Official Newsletter of the Centre for Patient Safety Solutions

Welcome to the first issue of Collaborations: The Official Newsletter of the WHO Collaborating Centre for Patient Safety Solutions. We hope this quarterly electronic publication will be a useful resource for keeping you informed of the progress of the WHO Collaborating Centre for Patient Safety Solutions.  The newsletter will be sent via email four times each year, with special issues as needed.

A note to readers: You are receiving this electronic newsletter because you have been a subscriber of Patient Safety Link, which will resume publication in another form in October 2008. If you do not wish to receive Collaborations in the future, send an email with “cancel” in the subject line.

Collaborations replaces Patient Safety Link as the official newsletter of the WHO Collaborating Centre for Patient Safety Solutions.  As you may recall, the World Health Organization (WHO) designated the United States–based accreditation body, The Joint Commission, as well as its global subsidiary, Joint Commission International (JCI) as the Collaborating Centre for Patient Safety Solutions in 2005.  Recognized as leaders in patient safety, The Joint Commission and JCI promote and provide for the delivery of safe, high-quality care in part through the following initiatives (click on each title for more information):

  • Health care accreditation standards developed by the Joint Commission and Joint Commission InternationalSentinel Event Database
  • Sentinel Event Alert —a call to action to correct a serious patient safety problem
  • Speak UpTM programs to empower patients
  • National Patient Safety Goals
  • International Patient Safety Goals

JCI promotes health care quality and safety through international accreditation, domestic and international consulting, education, and publications. Both The Joint Commission and JCI are not-for-profit organizations.  As the only WHO Collaborating Centre dedicated solely to patient safety, the Joint Commission and JCI further advance the entire continuum of patient safety including principles related to system design and redesign, product safety, safety of services, and environment of care, as well as offering proactive solutions for patient safety, whether based on empirical evidence, hard research, or best practices.

Next President of The Joint Commission

(OAKBROOK TERRACE, Ill. – August 1, 2007)  The Board of Commissioners of The Joint Commission today announced the appointment of Mark R. Chassin, M.D., M.P.P., M.P.H., to lead The Joint Commission as its next President. The appointment is effective January 1, 2008.

Dr. Chassin is the Edmond A. Guggenheim Professor of Health Policy and Chairman of the Department of Health Policy at Mount Sinai School of Medicine, New York, and Executive Vice President for Excellence in Patient Care at The Mount Sinai Medical Center. Prior to joining Mount Sinai, Dr. Chassin served as Commissioner of the New York State Department of Health. He is a board-certified internist and practiced emergency medicine for 12 years.  His background also includes service in the federal government and many years of health services and health policy research. He is a member of the Institute of Medicine of the National Academy of Sciences and co-chaired its National Roundtable on Health Care Quality.

While at The Mount Sinai Medical Center, Dr. Chassin built a nationally recognized quality improvement program which focuses on achieving substantial gains in all aspects of quality of care, encompassing safety, clinical outcomes, the experiences of patients and families, and the working environment of caregivers. In addition, Dr Chassin has led successful efforts to introduce Six Sigma quality improvement methods in Mount Sinai’s hospital and medical school, using them to enhance both patient safety and the efficiency of operations.  His research during his 12 years at Mount Sinai has focused on developing health care quality measures; using those measures in quality improvement; and understanding the relationship of quality measurement and improvement to health policy.  More recently, he has expanded his research program to include a number of intervention trials that concentrate on reducing racial and ethnic disparities in health and health care. 

In 2001, Dr. Chassin was recognized for his contributions to the fields of quality measurement and improvement with several honors. He was selected in the first group of honorees as a lifetime member of the National Associates of the National Academies, a new program of the National Academy of Sciences recognizing career contributions to the National Academies. He also received the Founders Award of the American College of Medical Quality and the Ellwood Individual Award of the Foundation for Accountability.

"Mark Chassin is a leading force in patient safety and quality as demonstrated in his long, distinguished career in the public and private sector," says David L. Nahrwold, M.D., Chairman of the Joint Commission Board of Commissioners. "The Board of The Joint Commission has the utmost confidence in his ability to lead The Joint Commission with intelligence and vision as the organization continues its mission to continuously improve the safety and quality of care provided to the public."

"Mark Chassin is a superb choice to guide The Joint Commission into the future," says Dennis S. O’Leary, M.D., current Joint Commission President. "His wealth of knowledge and experience in health care and his personal priority for patient safety and health care quality portend a smooth and seamless leadership transition for this organization."

"I am very excited about the opportunity to lead The Joint Commission because of my life-long passion for quality improvement and patient safety," says Dr. Chassin. "The Joint Commission is transforming health care through its accreditation process and other programs to help health care organizations provide safe, high quality care for all Americans. I look forward to working with Dennis O’Leary to ensure a smooth transition.  He has provided outstanding leadership to The Joint Commission for so many years."

Dr. O’Leary, who has led The Joint Commission for the past 21 years, will become President Emeritus of The Joint Commission on January 1, 2008.

Dr. Chassin received his undergraduate and medical degrees from Harvard University, Cambridge, MA, and a master’s degree in public policy from the Kennedy School of Government at Harvard. He also holds a master’s degree in public health from the University of California at Los Angeles.

Facts about the Centre

In 2005, WHO designated The Joint Commission and Joint Commission International as its Collaborating Centre on Patient Safety Solutions.  The Joint Commission International Center for Patient Safety operationalized this effort by identifying widespread problems and challenges to safe care, identifying promising solutions, and vetting them through an extensive field review process that garnered feedback from health care providers, practitioners, and other experts from more than 100 countries.

The Patient Safety Solutions were developed with the assistance of an International Steering Committee of patient safety experts and patient representatives, as well as Regional Advisory Councils in Europe, the Middle East, and the Asia-Pacific region.  A major international field review of the proposed solutions was also conducted to gather feedback from leading patient safety entities, accrediting bodies, ministries of health, international health professional organizations and practitioners, patients, and other experts.

"These Patient Safety Solutions were designed through a truly international collaborative effort, and represent what has been learned internationally about where, how and why certain adverse events occur.  A critical component of their development has involved inclusion of input from patients and their families who have experienced preventable harm."

Recognized as a leader in patient safety, The Joint Commission promotes and provides for the delivery of safe, high-quality care through its standards, sentinel event database, Sentinel Event Alert, Speak UpTM programs and, most recently, its National Patient Safety Goals.  Joint Commission Resources (JCR), or as it is known internationally, Joint Commission International (JCI), promotes health care quality and safety through international accreditation, domestic and international consulting, education and publications. Both the Joint Commission and JCR/JCI are not-for-profit organizations.  As the only WHO Collaborating Centre dedicated solely to patient safety, the Joint Commission and JCR/JCI further advance the entire continuum of patient safety including principles related to system design and redesign, product safety, safety of services, and environment of care, as well as offering proactive solutions for patient safety, whether based on empirical evidence, hard research or best practices.

Web Site Links for Government and Business Leaders

Joint Commission on Accreditation of Healthcare Organizations An independent, not-for-profit organization that evaluates and accredits more than 15,000 health care organizations and programs in the United StatesJoint Commission Resources (JCR)Global, knowledge-based organization which disseminates information regarding accreditation, standards development and compliance, good practices, and health care quality improvementJoint Commission International (JCI)Helps to improve the quality of patient care internationallyAgency for Healthcare Research & Quality (AHRQ) Agency of the U.S. Department of Health and Human Services charged with supporting the improvement of quality healthcare, reducing costs, improving patient safety, decreasing medical errors, and broadening access to essential services AHRQ Patient Safety Network (PSNet)Web site resource featuring news and essential resources on patient safety American Hospital Association (AHA) A national organization that represents and serves hospitals, health care networks, and their patients and communities Food and Drug Administration (FDA)Responsible for protecting the public health by assuring the safety, efficacy, and security of human and veterinary drugs, biological products, medical devices, our nation’s food supply, cosmetics, and products that emit radiation Institute for Healthcare Improvement (IHI) A not-for-profit organization driving the improvement of health by advancing the quality and value of health careInstitute of Medicine (IOM) Serves as an independent, scientific adviser to improve health and to provide advice that is unbiased, based on evidence, and grounded in scienceInternational Society for Quality in Health Care (ISQua)A non-profit, independent organization working to provide services to guide health professionals, providers, researchers, agencies, policy makers and consumers to achieve excellence in healthcare delivery to all people, and to continuously improve the quality and safety of careThe Leapfrog GroupInitiative driven by organizations that buy health care who are working to initiate breakthrough improvements in the safety, quality and affordability of healthcare for AmericansNational Committee for Quality Assurance (NCQA) Premier source for information about the quality of the nation’s managed care plansNational Patient Safety Agency (NPSA) Coordinates the efforts to report, and more importantly to learn from mistakes and problems that affect patient safetyNational Patient Safety Foundation A resource for individuals and organizations committed to improving the safety of patients Partnership for Patient Safety Patient-centered initiative to advance the reliability of healthcare systems worldwideWorld Health Organization (WHO)The United Nations specialized agency for health

Web Site Links for Health Care Professionals & Providers

Joint Commission on Accreditation of Healthcare Organizations An independent, not-for-profit organization that evaluates and accredits more than 15,000 health care organizations and programs in the United StatesJoint Commission Resources (JCR)Global, knowledge-based organization which disseminates information regarding accreditation, standards development and compliance, good practices, and health care quality improvementJoint Commission International (JCI)Helps to improve the quality of patient care internationallyAgency for Healthcare Research & Quality (AHRQ) Agency of the U.S. Department of Health and Human Services charged with supporting the improvement of quality healthcare, reducing costs, improving patient safety, decreasing medical errors, and broadening access to essential services AHRQ Patient Safety Network (PSNet)Web site resource featuring news and essential resources on patient safety Advances in Patient Safety: From Research to Implementation (Compendium sponsored by the Agency for Healthcare Research and Quality (AHRQ) and the Department of Defense (DoD)-Health Affairs)Describes what federally funded programs have accomplished in understanding medical errors and implementing programs to improve patient safety American Hospital Association (AHA) A national organization that represents and serves hospitals, health care networks, and their patients and communities American Medical Association (AMA) Physicians dedicated to the health of AmericaCenter for Disease Control (CDC) Principal agency of the US government protecting health and safety and providing essential human servicesFood and Drug Administration (FDA)Responsible for protecting the public health by assuring the safety, efficacy, and security of human and veterinary drugs, biological products, medical devices, our nation’s food supply, cosmetics, and products that emit radiation Institute for Healthcare Improvement (IHI) A not-for-profit organization driving the improvement of health by advancing the quality and value of health careInternational Society for Quality in Health Care (ISQua)A non-profit, independent organization working to provide services to guide health professionals, providers, researchers, agencies, policy makers and consumers to achieve excellence in healthcare delivery to all people, and to continuously improve the quality and safety of careThe Kenneth B. Schwartz CenterDedicated to strengthening the relationship between patients and caregiversThe Leapfrog GroupInitiative driven by organizations that buy health care who are working to initiate breakthrough improvements in the safety, quality and affordability of healthcare for AmericansMassachusetts Coalition on Prevention of Medical Errors Disseminates knowledge and information about the causes of sentinel events and develop strategies for preventionNational Committee for Quality Assurance (NCQA) Premier source for information about the quality of the nation’s managed care plansNational Patient Safety Agency (NPSA) Coordinates the efforts to report, and more importantly to learn from mistakes and problems that affect patient safetyNational Patient Safety Foundation A resource for individuals and organizations committed to improving the safety of patients National Quality Forum A private, not-for-profit membership organization created to develop and implement a national strategy for healthcare quality measurement and reportingPartnership for Patient Safety Patient-centered initiative to advance the reliability of healthcare systems worldwidepatientINFORMAn online service that provides patients and caregivers access to up-to-date, reliable and important research available about the diagnosis and treatment of specific diseasesUnited States PharmacopeiaPublic standards-setting authority for all prescription and over-the-counter medicines, dietary supplements, and other healthcare products manufactured and sold in the United StatesWorld Health Organization (WHO)The United Nations specialized agency for health2006 Medical Product Safety AlertsMed Watch – The FDA Safety Information and Adverse Event Reporting ProgramThe Patient Safety GroupHealth Care Organizations Empowered to Communicate, Collaborate, Improve and Share

Web Site Links for Patients and Families

Joint Commission on Accreditation of Healthcare Organizations: Quality Check A comprehensive guide to the more than 15,000 Joint Commission-accredited health care organizations and programs throughout the United States Joint Commission on Accreditation of Healthcare Organizations: Report a Complaint Report a complaint about the quality of care at a Joint Commission-accredited health care organization Joint Commission International: Report a Complaint Report a complaint about the quality or safety of care at a Joint Commission International accredited organization Agency for Healthcare Research & Quality (AHRQ) Agency of the U.S. Department of Health and Human Services charged with supporting the improvement of quality healthcare, reducing costs, improving patient safety, decreasing medical errors, and broadening access to essential services AHRQ Patient Safety Network (PSNet) Web site resource featuring news and essential resources on patient safety Center for Disease Control (CDC) Principal agency of the US government protecting health and safety and providing essential human services Food and Drug Administration (FDA) Responsible for protecting the public health by assuring the safety, efficacy, and security of human and veterinary drugs, biological products, medical devices, our nation’s food supply, cosmetics, and products that emit radiation Institute for Safe Medication Practices Dedicated to learning about medication errors, understanding their system-based causes, and disseminating practical recommendations that can help healthcare providers, consumers, and the pharmaceutical industry Consumers Advancing Patient Safety CAPS envisions a partnership between consumers and providers to create global healthcare systems that are safe, compassionate and just The Kenneth B. Schwartz Center Dedicated to strengthening the relationship between patients and caregivers The Leapfrog Group Initiative driven by organizations that buy health care who are working to initiate breakthrough improvements in the safety, quality and affordability of healthcare for Americans Medically Induced Trauma Support Services (MITSS) A non-profit organization that supports, educates, trains, and offers assistance to individuals affected by medically induced trauma National Committee for Quality Assurance (NCQA) Premier source for information about the quality of the nation’s managed care plans National Patient Safety Agency (NPSA) Coordinates the efforts to report, and more importantly to learn from mistakes and problems that affect patient safety National Patient Safety Foundation A resource for individuals and organizations committed to improving the safety of patients patientINFORM An online service that provides patients and caregivers access to up-to-date, reliable and important research available about the diagnosis and treatment of specific diseases Persons United Limiting Substandards and Errors (PULSE) A nonprofit organization working to improve patient safety and reduce the rate of medical errors using real life stories and experiences WebMD Provides services that help physicians, consumers, providers and health plans navigate the healthcare system World Health Organization (WHO) The United Nations specialized agency for health The Institute for Family-Centered Care Provides Leadership to advance the understanding and practice of patient- and family- centered care in hopitals and other health care settings The Josie King Foundation A patient safety program to prevent hospital errors PICK-Parents of Infants and Children with Kernicterus Founded in late 2000 by a group of parents whose children suffer from Kernicterus Patients for Patient Safety World Alliance for Patient Safety Ask Me 3 Three simple but essential questions that patients should ask their providers in every health care interaction Safe Care Campaign SAFE CARE CAMPAIGN is a not-for-profit corporation created to help eradicate hospital acquired infections Irish Patients’ Association

RCA in Health Care: Preparing for Root Cause Analysis

This update to the popular second edition is designed to help health care organizations prevent system failures by using root cause analysis to identify causes of sentinel events, implement risk reduction strategies, and identify effective and efficient ways to improve processes. This edition includes a CD-ROM with tools to assist in conducting effective root cause analyses. Click on the following links to view the Introduction and Chapter 3 from Root Cause Analysis in Health Care: Tools and Techniques, Third Edition, Joint Commission Resources 2005. Call (630) 268-7469 to order this book.

FMEA in Health Care: Selecting a High-Risk Process and Assembling a Team

This JCR publication is designed to help health care organizations meet Joint Commission requirements by using failure mode and effects analysis (FMEA) to proactively identify and manage potential risks in all processes of various health care settings. By utilizing this process, health care professionals can continue to provide a systematic approach toward the development and implementation of proactive risk assessment and management activities so that patient care, treatment, and service processes can be designed or redesigned to prevent failure. Click on the link to view Chapter 2 from Failure Mode and Effects Analysis in Health Care: Proactive Risk Reduction, Second Edition, Joint Commission Resources 2005. Call (630) 268-7469 to purchase this book.

Limiting Fatigue in Medical Residents: Improving awareness by increasing rest

Limiting fatigue in medical residents is crucial to improving patient safety in a teaching hospital setting. Residents who suffer from sleep deprivation run a greater risk of creating serious medical errors than those who have had an adequate amount of rest.1 “When someone is fatigued, they are not as accurate and are more prone to error at that time,” says Teresa Stewart, associate director, Office of Quality Monitoring for the Joint Commission.

Fatigue prompts wide-ranging neurobehavioral and cognitive deficits. As lapses of attention increase, alertness and vigilance become unstable. In addition, cognitive slowing occurs, time pressure increases errors, and working memory declines.2

One recent study found that residents reported adverse effects of sleep loss and fatigue on their abilities to learn, either in short-term or long-term acquisition of cognitive or noncognitive material.3

Standards to Address the Issue

The Accreditation Council for Graduate Medical Education (ACGME),the accrediting body for U.S. residency programs, has attempted to address the problem of fatigue in residents by issuing work limitation standards in 2003.The standards limit the following:

  • Maximum hours a resident physician can work (limited to 80 hours per week, averaged over 4 weeks)
  • Continuous duty time (limited to 24 hours)

The standards also require rest periods between duty shifts and that the resident has one day in seven to be free of program responsibilities. An 80-hour limit was chosen as the upper limit to safeguard against the negative effects of chronic sleep loss. Studies in New York, which has a 14-year history of having stateregulated duty hour limits for resident physicians, have shown that duty hour limits help to reduce resident fatigue.4

Although the new standards are more stringent than their predecessors, they are much more lenient than those in other hazardous industries with similar safety concerns.5 Medical residents are working beyond the limits that society feels are acceptable in other sectors where public safety is of vital concern. This practice is incompatible with a safe, high-quality health care system.

Proactive Strategies for Risk Managers

The following are specific tips risk managers can use to address fatigue in medical residents:3

  • Reform work practices. The aim is to change attitudes toward work so that exhaustion is thought of as posing an unacceptable risk rather than as a sign of dedication. “Fatigue is to be avoided, not admired,” says Richard J. Croteau, M.D., executive director for strategic initiatives at the Joint Commission.
  • Consider testing for alertness. Although there is no consensus on the appropriate tests or on thresholds for establishing fitness for duty, leaders can observe for excessive fatigue. Be sure residents adhere to ACGME standards for work hours.
  • Schedule periods of duty to account for the known effects of sleep physiology. For example, because of circadian effects on clockwise shift rotation (such as from days to evenings to nights), it is preferable to schedule a counterclockwise rotation.
  • Institute nap periods for clinicians during night shifts. Naps lasting 40 minutes help avoid drowsiness when awakening. In addition, a nap taken before a clinician drives home may reduce the risk of an automobile accident related to fatigue.
  • Transfer some work performed by residents to others. Consider using attending physicians, clinicians other than physicians, or nonclinicians to do some of a resident’s work. However, solving the problem of sleep deprivation among residents by shifting the work to others could be shortsighted.
  • Refashion some resident programs. Consider establishing part-time residencies and job shares to create a balance for trainees who are willing to extend the length of their residencies.

From the Physician’s Point of View—William Jacott, M.D., Joint Commission Medical Staff Liaison It’s been more than 20 years since the Libby Zion case in New York. That was a tragic situation that resulted in the death of a young woman who entered an emergency department for help and was seen by a fatigued, sleep-deprived resident. The case resulted in an explosion of activities all over the country dealing with resident work hours, sleep deprivation, and resident supervision. As a result, the New York legislature mandated a restriction on resident work hours, and other regulatory bodies throughout the country considered the same.

Thereafter, a series of resolutions went to the American Medical Association (AMA) house of delegates from medical students, residents, and young physicians. They developed a policy that the AMA—as a member organization—could bring to the Accreditation Council for Graduate Medical Education (ACGME) and the affiliated residency review committees (RRCs). ACGME and RRCs are the groups that enforce the general and special requirements for residency training.

Eventually, through the efforts of the AMA Council on Medical Education, policy was developed which looks much like that which is in effect today.(See AMA policy H-310.979, “Resident Physician Working Hours and Supervision”) Program directors and department heads were resistant to change and concerned about the impact on medical education. The proposals represented an interference with continuity of care and education. Individual faculty physicians stated that they trained under those conditions, and why can’t today’s residents do so? Those veteran physicians were on call every other night for months at a time and survived “just fine.” What is forgotten and not recognized is that hospitals today have become one large intensive care unit with an increased severity of the case mix. Residents can no longer order laxatives and sleeping pills from their beds in the call room. With hospitals admitting only the very ill or complex patients, residents now have to manage and provide care in busy emergency departments and critical care units.

After all the debate, it has only been a few years since the ACGME has been enforcing a policy on resident work hours. Now they have become more restrictive, and a few prestigious residency programs have been warned or placed on probation for not complying with the requirements. There is no doubt that residents who are fatigued, sleep deprived, or undersupervised will commit medical errors. Therefore, the care of the patient is no longer dependent on one person, but is a health care team effort (for the physician, patient care is often delivered as a group practice). Hospitals have had to hire additional staff to provide constant care and make up for the loss of resident hours,but this has been a positive development for the patients.

The tips suggested in this article may be difficult to implement in certain organizations, but they could be adapted to your organization’s needs. For example, testing for alertness is difficult, but with appropriate supervision by faculty and attending physicians, the fatigue status of a resident can be observed. Scheduling the duty hours to coincide with sleep physiology is a challenge when dealing with multiple residents, patients, and services. Part-time residencies do occur now, but mainly for reasons like pregnancy and child care. Overall, scheduling and cost are major factors.

References

  1. Landrigan C.P., et al.: Effect of reducing interns’work hours on serious medical errors in intensive care units. N Engl J Med 351:1838–1848, Oct. 28, 2004.
  2. Lamberg L.: Long hours, little sleep, bad medicine for physicians-in-training? JAMA 287:303–306, Jan. 16, 2002.
  3. Gaba D.M.,Howard S.K.: Fatigue among clinicians and the safety of patients. N Engl J Med 847:1249–1255, Oct. 17, 2002.
  4. Accreditation Council for Graduate Medical Education (ACGME):The ACGME’s Approach to Limit Resident Duty Hours 12 Months After Implementation:A Summary of Achievements. http://www.acgme.org/acWebsite/dutyHours/dh_dutyhoursummary2003-04.pdf (accessed Feb. 17, 2005).
  5. Howard S.K., et al.:The risks and implications of excessive daytime sleepiness in resident physicians. Acad Med 77:1019–1025, Oct. 2002.

This article is an exact reprint from the Joint Commission Perspectives on Patient Safety, May 2005, Volume 5, Issue 5. Call (630) 2668-7469 to subscribe.

Enhance the Healing Environment by Reducing Noise

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.”

Modifying Equipment

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.

Changing Procedures

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.