Stop the Noise : A Quiet Environment Promotes Healing
ALARMES BRUITS VOIX FORTES SANS CESSE DERANGEANT MANQUE DE SOMMEIL SANS REPOS ENVIRONNEMENT POUR GUERIR ALARMES BRUITS VENVIRONNEMENT SSE DERANGEANT MANQUE DE SOMMEIL SANS
REPOS ENVIRONNEMENT POUR GUERIR ALARMES BRUITS VOIX FORTES SANS CESSE DERANGEANT MANQUE DE SOMM SANS REPOS ENVIRONNEMENT POUR GUERIR ALARMES BRUITS VOIX FORTES SANS CESSE
DERANGEANT MANQUE DE SOMMEIL SANS REPOS ENVIRONNEMENT POUR GUERIR ALARMES BRUITS VOIX FORTES SANS CESSE DERANGEANT MANQUE DESOMMEIL SAN NVIRONNEMENT POUR GUERIR ALARMES
MAI
NGUYEN
,
JULIE
KINNON
,
BEA
KRISTINE
CANAPI
,
MARTIN
DARBOUZE
,
JOSIE
DEL
CAMPO
,
WINSOME
WRIGHT
VOIVOIX FORTES SANS CESSE DERANGEANT MANQUE DE SOMMEIL SANS REPOS ENVIRONNEME POUR GUERIR ALARMES BRUITS VOIX FORTES SANS CESSE DERANGEANT MANQUE DE SOMMEIL SANS REPOS ENVIRON
INTENSIVE CARE UNIT - MONTREAL GENERAL HOSPITAL, MCGILL UNIVERSITY HEALTH CENTRE
POUR GUERIR ALARMES BRUUITS QUIITS VOIX FORDERANGE SANS CESSE DERANG SANS REPOS ENVIRONNEMENT POUR GUERIR ALARMES BRUITS VOIX FORTES SANS CESSE DERANGEANT MANQUE DE SOMMEIL
SANS REPOS ENVIRONNEMENT POUR GUERIR ALARMES BRUITS VOIX FORTES SANS CESSE DERANGEANT MANQUE DE SOMM UITS SANS REPOS ENVIRONNEME POUR GUERIR ALARMES BRUITS VOIX FORTES SANS
  OUTCOMES
CESSE
DERANGEANT
MANQUE
DE
SOMMEIL
SANS
REPOS
ENVIRONNEMENT
POUR
GUERIR
ALARMES
BRUITS
VOIX
FORTES
SANS
CESSE
DERANGEANT
MANQUE
DE
SOMME
SANS
REPOS
ENVIRONNEMENT
POUR
GUERIR
sdsdfsdf
SOUND
LEVEL
COMPARISON
INTRODUCTION  
Random sound level measurements
Most ICU environments
have noisetalking
levels far above the loud
World Health
Organization (WHO)
Excessive
alarmsnon
stop
noises
norecommendations.
rest disruptions
no healing environment loud alarms ringing beeping talking RESTINGloudly constant
noise
no
rest
disruptions
healing
before and 8 months after project
noise in ICU has been found to have negative impacts on the physiological and psychological health of patients. Important
implementation revealed some noise
PHASE
(
1
)
environment
talking
ringing
beeping
talking
healing
environment
loud
alarms
ringing
beeping
talkiNg
loudly
constant
noise
no
rest
links between error rate and
environmental alarms
noise have been established.
Noise reduction
strategies aimed
at behaviour loudly constant noise no rest disruptions
PHASE
(
3
)
reduction.
FORMING THE PROJECT COMMIT TEE
change have revealed a reduction in environmental noise in hospitals. This quality improvement project sought to raise
disruptions
healing
environment
loud
noise
ringing
beeping
talking
loudly
constant
noise
non
stop
rest
disuptions
healing
environment
loud
alarms
ringing
beepinG
talking
loudly
IMPLEMENTING
STRATEGIES
TO
REDUCE
NOISE
LEVELS
•
14
Staff
Nurses
volunteers.
awareness of noise in our unit and test out strategies to create a quiet healing environment for our patients and families.
• Task division: survey & intervention groups.
constant noise no rest disruptions healing environment loud
alarms
ringing
beeping talking
loudly
constant
noise
no
rest
disruptions
healing
environment
loud
alarms
beeps
loudNESS
• Communication
via monthly meetings
& e-mail.
EDUCATION
ACTIONS
STAFF
SURVEY
RESPONSES
• Poster emphasizing
environment
nonstop
loudalarms
ringing beeing talking loudly consTant HEALING REST noise
non stop
no
rest
talking
loudly
constant
noise
no
rest
disruptions
healing
LITERATURE
REVIEW

• Lowering alarm monitor
A Quieter Environment Nurses
answered
a
survey
with
open-ended
questions
8
months
after
the
project.
negative impact of
One Voice at a Time
volumes.
[1]
WHO
states
that
hospital
noise
levels
should
not
exceed
45dB(A)
during
the
day
and
30
dB(A)
during
the
night.
PHASE
(rest
2)
talking
loudly
constant
noise
no
rest
disRuptive
non
stop
no
healing
environment
loud
alarms
ringing
disruptions
healing
environment
loud
alarms
ringing
beeping
• Individualizing alarm
noise.
[2] Studies in ICUs reported average noise levels of 60-70 dB(A) with peaks over 90dB(A).
IS NOISE AN ISSUE IN OUR UNIT?
Nurses identified
parameters.

• Presentation &
eeping
talking
loudly
constant
noise
non
stop
HEALING
[3] Negative effects of noise on patients include: sleep disturbance, increased stress response, immunosuppression,
noise-reduction
• Responding quickly to
discussion during
SOUND MEASUREMENTS
delirium, and delayed healing.
alarms,
call
bells
&
phones.
strategies
they
AM
Nursing
Rounds
DE SOMMEIL
SANS
REPOS
ENVIRONNEMENT
POUR
GUERIR
ALARMES
BRUITS
VENVIRONNEMENT
SSE
DERANGEANT
MANQUE
ALARMES
BRUITS
VOIX
FORTES
SANS
CESSE
DERANGEANT
MANQUE
Nurses felt positively
• Sound level measurements in patient rooms
[4] Equipment alarms ringing near ICU patients’ heads contributes to interruption of sleep.
had
used.
•
Reducing
volumes
on
• Posting of current
about
the
signage.
and
the
hallways
were
taken
during
day,
phones
and
IV
pumps.
[5] Patients
and families
felt privateSANS
rooms wereCESSE
quieter but hallway
noise continued to be a MANQUE
problem.
BRUITS
VOIX
FORTES
DERANGEANT
DE SOMM SANS REPOS
ENVIRONNEMENT
POUR
GUERIR
ALARMES
BRUITS
DE
SOMMEIL
SANS
REPOS
ENVIRONNEMENT
POUR
GUERIR
ALARMES
journal
articles
Nurses
described
evening and night.
•
Adjusting
music
volume
to
Nurses
felt
families
[6] Measured noise levels before and after an educational and awareness campaign indicated noise reduction.
• Distribution of
important risk factors
•
The
following
were
also
measured:
VOIX
FORTES
SANS
CESSE
DERANGEANT
MANQUE
DE
SOMMEIL
SANS
REPOS
ENVIRONNEMENT
POUR
GUERIR
ALARMES
BRUITS
VOIX
FORTES
SANS
CESSE
DERANGEANT
MANQUE
DESOMMEIL
SAN
NVIRONNEMENT
POUR
patients’
preference.
were
impacted
[7] Earplugs could be a reasonable noise-reduction strategy for improving sleep in certain ICU patients.
of noise.
handouts >>>
• Closing doors during
by noise.
GUERIR ALARMES VOIVOIX FORTES SANS CESSE DERANGEANT MANQUE DE SOMMEIL SANS REPOS ENVIRONNEME POUR GUERIR ALARMES
rounds & at night.BRUITS VOIX FORTES SANS CESSE DERANGEANT MANQUE DE SOMMEIL SANS
Nurses
were
able
to
identify
Nurses are thinking about
OBJECTIVES

REPOS
ENVIRON POUR
GUERIR ALARMES BRUUITS QUIITS VOIX FORDERANGE SANS CESSE DERANG SANS REPOS ENVIRONNEMENT POUR GUERIR ALARMES BRUITS VOIX
FORTES
SANS
CESSE
DERANGEANT
MANQUE
DE
safe
dB(A)
levels
.
future
strategies
.
SIGNAGE
STAFF SURVEY
• Explore nurses’ perceptions of noise and its impact on patients.
SOMMEIL
SANS
REPOS
ENVIRONNEMENT
POUR
GUERIR
ALARMES
BRUITS
VOIX
FORTES
SANS
CESSE
DERANGEANT
MANQUE
DE
SOMM
UITS
SANS
REPOS
ENVIRONNEME
POUR
GUERIR
ALARMES
BRUITS
VOIX
FORTES
SANS
• Sensitize nurses to the negative impact of noise on patients, family and staff.
Quotes to Remember and Make Part of our Care
•
Identify
sources
of
noise
in
our
unit.
  LIMITATIONS
CESSE
DERANGEANT
MANQUE
DE
SOMMEIL
SANS
REPOS
ENVIRONNEMENT
POUR
GUERIR
ALARMES
BRUITS
VOIX
FORTES
SANS
CESSE
DERANGEANT
MANQUE
DE
SOMME
SANS
REPOS
ENVIRONNEMENT
POUR
GUERIR
Reminding
& Encouraging Change
in Practice
• Develop unit-based noise reduction strategies.
• Project was directed mostly towards nurses.
• Evaluate the impact
of the project
on staff and
the environment.
alarmsnon
stop
talking
loud
noises no rest disruptions no healing environment loud alarms ringing beeping talking RESTINGloudly constant noise
no
rest
disruptions
healing
environment
• Low survey response rate (patient & family survey, post-intervention nursing survey).
• Environmental
variability noise
during soundno
measurements.
talking alarms ringing beeping talking loudly constant noise no rest disruptions healing environment loud alarms ringing beeping talkiNg loudly
constant
rest disruptions healing
METHOD


environment loud noise ringing beeping talking loudly constant noise non stop rest disuptionsEveryone
healing
environment loud alarms ringing beepinG talking loudly constant
noise
no
rest
Can Help Promote


CONCLUSION
SETTING
QUANTITATIVE
a Quiet, Healing Environment
disruptions
healing
loud alarms ringing beeping
loudNESS
talking
constant
“Stop thebeeps
Noise - A Quiet
Environment Promotes
Healing” was aloudly
project pioneered
by ICU
PATIENT &talking
FAMILY SURVEY loudly constant noise no rest disruptions healing environment loud alarms
• Sound meter measurements
before andenvironment
after
nurses to highlight the issue of excessive noise in the ICU. This quality improvement project
the project.
noise no rest disruptions healing environment nonstop loud alarms ringing beeing talking loudly consTant HEALING REST noise non stop no was
rest
disruptions
healing
environment
loud
successful in raising the nurses’ awareness of noise in our unit. Results of our surveys and
QUALITATIVE
sound
measurements
established
that
noise
is
disturbing
and
that
some
simple
strategies
can
alarms
ringing
beeping
talking
loudly
constant
noise
no
rest
disRuptive
non
stop
no
rest
healing
environment
loud
alarms
ringing
eeping
talking
loudly
constant
noise
non
stop
HEALING
sg
• Survey (before project):
make a difference in the “health” of our environment.
- staff perception
ALARMES
BRUITS
VOIX
FORTES
SANS
CESSE
DERANGEANT
MANQUE
DE
SOMMEIL
SANS
REPOS
ENVIRONNEMENT
POUR
GUERIR
ALARMES
BRUITS
VENVIRONNEMENT
DE
SOMMEIL
We lookSSE
forwardDERANGEANT
to future developments of this MANQUE
project in order to sustain
this change. We aim SANS
- patient & family perception
• University-affiliated teaching hospital in Montreal (~500 beds)
to continue developing new signage and awareness strategies, to include ancillary and profesREPOS
POUR
GUERIR
• SurveyENVIRONNEMENT
(after project):
• ICU staff
with variableALARMES
levels of experience. BRUITS VOIX FORTES SANS CESSE DERANGEANT MANQUE DE SOMMEIL SANS REPOS ENVIRONNEMENT POUR GUERIR ALARMES BRUITS VOIX FORTES SANS CESSE
sional staff in the project and to consider a “noise policy” in our unit. Finally, we would like test
staff perception & behavioral change
• Staff and patients from a culturally diverse population.
the use ofSAN
earplugs NVIRONNEMENT
on appropriate patients and considerPOUR
conductingGUERIR
a formal researchALARMES
project.
DERANGEANT MANQUE DE SOMMEIL SANS REPOS ENVIRONNEMENT POUR GUERIR ALARMES BRUITS VOIX FORTES SANS CESSE DERANGEANT MANQUE DESOMMEIL
VOIVOIX FORTES SANS CESSE DERANGEANT MANQUE DE SOMMEIL SANS REPOS ENVIRONNEME POUR GUERIR ALARMES BRUITS VOIX FORTES SANS CESSE DERANGEANT MANQUE DE SOMMEIL SANS REPOS ENVIRON
POUR GUERIR ALARMES BRUUITS QUIITS VOIX FORTES DERANGE SANS CESSE DERANG SANS REPOS ENVIRONNEMENT POUR GUERIR ALARMES BRUITS VOIX FORTES SANS CESSE DERANGEANT MANQUE DE SOMMEIL
Acknowledgements
Further
Information
Affiliations
References
SANS REPOS ENVIRONNEMENT
POUR GUERIR ALARMES BRUITS VOIX FORTES SANS CESSE DERANGEANT MANQUE DE SOMM UITS SANS REPOS ENVIRONNEME POUR GUERIR ALARMES
BRUITS VOIX FORTES SANS
CESSE DERANGEANT MANQUE DE SOMMEIL SANS REPOS ENVIRONNEMENT POUR GUERIR ALARMES BRUITS VOIX FORTES SANS CESSE DERANGEANT MANQUE DE SOMME SANS REPOS ENVIRONNEMENT POUR GUERIR
MAI NGUYEN
JULIE KINNON
alarmsnon stop talking loud noises no rest disruptions no healing environment loud alarms ringing beeping
talking
RESTINGloudly
constant
noise
no
rest
disruptions
healing
environment
main13@videotron.ca julie.kinnon@muhc.mcgill.ca
talking alarms ringing beeping talking loudly constant noise no rest disruptions healing environment loud alarms ringing beeping talkiNg loudly constant noise no rest disruptions healing
environment loud noise ringing beeping talking loudly constant noise non stop rest disRuptions healing environment loud alarms ringing beepinG talking loudly constant noise no rest
RN, BScN, CCRN, CNRN, CNCC(c)
BScN, MScN
RN, BScN
RN, BScN
RN, CNCC(c)
RN, BScN
. . . W H AT W E D I D . . .
[dB] Noise Levels in the ICU Before and After Applying Noise Reduction Measures 80 70 60 50 40 30 20 10 0 Before A1er Before DAY Why reducing
unnecessary noise is
important to our patients?
Empty Room (no equipment) - 50 db(A)
CT (portable) - 72 dB(A) POD Meeting - 65-75 db(A)
Monitor Alarm - 79 dB(A) IV Pump Alarm - 70 dB(A)
Phone Ring - 60-70 dB(A) Humidifier - 100 dB(A)
“ I now try closing patient
room doors more often.”
“ I speak more quietly outside
patient rooms. ”
“ I avoid crushing pills
when I can.”
* Noise reduction helps them heal.
* 4 to 5 hours of continuous
sleep decreases overall stress
levels.
* Patients who get adequate
sleep are better able to participate
in their care.
* No one likes interruptions when
trying to fall asleep.
* Noise management is part of
total patient care.
* Good service is partly defined
by a quiet healing environment.
“ Sleep deprivation ”
“ Increased error rate ”
“ Psychosis & restlessness”
“ Music therapy ”
“ Place sound measuring devices
in the unit. ”
“ Establish non-disturbance
periods. ”
“ Involve others in the project
(e.g. housekeeping, physicians) ”
Do patients develop anxiety, panic, or paranoia from overhearing conversations between staff? Do you experience "alarm fatigue" when working in the ICU? Do frequent warning alarms interfere with care delivery to patients? 0
20
40
Yes
60
80
100
[%] No
Excess noise and alarms can increase stress, anxiety and confusion in ICU patients Excess noise and monitor alarms have a substantial impact on patients' sleeping pattern Recurrent warning alarms can reduce trust in seriousness of the call 0 Strongly Agree 10 Agree ICU: 22 BEDS, HALLWAY DESIGN
MedICAL/SURGICAL/TRAUMA
Not at All Phones rings Very Slow Medical devices Slow Housekeeping staff/
Fast Health-­‐care Very Fast 20 30 40 [%] 40 50 60 70 Strongly Disagree 80 90 100 [%] NEAR MONITOR / IV PUMPS
ABOVE VENTILATOR
MEDICATION PREPARATION
ABOVE LIGHT SWITCHES
Patient Survey on RNs' Alarm Response Rate Footsteps 10 30 Disagree Noise Contributors 0 20 50 0 60 10 20 [%] 30 40 50 Will music in your room help you sleep? Do monitoring alarms interfere with your sleep? IN FRONT OF PATIENT ROOMS
Are you often awoken by excessive noise in the ICU? 0 20 40 Yes [1] Dennis, C.M. et al (2010). Benefit of Quiet Time for Neuro-Intensive Care Patients, Journal of Neuroscience Nursing, 42(4), 217-224.
[2] Cmiel, C.A. et al (2004). Noise Control: A Nursing Team’s Approach to Sleep Promotion. American Journal of Nursing, 104(2), 40-48.
[3] Lower, T.S., Bonsak, C., Guion, J. (2003). Peace and Quiet Nursing Management, 34(40), 40A-40D.
[4] Tracy, M.F. & Chlan, L. (2011). Nonpharmacological Interventions to Manage Common Symptoms in Patient Receiving Mechanical Ventilation.
Critical Care Nurse. 31(3). 19-27
[5] Trochelman, K. Albert, N.et al (2012). Patients and their Families Weigh In on Evidence-Base Hospital Design. Critical Care Nurse, 32(1), e1-e10.
[6] Duart et al. (2012). Practicing Silence: Educational Intervention For Reducing Noise In The Intensive Care Unit. Rev. Bras. Enferm. 65(2): 285-90.
[7] Rong-Fang, H., Xiao-ying et al. (2010). Effects of Earplug, Eye Masks on Nocturnal Sleep, Melatonin and Cortisol in a Stimulated ICU Environment.
Critical Care. 14: R66
No 60 80 100 [%] * Other members of the Project Committee: Jacynthe Caron, Amanda DiFlorio, Margaret Hemmings,
Seny Lopez, Olga Novak, Myriam Pelletier, Nola Young
* Contributors to visuals: Eshwari Ambalapady, Louise Beauregard, Andrei Belkin, Josie del Campo,
Nadia Feroze, Akeyicha Gittens, Dr. Ash Gursahaney, Dr. David Hornstein, Julie Kinnon, Tony Paolucci
* The staff of the Montreal General Hospital ICU for their participation.
* The management team of the Montreal General Hospital ICU for their support.
UNIT MAIN ENTRANCE
“ The signage reminded people
to be quiet. ”
“ The SILENCE and HEALING
poster reminded me of the
impact of noise. ”
“ I was happy to see the reminder
to reduce pill crushing. ”
“ Noise can be perceived
as unprofessional. ”
“Noise added to their
stress level. ”
EVENING A1er Before A1er NIGHT