Sound Advice: Seven Steps for Abating Hospital Noise Problems
By Susan E. Mazer, MA
Note: This article originally appeared in the May 2002 issue of Health Facilities Management magazine (www.hfmmagazine.com).
Is your hospital a place that makes every effort to have staff members who are of the highest competence, technology that is the best and newest, exemplary architecture and interior design? Assuming this to be so, all of this reflects a commitment to providing the highest standard of patient care. Now, ask yourself if those same high standards are reflected in the sounds that resonate throughout the rooms and corridors.
If we take for granted that hospitals are institutional and designed to be "one-size-fits-all" kinds of places, then their physical character can appear to be generic. However, while the hospital environment is most commonly thought to be about beds, walls, windows, floors, ceilings, and technology, it is also about people, clutter, and noise. In fact, according to patient satisfaction surveys, the quality of the healthcare experience is often evaluated according to the quality of the hospital's dynamic environment, which is circumstantial and changeable.
As a major component of the dynamic space, noise is one of the most invasive aspects of the hospital environment. The sounds of suffering and trauma overheard through thin walls and curtains become the context in which patients and their families undergo their own healthcare experiences. To the innocent listener, what is heard and overheard becomes an indicator of "relational temperature" of the organization. When patients' acuity is high, their adaptive capacity is low, resulting in a greater sensitivity to these kind of environmental stressors. Therefore, erratic sounds that create "apprehension and expectation contribute to the need for restraints, requested pain medication, and nursing assistant calls.
Both casual and confidential conversations between and among patients, staff, and visitors, as well as the sounds of slammed doors, carts that are in need of repair, phones, beepers, buzzers, and paging...make up the "sound environment." Here is where stress, competence, caring, compassion, and concern are qualitatively demonstrated. Therefore, leaving the sound environment to chance -- or allowing it to be a random consequence of institutional care -- places the outcomes that help determine the quality of healthcare at risk.
Whether by accident or incident, the accumulation of noise, gossip, and unwanted distraction adds up to a negative healthcare experience.
So, how can the sound environment of hospitals be improved? Here are seven steps to follow to make it happen:
Step 1: Assess the Sound Environment
First, establish a multidisciplinary Sound Quality Committee. Besides people from the facility management staff, include doctors, nurses, housekeepers, volunteers, administration, and ancillary staff. Have the committee determine a protocol for initial assessment of the sound environment.
The Sound Quality Committee at Northside Hospital in Atlanta, Georgia, decided that the best way to measure how "loud was loud" was to use digital decibel meters to measure the sound levels at specific areas of the hospital at different times of day. All in all, they determined the decibel levels of 238 pieces of equipment, including all 59 heavy rolling carts.
Besides carts, the long list of small and large equipment included doors, cabinets, monitors, floors, communication devices, chairs, and anything that significantly contributed to the complex orchestration of the sounds impacting patients and staff. Equipment noises were measured at distances relative to the listener.
The investigators grouped sound levels according to dB ratings, indicating the time of day at which they occurred. For instance, at 1 p.m., they found the pneumatic tube and paging system rated at over 80 db (and often increased past 90dB, equivalent to the volume of a hair dryer next to our ears). In the afternoon, they found monitors, the nurses' station, food carts, groups of five people with pagers, and other typical scenarios to vary between 70-79 dB. Late in the evening, after 9 p.m., they found that printers, elevator buzzers, trash carts rolling at high speed, and the ice machine rated even higher.
In addition to looking at the quantitive measure of sounds, they looked at the perception of noise by patients and families. Specifically, they reviewed their patient satisfaction scores specifically relating to noise to get a baseline of patient experience.
Other factors that should be looked at include functional noise levels of all mobile equipment, door-closures, paging system volume levels, frequency of use, as well as intelligibility, medical monitors, and other technological sound sources.
Step 2: Establish Sound Standards
After the data has been collected, the Sound Quality Committee should establish qualitative sound standards that can be measured and maintained. This may involve setting comparative goals that respond to the known decibel levels, equipment, clinical areas, and times of day. A level of acceptability, i.e., one at which the equipment had only a benign impact on the environment, should be determined.
Sound levels vary, with the "noise floor" being the level of continuous sound that characterizes an area at any given time. Other sounds, to be perceived, must rise above this "floor." If a sound rises 30dB above the noise floor it can cause a "startle response." However, if the sound level is too quiet, conversations and unavoidable sounds become distractions. Therefore, when goals are set, both the optimum continuous volume level (recommended average at 50dB) and the maximum level for incidental sounds must be taken into a account.
Besides these types of changes, the committee should also make recommendations for other ways to enhance the sound environment. Most of us are familiar with "pink noise," which is a frequency-specific sound that is introduced into an environment to basically cancel out or render inaudible conversations that need to be private. Although pink noise has been shown to be effective in many workplace settings, it is not appropriate for hospitals.
For example, in an initial effort to reduce the effect of ambient noise in its intensive care unit, a hospital in Omaha, Nebraska initiated a pilot study on the use of pink noise. It soon became apparent that pink noise rendered sounds not only inaudible, but also non-directional. Staff found that the observation of or response to patient alarms was difficult because they could not accurately and quickly locate the alarming device.
Enhancing the sound environment with music is a viable option if used appropriately. As shown in other industries, foreground music can mask other irrelevant sounds and maintain an appropriate noise floor. In hospital settings, music combined with images of nature have been shown to reduce the amount of requested pain medication and/or improve its analgesic effect. In addition, when used appropriately, music acts as an effective audio-anxiolytic, improving restfulness and the quality of sleep, and inducing relaxation.
There are several programming alternatives for hospital television on the market that cost only pennies per bed, per day. They combine music with images, as well as devices for patients to use during surgical procedures. Important considerations for this type of programming include choosing music and imagery that crosses the age, gender, and cultural boundaries. The musical content used to create night and day programming is also a plus, as well as a 24-hour minimum of non-repetitious play. While first only available in VHS format, some companies now offer digital programming.
Custom-distributed sound systems can also be installed. Henry Ford Hospital in Detroit, Michigan, St. Charles Medical Center in Bend, Oregon, Oconomowoc Regional Cancer Center in Oconomowoc, Wisconsin, and Sacred Heart Center of Eugene, Oregon, have invested in such systems to provide music in alignment with their mission of healing. These systems are parallel to but distinct from their emergency paging systems; are of higher quality; offer full-frequency; and are acoustically designed to support listening over many hours. They bring comforting "intention" into otherwise impersonal corridors.
Step 3: Establish Equipment Maintenance & Purchase Standards
Once standards or goals have been set, recommendations should be made for modifying equipment, changing staff practices, and altering purchasing policies. In addition, repair and maintenance policies should be reviewed to respond to a higher quality of functionality that includes quieter operation.
Much of the noise caused by the auditory predators in the hospital environment can be significantly reduced by mechanical adjustments, maintenance, or purchasing new equipment where possible. The auditory impact of equipment can be reduced by changing wheels, applying padding, repairing or replacing door bumpers, using thicker carpeting, and installing effective acoustic ceiling tiles.
It is not uncommon for a noisy cart that is still operational to be used for years without the staff addressing this as a malfunction because the loudness of the wheels does not impair their own functioning. Unless specific standards are set to identify squeaks, rattles, and noisy operations that mandate repair, this will not be perceived as a problem by staff.
Most hospitals have refrigerated soft drink and ice machines that "rattle and roll" at a pitch of 85-90 dB. Being conscious of their location and using alternative methods of refrigerating products in public areas are worth considering. Some hotels, for instance, have put vending and ice machines in isolated cubicles specifically to contain the mechanical rumble. Where padding or insulation is not a workable solution, the use of decorative baffles of plexiglass or other appropriate materials to control and direct the noise coming from these machines might be considered.
Purchasing new equipment based not only on function and price but also on auditory impact is another possible approach. Biomedical engineering departments that evaluate all patient care equipment prior to its use should be testing for its auditory impact, as well as for safety and operation. For maintenance equipment, such as floor buffers and vacuum cleaners, decibels should be measured and their operation schedules coordinated with the nursing staff to ensure that the auditory disturbance to patients is minimized.
Step 4: Make Decisions About Patient-Appropriate Equipment
For patients who need them, checking and adjusting monitors to avoid unnecessary alarms will undoubtedly reduce unnecessary noise exposure and distraction. Similarly, evaluating the patient's capacity to manage auditory stimuli will help improve the environment. Judiciously using barriers, such as doors and curtains, to provide both visual and auditory protection will begin the process of controlling sounds that resonate from one area to another.
At Northside Hospital, for example, the sonorous sound of the pneumatic tube system (an old and still functional technology) caused alarm to nearby ICU patients. The decibel level was brought down to 50dB (over 400% quieter) by the careful use of padding. And of course, any kind of padding or acoustic material used must conform to fire and infection control regulations.
Step 5: Design Areas for Sound Control
If we consider hospital design as a means of supporting a healthy sound environment, then we begin evaluating structural and design components that have auditory impact, such as flooring, ceiling materials, and door placement and function.
While setting up opaque sound baffles is not a desirable solution to auditory control, the use of transparent barriers for waiting areas and other large rooms where conflicting activities take place is a workable alternative. In a waiting area, if the objective is to provide television access for some visitors, then offer a quieter space for others. To maintain the openness of the area, and give visual access from the nurse's station or admitting, consider using clear plexiglass or nonbreakable glass. Use these materials for sound containment when a separate room is either not possible or desirable.
For example, The Karmanos Cancer Institute in Detroit, Michigan, designed its bone-marrow transplant unit using glass walls as a means of creating a feeling of openness, while providing auditory privacy for families and physicians during conferences. Privacy curtains that can be drawn when needed offer flexibility regarding visual privacy. Designers of corporate offices have long used glass walls in large conference rooms into order to maintain a sense of spaciousness and comfortable functionality.
Step 6: Educate Staff
Staff education, as well new employee orientation, should make staff aware every day of where they are and their accountability for maintaining an appropriate sound environment.
While mandating staff behavior has long been known to be the least effective method of managing noise, behavioral standards should nevertheless be modeled and extended organizationally. This includes standards governing private or confidential discussions that take place in public areas; use and methods of paging; and use of cell phones, nurse call systems, and the telephone.
Concord Hospital, Concord, New Hampshire, produced an effective educational video that demonstrated the best and worst behavioral examples regarding noise, conversations, use of pagers, beepers. Without a doubt, seeing and hearing from the standpoint of the patient is a great teaching tool.
There are also kinder, gentler methods to give the message to visitors. Longmont Hospital in Longmont, Colorado greets staff and visitors with a picture of a child in a colorful nursing uniform holding one finger to her lips and saying "Shhh!" Northside Hospital created signs and buttons saying "Quiet Please: Healing in Progress," reinforcing the awareness that a hospital needs first and foremost to be a place of recovery.
Step 7: Measure Results
The process of measuring results is similar to that of the initial assessment. Using both quantitative and qualitative measures -- decibel levels and patient satisfaction surveys -- make a comparative analysis to determine how far you have come and which aspects of the sound environment have yet to reach the established goals. Some survey organizations (including National Research Corporation, the company that bought the survey tool developed by The Picker Institute and The Center for Health Design) offer customized questionnaires that specifically focus on the environment of care. Before and after baseline data is the most helpful.
After two years of diligent work, Northside Hospital improved its patient satisfaction levels on noise by 10%. The Sound Quality Committee has been discharged and noise control responsibility has been turned over to the individual department heads, holding them accountable for sustaining a therapeutic sound environment, including all of its various components.
Conclusion
To be a state-of-the-art-hospital, the auditory environment must exemplify the highest and most compassionate standards of patient care. Setting sound standards for equipment, technology, and design makes it possible for a patient to move through the healthcare system, from department to department, and experience the same standards of care. Aim for more than auditory neutrality æ the myth of "do no harm" when it comes to noise and distraction æ by providing music and nature, fountains, or other pleasant sound sources that can improve the quality of the healthcare experience. Go back to your own hospital and listen. What you hear should reflect the same values and standards as the clinical care you provide.
