Download Does Noise Impact Patients Health?

Does Noise Impact Patients Health?
Antoinette L McNeil, BSN*
*
From the Department of Washington Adventist University
No financial disclosure
No previous presentation
No disclaimer
Corresponding author: Antoinette L McNeil, BSN, Washington Adventist University, 7600 Flower Ave., Takoma
Park, MD 20912 ([email protected])
ABSTRACT
Background: Sound travels and when in an environment that is constantly noisy often
healthcare workers are oblivious to noise levels in hospitals. Patients complain of noise and staff
at times will acknowledge noise and at other times deny. Often staff wonders why patients are
not recovering from their illness and it can be due to environmental noise.
Objectives: To determine if environmental noise impact patients recovery in the Intensive Care
Unit (ICU).
Methods: A systematic review was done using OVID and EBSCO data bases from 2008 to
2013, evaluating the effects environmental noise has on patients in the ICU.
Results: Noise decibels (dB) at night exceed the level per the World Health Organization
(WHO) and the US Environmental Protection Agency (EPA) standards. Noise levels in the
hospital/ICU can result in hearing loss, sleep deprivation, and delirium. Environmental noise
results from cardiac monitors, intravenous (IV) pumps, medical staff conversations, the overhead
paging system, and opening and closing doors.
Conclusions: Medical staff should minimize the noise level on the units to promote patient
safety. Patients with certain co-morbidities are at greater risk for dying due to the excessive
noise in the ICU. Education is needed to inform staff ways to promote noise reduction in the
ICU.
Key Words: noise, reduction, delirium
1
Patients and families often complain of how noisy the hospital intensive care units (ICU)
can be, unfortunately medical personal especially nurses are so used to the noise, that they do not
realize that the unit is boisterous. The noise in the hospitals are due to the overhead paging
system, telephones ringing, and equipment that falls to the floor, televisions blaring, and
environmental services striping and waxing the floors.
Sleep is essential for healing. When patients do not get adequate rest the statement
becomes, the patient is a sundowner when they become combative at night. Cells in the body
regenerate when an individual sleeps. Obtaining adequate sleep is essential for healing.
Impairment of one or all body systems is due to a disruption in the sleep cycle.1
The World Health Organization (WHO) has stated that hospital noise should be 30
decibels (dB) at night and not exceed 40 dB at night.2
A study was done that revealed that
some nighttime noise exceeded 50 dB also with some peaks between 80 and 86 dB.3
Another
study revealed that daytime noise were 59.1 dB during the day with a peak of 85.9 and 56.8 dB
at night with a peak of 82.8.3
Noise has been defined as an unwanted sound.4 Noise is everywhere but the question
that is raised is what effects noise has on patients and what can medical staff especially nurses do
to combat hospital noise. Education on noise and its effects on the body is one way to combat
the noise problem in hospitals.
LITERATURE REVIEW
The WHO and Environmental Protection Agency (EPA) has determine what noise levels
are acceptable and not acceptable. The WHO recommends hospital noise should not exceed 35
dB and in the patients rooms 30 dB but the EPA recommends that hospital noise should not
exceed 40 dB.5 In a literature review it was noted that the EPA recommends during waking
hours the noise level should not exceed 55 dB and 45 dB during sleeping hours.6 It has been
2
noted that a whisper is 20 dB, a normal conversation is 60 dB, a vacuum cleaner 70 dB and a
lawn mower is close 100 dB.5 Noise is everywhere, but no one thinks about noise levels due to
being in an environment of a noisy surrounding.
In the neonatal intensive care unit (NICU) one would expect the noise levels to be down
but to the contrary it has been noted that the levels are between 80 dB to 140 dB.6 Sounds that
are sustained at that level affects hearing and accounts for hearing loss in individuals who are
constantly subjected to loud noises. If loud sounds affect adults adversely think of what it does
to the infants, especially those in the NICU.
Many studies have been done looking at the different effects noise has on the human
body. As an individual no one responds to a stimulus in the same manner so the principle
applies also to loud noises. It has been noted that sounds with greater intensities and boisterous
levels have been associated with various health problems which includes hearing loss and high
blood pressure. 7 Knowing that noise can affect the body, the question then is, what effects does
noise have on the body?
Noise affects the body in different ways, in which the medical personnel can be oblivious
to the effects the hospital environmental noise can have on the body. Being able to get a good
night sleep is imperative for the regeneration of the body cells for healing. Rapid eye movement
(REM) sleep is one of the phases of sleep. REM sleep is where dreams occur and the brain is
active with absent muscle activity. 1 Nonrapid eye movement (NREM) is another phase of sleep.
NREM is divided into 3 stages. In stage 1 the eyes are moving slowly and there is excessive
muscle tone. In stage 2 muscle tone is decreased and occupies 50% of the sleep period. Stage 3 is
known as the delta stage and this is where the best sleep occurs and it helps promote a decrease
in cortisol secretion and body metabolism and an increase in growth hormone secretion. 1 With
3
the knowledge that the growth hormone is secreted during the delta stage of sleep, therefore, it is
important that children get their required amount of sleep for proper growth.
Sleep is essential for growing as well as for healing. It has been noted that important
circadian variations in protein synthesis as well as cellular division occurs during sleep.1
Nighttime shift nurses are aware that when their patients are not sleeping well they become
disoriented. Sleep deprivation is common in the ICU’s. Patients complain that it is too noisy
and their sleep is broken. Patients are not aware that if they want to sleep the hospital is not the
place to be. It is known that chronic sleep loss is harmful to the immune system.1
Delirium has been defined as a fluctuating level of attentiveness with a decreased ability
in focusing maintaining attention.8 Critical care nurses see delirium in their patient’s especially
those who have been there a long time and in the elderly. Unfortunately delirium occurs in 80%
of patients in the ICU and has been a predictor of outcomes in patients including increased risks
of mortality; lengthy hospital stay and higher cost.8 A study was done which demonstrated that
delirium occurred in patients in which they had less REM sleep and total REM periods. 8
Medical staff tends to be ignorant of the effects that occur during chronic loss of sleep and its
impact it has during hospitalization.
When patients are discharged from the hospital they may inform telephone customer
surveyor, that they did not get any rest while hospitalized. It cannot be stressed enough that
sleep is highly important for patients well being. A study demonstrated that patients who had
severe disruption in their sleep had a higher disease severity score and some that even died.1 It
is well noted that pain will awaken a patient from sleep but noise is a greater disruption to their
sleep.
It has been noted that irritability, memory loss, inattention, delusions, hallucinations,
slurred speech, blurred vision and in-coordination are associated with sleep deprivation.1
4
Several studies have been done that has looked at the effect of noise in the hospital environment.
One study noted that hallucinations occur in the ICU during the transition period from a state of
wakefulness in NREM sleep also from NREM sleep to a state of wakefulness, which is a big
problem in the ICU.2 After following, several days of sleep deprivation it revealed impair cellmediated immune reactions which had been measured by lymphocyte production and
adhesiveness.2 Noise affects the cardiovascular causing a rise in sympathetic activity moreover
respiratory, a rise in REM sleep leads to a reduction in ventilator response to hypoxia and
hypercapania.2
Note that sepsis has been associated with increases in NREM sleep and loss of
normal circadian melatonin secretion which has been seen in postoperative and long-term ICU
patients.1
Noise has affected different areas of the body. Noise is known to increase blood
pressure, increase respiratory rates, increase cortisol levels in the blood, impede digestion and
potentiate the effects of some drugs, alcohol and carbon monoxide.6 Noise levels at 85 dB
causes a rise in cortisol and adrenaline levels leading to a delay in wound healing.9 An increase
in noise also gives rise for an increase in sedation for ICU patients.9 Elevated boisterous noise
levels can lead to hypertension and ischemic heart disease.5 Patients are continuously being
affected by hospital environmental noise.
Florence Nightingale recognized that unnecessary noise hurts patients.5 Nurses are to be
observant and mindful of the noise levels in the units they work on and they should be like
Florence Nightingale, recognizing that noise is harmful to their patients. Nurses need to pay
attention to the environmental noises which they create in the patients’ rooms, such as rattling of
keys also recognizing that any sound that will cause undue anxiety such as tiptoeing in a room is
a noise that is worse than any loud noise because it produces nervousness and anxiety in
patients.5
5
Noise affects not only patients but also nurses. Noise induced stress levels that can lead
to burnout in critical care nurses.9 When nurses work in an environment where the noise level is
greater than 40 dB it will interfere with their concentration levels and lead to errors in patient
care. 10 When individuals work in a noisy environment they become less caring, less reflective
and less engaged and also becomes a contributor to environmental noise. 9
Sounds and noises are part of daily living for example city traffic is 85dB, motorcycles
120-150 dB and rock concerts are 140 dB. 6 Telephones ringing, loud conversations, doors
closing and opening, things falling on uncarpeted floors are the everyday sound one hears. One
article noted that regular conversation noise was the most common noise that one would hear in
the clinical setting. 4 It was noted that decibel levels were 99.6 dB at mid-afternoon shift change
and 52.5 dB during non-shift change. 4 The conversation levels are at its greatest when it is shift
change and when physicians are rounding on patients.
Opening and closing doors are a source of noise. It was noted that when people slammed
doors open, the decibels were 86.5 instead if they pushed the metal bar on the door then it was
72.0 dB. What a difference in decibels opening a door can make. When staff wears hard –soled
shoes on uncarpeted floors that sound is 69.4 dB. 4
In the literature it was noted that overhead paging, noise from alarms on equipment and
people talking in the hallways were the most troubling noises for patients. 11 It was also noted
that the most common environmental factors that prevented patients from sleeping were monitor
alarms, television, intravenous alarms, the telephone, the intercom, equipment, beepers and
conversations. 11 These sounds are common for hospital personnel in that it does not bother
them nor do they recognize that it is noise that is affecting their patient’s recovery and the
medical staffs’ health.
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The literature discussed treatments for the noise makers. It has been noted that sleep is a
basic human need that needs to be a priority when caring for patients. At night conversations
should be at a minimum especially near patient’s room. 1 The lights should be dimmed during
sleep hours and clustering of care for the patient to minimize disturbing their sleeping. 1
One may not be cognizant of the fact that medications can have an effect on patient’s
quality of sleep such as the use of morphine, barbiturates, and sedative-hypnotics due to they can
directly interfere with sleep. 1 Antidepressants may not have sleep-promoting effects but it has
been known to reduce REM sleep thus should not be used. 1 If the patient is a smoker, it is
known that patients may go through nicotine withdrawal while in the hospital, thus they should
be given a nicotine patch.
Music has many uses, one is enjoyment and another is for relaxation and tension reliever.
Music therapy has been used for pain management particularly post-operative pain and to
improve patients sleep. 1 The music that has been noted to be the best is music for sleep has a
tempo of 60 beats per minute, low tones and made up primarily of string instruments. 1
Not all
people like and listen to classical music but easy listening music is of quiet tones with string
instruments at a tempo of 60 beats per minute.
A study looked at the use of earplugs/earmuffs. It was noted that infants who wore
earmuffs, the noise reduction was 7 to 12 dB; their oxygen saturation levels were greater than
those infants who did not wear earmuffs. 2 Patients in the ICU were given either earplugs or
earmuffs to wear and it was noted that their REM sleep increased. 2
In the literature it was noted that a hospital installed a noise meter on all of their nursing
units. The noise meter green light indicates that the noise levels are within set limits but when
the light turns yellow, it indicates that the noise level is rising and at red indicates that the noise
exceeds the set limits. 5 The hospital installed self closing doors, decreased TV and telephone
7
volumes, and instituted “Quiet Time” which is where the unit is free of visitor and is kept quiet
for 1 hour.5 They also had the nurses change the IV fluid bags before the IV pump alarmed and
had restocking of the nursing unit done during the day to prevent interruption of patient sleeping
at night. 5 The nurses also had to monitor the fluid levels of the IV fluid bag in-order to change
the IV bags before the IV pump alarms.
It was noted that having an educational noise reduction program for hospitals staff has
been beneficial and is inexpensive for reducing boisterous noise. 10 Basic maintenance such as
fixing noisy doors and wheelchairs has a dramatic affect on the noise levels in the units. 10
The
noise levels automatically decreases when noisy equipment has been repaired.
Another study looked at creating a nighttime environment for sleep promotion. In the
study it looked at closing the door to patients rooms when possible, dimming the lights,
clustering care by doing lab draws, weighting patient’s and obtaining vital signs at one time to
minimize sleep interruptions and have the nurses speak in soft tones. 11
METHODS
A literature search was done via EBSCO, OVID, and Google Scholar from 2008 to 2013.
Key words use in the search was noise, prevention, ICU, environmental noise, hospital noise,
and sleep. A systematic review of the literature was done reviewing 13 articles. The literature
looked at the relationship between noise and sleep in patients in the ICU and the NICU and the
papers were written in English.
One of the articles was a cross-sectional, descriptive study. This study looked at 148
patients recovering from coronary artery bypass graft (CABG) surgery, cardiac valve surgery or
other cardiac surgeries and how noise affected nighttime sleep. 11
Another article was a quantitative and descriptive qualitative study. The study was done
at two hospitals looking at 57 patient care units (PCU) looking at noise levels before and after
8
intervention noise reduction measures. 12
A Likert 5 point scale was used for patients to
determine when it was very quiet to very loud at different times during the day for a 2 hour
period.
12
RESULTS
A study that was done looked at the different sounds patients in the ICU were subjected
to in their room. A comparison sound of a ventilator, IV pump, and cardiac monitor alarm in a
patient room versus in an adjacent room was done. The findings revealed that the cardiac
monitor alarm in the patient room was 86.5 dB and 67.5 dB in the adjacent room with the door
closed and 69.4 with the door open of the adjacent room. 3 The ventilator alarm was 86.0 dB in
the patient room, 71.5 dB in the adjacent room with the door open and 65.8 dB with the door
closed. 3 The IV pump alarm was 83.8 dB in the patient room and 67.9 in the adjacent room
with the door open.
Another article looked at 6 sources of noise on a hospital unit. The noises were
conversation, doors opening and closing, activity from housekeeping closet, the
pneumatic/message-tube station, hallway noise, and miscellaneous noises that were looked at. 4
The finding was conversation noise was 99.6 dB at mid-afternoon shift change and 52.5 during
nonshift change. 4 Noise from doors was 86.5 dB if the door was being slammed open and 72.0
dB if the door was opened by pushing on the bar. 4 The noise from the locker room was 76 dB. 4
Noise from the pneumatic-message tube station was 59.2 to 84 dB; noise from hard-soled shoes
on non-carpeted floors was 69.4 dB; noise from mounted metal flip down chart on the wall was
81.6 dB and pushing a cart down the hall was 90.9 dB. 4
The results from a cross-sectional, descriptive study revealed that the participants
identified 15 noises that interrupted nighttime sleep at some point. 11 The participants identified
9
overhead paging, alarms on equipment, people talking in the hallway near the patient room, open
and closing doors, TV blaring, and telephones ringing were noise makers that would interrupted
their sleep at night. 11
The results from the mixed-method design revealed, that patients found that from 7 AM
till 12 noon to be the noisiest period of time during hospital operation. 12 The noises identified
were voices, carts traveling in the hall, foot traffic in the hall, cardiac monitor alarms, overhead
pages, pulse oximeter alarms, and other. 12
DISCUSSION
Minimizing noise perceived by patients as noxious can improve the environment of care
for the patient as well as the medical staff. 12 In the mixed-method research, staff was more
aware of the environmental noise based on the number of interventions they were using to reduce
the noise levels on the PCU. 12 Educating staff regarding noise on the unit is paramount. When
interventions are done it does make a tremendous difference in the noise levels.
Often staff is unaware of noise levels due to the fact that society noise is all around.
When an individual is sick, sound becomes enhanced and patients are the main ones to complain
about noise due to they are the ones who are impacted the most. Nurses are the gate keeper for
promoting patient health and providing an environment conducive for healing but often time’s
nurses are the culprit for producing noise that impact patient’s health. There are noises that
medical staff has no power over but change still can occur to minimize noise levels on PCU.
Making staff aware what the decibels of different sounds are and what the recommended hospital
noise levels should be for the hospital is what is needed for providing a safe environment for
patients.
Noise levels are not to be ignored, the Hospital Consumer Assessment of Healthcare
Providers and Systems (HCAPHS), are looking to see if hospitals are providing a quiet
10
environment for patients. 13 Hospitals need to take notice, a proposal is looking at tying
payment to hospital’s performance, the Center for Medicare and Medicaid Services has
recommended the HCAPHS survey as a performance measure. 13
Noise affects patient sleep but not only that it also affects their health by contributing to
an increase in their blood pressure, heart rate, respiratory rate, mortality, and length of stay in the
hospital. One has to remember that noise affect nurses also in that there is an increase in
burnout, stress and annoyance, fatigue and emotional exhaustion, also interferes with clear
communication and an increase in errors can occur. 13
Nurses must be aware that sleep plays a tremendous part in preserving physical and
mental health in the patients we care for. 1 It well established that patients do not sleep well in
the ICU. Sleep deprivation has been and is associated with worse outcomes. 1 Educating staff
on the effect of sleep deprivation is a must and it should be part of a nurses ICU orientation.
Nurses need to be aware of the prescriptions that do not promote REM sleep in their patients.
Decreasing the noise levels on units will help to promote sleep in patients thus avoiding delirium.
There is always a need for increase in research in any given topic. Performing an
assessment on noise will lead to results which then can be used to develop a larger and longer
research project. 4 There can be a research study done on products that can affect sleep patterns
in patients thus leading to delirium. There are products that will evaluate noise levels on the
different nursing units that need to be further investigated to determine if they truly promote an
environment of healing for patients.
When it comes to nursing practice, the staff needs to be aware that their conversations are
disturbing to patients, thus the need to identify ways to decrease the noise levels on their unit.9
It was noted that 49% of the noise levels that were greater than 80 dB were staff conversations
and the TV. 9 Knowing that noise is a problem then turning off the central TV is to be done,
11
place pagers on vibration mode, decrease volume on telephones, sticking to the rule of only two
visitors at a time, decrease conversation volumes on the unit. 9
It was noted that the University of Maryland instituted the “quiet hour” for one of their
units in which no visitors are allowed on the unit from 1400 to 1500 and no deliveries were done
not unless it was an emergency. Also the lights were dimmed to promote quietness, alarms were
decreased and doors were closed to promote a restful environment for their patients. 9
Other
hospitals have tried the quiet hour in their institutions and it is showing promising results.
Florence Nightingale was observant in recognizing that noise impacted her patient’s
health. Nursing is an art and a science. As an investigator, nurses need to observe their patients
surrounding more closely in particular the noise environment and promote a calmer healing
environment thus improving patient satisfaction.5 Not only nurses but all hospital personnel
must remember that during the day the noise dB should be at 35 and at night it should be 30 dB
furthermore at no time should the level rise greater than 40 dB. 13
As an advocate for patients
nurses must provide and promote a calm, healthy and safe environment for patients.
12
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