Attention to hospital noise is on the rise — not merely because the HCAHPS survey has heightened awareness of the issue, but also because the hospital environment is a living, active organism. It breathes, it speaks and it has its own high level of acuity. In spite of all efforts to control how the environment sounds, it has its own life and decibel level.
Who Is the Alpha?
If you ever have had a dog, you know that the tug of war for control is ongoing. When a dog barks, you do whatever it takes to quiet it down. Usually, the quickest effective route is to give the dog a treat. The result, however, is more barking, more treats, more barking and, alas, the dog runs you and the house. It is no different with the hospital sound environment. And taming the environment is not unlike taming a dog.
Noise begets noise; it forces all of us to speak louder to hear each other better — 150 percent louder to be exact. Then, when we speak louder, we are the background to everyone else's conversations and they must speak louder still. We feed the beast and the beast grows.
Establishing Ground Zero
To create a quieter environment in the hospital, we must understand and take control of the noise that occurs prior to anyone's saying or doing anything. We must define the acoustic ground zero.
If we remove all the people, what remains is the "noise floor," the level over which every voice must rise. The noise floor results from the many technologies that continue at the same volume with or without people — heating, ventilation and air conditioning; ice machines that are usually put in a place more convenient than soundproof; and walls and floors that amplify every sound that bounces off them.
Next, let's consider the things that move. Doors that slam, because their hydraulic closers broke long ago, create a loud noise that is ignored by everyone except the patients. Then there are carts with hard wheels when rubber wheels would make them so much quieter and a bit of WD-40 would get rid of squeaks. Vacuum cleaners and floor waxers take over the unit with their irritating and familiar roar; they should be used only when they can be the least disruptive to patients and staff. Escalators and elevators are part of this sound story. The bell rings when the elevator stops, and the opening and closing of the doors reverberate off the walls.
Finally, there's the ongoing din of construction outside or around the patient areas.
Alarm fatigue, finally identified as a patient safety hazard, now is demanding new policies and practices. But since being identified as a critical safety issue, a standardized protocol for reducing alarm fatigue has yet to emerge and be implemented across health care.
The Human Equation
Once we start adding the human equation into a health care environment, the noise floor is multiplied many times.
People moving. People in motion — the sound of their feet on the floor — are noisy from the start. Florence Nightingale basically said that any patient subject to the rustling of a nurse's dress is being abused. Today's nurses are far louder.
Second, people walking mean people talking. No, not necessarily loud, but remember: Every component raises the noise floor.
Communication equipment. This is like the dog next door that barks and causes your dog to bark. At first, hospitals just had phones ringing and emergency paging systems. Now, there are phones ringing, some emergency paging, plus cellphones, personal pagers and people who respond to these devices where they are standing or walking, away from an appropriate place to talk.
Also, we talk into cellphones at a volume determined by where we are, not what we are hearing from the phone. Traditional telephones have a microphone that feeds us back our own voice. Mobile phones do not. So, we talk really loudly when we cannot hear — no matter where we are and who else is around. This does not happen with people who are wearing ear buds, but do we want nurses to walk around with one ear plugged into a phone?
Patients, visitors and others. Patients and visitors add their own sound environment. Elderly patients speak and are spoken to in raised voices. Televisions are blasting from the pillow or bed-rail speakers meant only for the patient, but are turned up so visitors also can hear. The noise floor, now enhanced to its second and third level, is where patients start to experience their condition, suffering, needs and fears.
There are solutions to all of these noisemakers. Nothing on its own is unmanageable. However, doing so requires a will and determination so consistent that noise never again takes control of the patient experience or the quality of the hospital environment.
At What Cost?
The incessant barking dog in the backyard becomes the drone of life in the house. Eventually, it is ignored by those who live there, but not by those who are visiting. What staff members tolerate, the patients cannot.
The cost of a noisy environment is high. The price of fixing it is relatively low, sometimes not even requiring a budget request.
The hidden costs for a high-noise environment include increased patient agitation, aggression and delirium; increased pain and less-effective pain management; slower wound healing; and violations of privacy. Sleep deprivation, increased falls, increased risk of medical and nursing errors, increased episodes of delirium, and nursing fatigue all add up to lower HCAHPSscores.
If you doubt the price for a noisy environment, try adding up the costs related to intensive care unit psychosis, in great part caused by a high-noise environment and sleep deprivation common to the ICU experience. In the United States, the cost of a single patient with delirium is 39 percent higher in the ICU and 31 percent higher in the hospital. The other costs that add up include errors, an increase in requested pain medication, and staff stress and fatigue. Recent statistics involving medical-alarm fatigue have human and economic implications, with clinical alarms being a top contributor to noise, and noise being a major patient safety hazard.
Improving the hospital sound environment mostly involves staff time, with perhaps some investment in new equipment or acoustical treatments. Solutions to the noise problem include:
Assessment. Figure out what to do by engaging everyone, including your own staff, to account for the current status. Then determine what is needed and the best outcome.
Acoustic treatments and sound-masking. Install new flooring that is quiet and cleanable as well as wall and ceiling treatments that are sound-absorbent and meet all regulatory controls. Look for other kinds of hospital-grade acoustic treatments that enhance speech privacy. Sound-masking can be effective with careful attenuation and balance. Music is also effective for masking and can be a positive distraction.
Equipment repair and maintenance. While hospitals are already paying for equipment repair, they need to focus on the auditory impact of each piece of equipment. Establish purchasing standards that require manufacturers to report the auditory impact to the user, environment and patient.
Communication technology policies. Control the dog before it controls you. Create a policy of use for every technology, training for the staff, and reporting of success or failure. There are several personal paging systems that work quite well, but raise the noise level and violate speech privacy. Without a policy, they are of no use.
Organizational culture. Every hospital culture has a "sound," not unlike the way families can be quiet or loud. It is clear that a loud family is loud — whether in a well-carpeted house or a shopping mall. So it goes with a hospital culture. Every acoustic fix can be made, but the culture will still be loud. The only way to shift that is to deal with it head-on.
Involve the staff in owning where they live. Have them reframe the environment to be an extension of their professional responsibilities. Educate, engage your staff, do ongoing assessment and hold everyone in your organization accountable. The goal is not to silence your organization, but to have the sound of your hospital reflect your mission and values.
Silence Is Not Necessarily Golden
A passive, inactive lump of a dog is not ideal. And, an environment devoid of appropriate sounds of hospitals involved in caring for patients is not the optimal outcome. In fact, a silent environment will backfire: The quieter the environment, the more transparent it is. Every single word, buzz or bell will be loud and clear as there will be nothing to stop the sounds from reaching exactly the wrong ears.
The challenge then is to design the sound environment. Create an appropriate noise floor that provides auditory cover, but is not disturbing or invasive. To improve the patient and visitor experience and not merely mask other sounds, add positive, therapeutic sounds where there are none, such as water fountains or appropriate music. This is especially true at night because the environment at that time is literally as hear-through as glass is see-through.
Realize that an appropriately designed auditory environment is dynamic, changing, resilient and responsive to what is needed. Its intention is healing and its demand is appropriate behavior. Nurses again will be able to trust what they hear and do not hear; conversations will occur at lower-volume levels. Your staff intuitively will know when not to talk in the halls or near the door of a patient's room. Self-regulation is the best outcome, and a quiet healing environment requires diligence and vigilance to maintain.
Noise begets noise. People make noise. Everything in the hospital makes noise. Silence is the auditory vacuum that adds to the perception of noise. So, to control the beast, go through every auditory layer, fix what needs fixing, and then, in a final act, work with everyone to shift the culture from loud to healing.
Susan E. Mazer, Ph.D., is the president and CEO of Healing HealthCare Systems in Reno, Nev., which produces The C.A.R.E.™ Channel.