A news article over the weekend in The Chicago Tribune, brings the discussion of hospital noise levels and patient healing to the awareness of the general public. As I was reading it over the weekend I realized that this is one of the first mass media news stories I have seen on this topic… The research has been out there for a long time-starting around 2004. However I think most institutions are really just starting to change their practice and their culture. I can speak from professional experience that the hospital I work at has embarked on this endeavor within the last 6 months as well.
Elevated noise levels in the hospital setting are, I will admit, a huge barrier to patient healing and quality nursing care. I have worked in ICUs that have varied completely in noise levels from that of a library to a what I imagine the working side of an airport to sound like. The hospital that I currently work at established set quiet times on both the day shift and the night shift and began tracking decibel levels over the course of 24 hours. The transition that our hospital was making was driven by our patient satisfaction feedback and one ICU attending whose family member had been in a hospital recently and realized first hand the impact of noise on her stress level as a visitor and her family members stress level as a patient.
Elevated noise levels, especially in the ICU, have profoundly negative impacts on patient outcomes. This can not be disputed. In the ICUs the amount of equipment we use for care and lifesaving interventions is just greater than on the general medical floors for example; ventilators, cardiac monitors, IV pumps, mechanical beds, and dialysis machines all make noise and as a nurse at the bedside I need them to make noise. However, respecting the impact noise has on lost sleep for patients in the ICU and how serious sleep deprivation can be on healing, it is important to talk about this as a step to patient care and quality improvement.
Per the fantastic American Journal of Critical Care Nursing, Sleep deprivation can lead to delirium, affect blood pressure, and have an impact on cortisol levels . In the long term it can slow healing, decrease an already compromised patients immune response, and sleep deprivation can definitely decrease cognitive function (I can attest to this as a night shift worker).
The quietest ICUs I have worked in have been those that have decentralized nursing stations. This is just a fact. If you spread out patient rooms over a greater area and create “pods” (for example) you physically have fewer staff members in each area and it is by default quieter. From the viewpoint of practice reality, if you decentralize nursing stations- especially in the ICU you have fewer people available to help out in an emergency when you need as many hands on deck as possible. I have seen and worked both sides of this viewpoint. If you are in a corner far away by yourself. It is very easy not to know what is going on with other patients on the unit and if other staff members are in need of help. The other negative impact is that if patients become to sick to be paired or staffing and patient assignments need to change, you don’t have the same flexibility of changing assignments. It is unsafe and not reasonable in an ICU to have 1 nurse caring for patients spread out in different “pods.” As ICU nurses we like centralized nursing units a lot- it allows us to help each other, know what other nurses need help with, and work together as a team. So then in centralized nursing units the biggest step to appropriate noise reduction is staff education. Really making people aware of how loud they really are. An article written in the Journal of Patient Safety & Quality Healthcare in 2005, about changing hospital units to decrease noise levels and improve patient outcomes discussed these points exactly.
One hospital I worked in on the east coast had the loudest ICU I have ever been in. I know when I left there everyday my stress level was off the charts. I can’t speak to whether or not the incidence of medication errors was higher because of constant noise stimulation- I personally didn’t notice that, but the research does point to it. I do know that it increased my stress, anxiety, anger, and frustration levels. What was the most challenging was that we were not allowed to change the alarm limits on heart rate and blood pressure, we were not allowed to silence or pause the alarms even if we were at the bedside turning the patient or giving a bath. Because of these rules, alarms would sound continuously all day and never stop. Alarm monitors in the ICU are computers and they do not know whether you are doing patient care, the patient is brushing their teeth, getting out of bed to go to the bathroom, or if a real emergency is occurring. They alarm that something has changed or a different rhythm has been noted. I am the human at the bedside interpreting the computer, I know full well that the patient is fine and talking to me and the alarm is going off because I am touching the patient.
On the converse, if I have a patient that is getting sicker from an infection or bleeding severely for example, their heart rate will be higher and that is not unusual. Their heart rate will be high but I am aware of it, and I am taking steps to intervene and correct it. This is the same for a low or high blood pressure. In most ICU’s I would adjust that alarm limit so that I know if it now goes above the number I’m already watching or the blood pressure increases or drops further beyond the point I am already aware of and working to correct. That is the point of an alarm system. However within this specific organization, the HR and blood pressure alarm limits had to stay at fixed parameters and as the clinician you were never allowed to change it. Well healthy people also have normal heart rates that are outside that set parameter as well. So alarms would be constantly stimulating, and beeping and you could never change them or silence them; and after awhile you would start to ignore them- which is in my opinion even more dangerous. The second fantastic thing about the The Chicago Tribune is that they agree with me and have discussed it in an article on alarm fatigue as well.
These are some of my experiences with noise and alarms in the ICU setting…. what are some of yours? Are the steps we are taking as a culture moving us in the right direction to improve patient safety and promote healing within the hospital setting? As nurses and doctors this information and the research that is being done is invaluable. As patients and the general population, everyone needs to know what is important for them and their family members while they are in the hospital, how to direct their own care, and empower their own healing!