriving in the delivery receptacle.
- Chart holders outside patient rooms—Foam padding effectively dampened this consistent source of noise.
- Paper towel dispensers—Noisy roll dispensers were replaced with quiet flat-paper dispensers.
While changes to equipment were important, modifications to clinical procedures were a big part of the project team’s noise reduction strategy. An example is the way the team dealt with the noise of portable x-ray machines rolling into the unit at 3 A.M. “We did nothing with the machines themselves,” says Cmiel. “Instead, our approach was, ‘How can we work with what we have?’ ” Thoracic surgeons cooperated with the initiative by reevaluating which early-morning chest x-rays were needed on a routine basis.
Reducing the number of nighttime x-rays yielded promising results. The care team eventually found that moving the routine test time to 10 P.M. made the process easier for both patients and radiology staff and did not adversely affect outcomes.
Noise from IV pumps—bag alarms and beeping key pads—also called for a procedure-based approach. The project team trained nurses to place one hand over the pump’s speaker when keying in new settings. It also encouraged staff members to head off alarms when possible, by returning to replace an IV a few minutes before the bag is empty.
The team put several additional measures in place to create “quiet zones” during nighttime hours—posting reminder signs at stairwell entrances, lowering lights, and closing one of the sets of doors that lead to the area. “These changes helped increase awareness for those people who might just be walking through the unit,” says Cmiel. In addition, nurses became careful to close patient room doors and began using flashlights when entering rooms at night. To reduce the noise at shift changes, staff reports were moved from the nurses’ desk to an enclosed room.
Working with Others
Cmiel says working with other departments was essential for reducing many noise sources. She and her team colleagues detailed several such initiatives in a paper published in the American Journal of Nursing (Feb. 2004). For example, project team members found that housekeeping staff routinely used the thoracic care unit as a shortcut to other parts of the hospital. Communication with the housekeeping supervisor largely took care of this issue. The team also found that supply staff restocked the thoracic care area daily between 3 and 4 A.M. By working with that department, team members were able to reschedule routine supply deliveries to an evening time slot. This simple change removed another source of night-shift noise.
Multidisciplinary staff meetings proved very effective for finding solutions to noise issues. “We involve everyone who affects patient care on a daily basis,” says Cmiel. The team used multidepartment meetings to share project findings and brainstorm noise control strategies. “The things surgeons come up with may be totally different from what the nurses think of,” she notes. “It needs to be a team effort, instead of one group doing something and expecting all others to follow.”
Cmiel says one of the best ways to reduce noise is simply to make staff members more aware of the issue. “It’s important to become attuned to how loudly or softly we talk, how we carry out our activities,” she says. “Staff education is the biggest thing we can do.”
Spreading the News About Noise
Measurements taken after intervention showed a significant reduction in noise levels in the thoracic care unit. In addition, patient surveys have gathered positive feedback on nighttime noise and the ability to sleep. Since the conclusion of the noise control initiative, project team members have concentrated on developing an awareness of noise issues among new staff. The team has also worked to spread information about the noise reduction process to other nursing units at Saint Marys as well as Rochester Methodist Hospital, the other Mayo hospital in town. Cmiel believes this has helped back up noise control efforts in the thoracic care unit.
“By taking a hospitalwide approach, we feel we get better compliance from all nursing units.”
This article is an exact reprint from Environment of Care® News, June 2005, Volume 8, Issue 6. Call (630) 268-7469 to subscribe.