Published in the April 2004 issue of Today’s Hospitalist
Two facts of life for hospitalized patients “lackluster food and the nearly constant, intrusive thrum of activity” have been fodder for comedians for decades. But for the patient who is trying to rest and recover, the background noise that at times approaches cacophony is no joking matter.
Yet the very thing that often prevents patients from resting has received scant attention in the medical research and tends to be under-addressed in the hospital setting. That’s what a Mayo Clinic nursing team discovered when it studied the issue at Saint Marys Hospital in Rochester, Minn.
The continuous improvement project, which was highlighted in the February issue of the American Journal of Nursing, examined why post-surgery patients have such difficulty sleeping during their hospital stay. It yielded two surprising findings.
First, the sleep promotion team found that transient peak noise levels on the thoracic surgery unit approached the decibel level produced by a jackhammer. Second, both peak and overall noise levels could be addressed with relatively simple fixes.
To conduct the study, the team first placed noise dosimeters in three empty patient rooms during the night shift, without the knowledge of the nursing staff, to measure decibel levels. Two nurses then volunteered to spend the night in a semi-private room equipped with the monitors and other equipment used during a typical patient’s stay on the 33-bed unit.
After identifying the sources of sleep-disturbing noises, the investigators worked with nurses, physicians and other hospital staff members to devise remedies.
In a conversation with Today’s Hospitalist, project leader Cheryl Cmiel, RN, talked about the group’s findings. She also explained how the project prompted nurses and physicians at the 1,157-bed, Mayo-affiliated facility to modify their work and practice patterns.
What were the most surprising findings of the study?
Although we were pretty satisfied with our baseline level of 45 decibels, which is in line with a library’s noise level, we were all surprised by how loud some of our peak noise levels were. Though short in duration, the peak level at shift change was as high as 113 d(B)A. [The project used A-weighted decibels.] That compares with a jackhammer or a chainsaw.
We were also surprised by how noisy the conversations at the nursing desk could be, and how noisy and intrusive it was to patients when we put the charts on the door. Chart placement is such a basic part of the daily routine that it never occurred to us that it could produce so much noise or that it was so irritating to patients who were trying to recover. That wouldn’t have occurred to us without patient feedback.
What did you find in the literature about hospital noise levels, and how did your study fit into the picture?
We found that although there is research on the noise issue that acknowledges noise as a problem for patients, most of it was focused on ICUs. Also, most of the research was done in the 1970s and 1980s, and very few of the articles addressed interventions. Current research tends to be limited.
Surprisingly, most of the research we found was published in the more obscure journals and magazines, not publications nurses would read on a routine basis. So the information was out there, but it was not readily available to those who would use it most.
That’s why we targeted a major journal and have been making presentations on the project at conferences.
Based on your findings, what kinds of sleep-promoting interventions have you undertaken, and how difficult was it to make the changes?
The main change was moving the staff reports at shift change to enclosed rooms, not the nurses’ desk. We also tried to increase awareness of the noise issue through staff education.
We now encourage staff to hold their social conversations in more enclosed areas, such as the medication or report room. There’s no need to have the “How was your weekend?” conversation right outside a patient’s room.
Most of the other interventions were fairly easy. Putting foam rubber padding on the chart holders and in the pneumatic tubes for document delivery helped reduce the noise a lot.
We changed the cardiac monitor settings to reduce the volume in patients’ rooms. We also routinely close the doors to patients’ rooms and use flashlights when we enter their rooms at night.
And when we found that the housekeeping staff was “cutting through” the unit at night with their carts, which disturbed patients’ sleep, they were asked to stop taking the shortcut.
Changing the nightly X-ray time to 10 p.m. instead of 3 a.m. was more difficult. We talked to the surgeons about re-examining which patients need routine chest X-rays during the night.
After a six-month trial, the surgeons changed how frequently they order routine X-rays in the middle of the night. The 10 p.m. time for routine X-rays is standard on our nursing unit.
This change in timing, coupled with an overall reduction in the number of X-rays taken, has helped our patients sleep. The change did not affect when patients’ chest tubes were removed or when they were discharged.
After the interventions, the loudest peak noise was only 86 d(B)A “during shift change “which was a reduction of more than 80 percent in peak noise intensity. We were encouraged by that, and by the fact that our baseline noise level went from 45 to 42 d(B)A.
It’s also interesting that the residents who rotate through our unit notice that it’s quieter. They say that the atmosphere is different here than in other areas of the hospital.
Our goal now is to incorporate these changes in other parts of the hospital, and the administration has been very responsive and encouraging.
Have the study’s findings prompted other changes at the hospital or in physicians’ practice patterns?
Yes. In fact, the study itself and the work our sleep promotion team did to develop the interventions forced all of us to look at other things that might disturb patients’ sleep. A good example is how frequently we do vitals during the night and how often certain tests and procedures are ordered. The whole idea is to look at practice patterns in the larger context of patients’ ability to sleep and to think about limiting the number of times we interrupt our patients’ sleep.
For example, before starting the study, we gave patients Halcion to help them sleep. But when we were brainstorming with physicians during our staff education activity, the nurses mentioned that a lot of patients get confused after taking Halcion. As a result, it was taken off standing orders and we now use other drugs.
Bonnie Darves is a freelance writer specializing in health care. She is based in Lake Oswego, Ore.