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Running head: EFFECTS OF NOISE ON PATIENT SAFETY 1

Effects of Noise on Patient Safety in the Operating Room

Jacqueline E. Bertucci, CRNA MSN and Cassie M. Ishmael, CRNA MSN

Major Peter Strube CRNA MSNA APNP ARNP

Rosalind Franklin University of Medicine and Science

EFFECTS OF NOISE ON PATIENT SAFETY 2

Abstract

Noise is unavoidable in the operating room environment. Hospitalized patients are more

susceptible to the effects of noise because of their diminished capacity to cope during

stressful situations. The World Health Organization (WHO) recommends that operating

room noise levels should not exceed 30 dB (A). Elevated noise levels in the operating room

are correlated with negative physiological changes, hearing loss, tinnitus, patient anxiety

and distraction. Noise reduction measures are essential to ensure an optimal surgical

environment.

Keywords: operating room, noise, sound, physiologic effects, anesthetic needs, hazards


Objectives

1. Describe the physiologic effects of noise

2. Explain the effects of noise on anesthetic need

3. Define the hazardous effects of noise

4. Identify acceptable amounts of noise in operating room suites

5. Outline operating room noise reduction measures


Effects of Noise on Patient Safety in the Operating Room

Introduction

Noise comes from the Latin word nausea and is defined as any undesirable sound or

interference with the process of hearing (Merriam Webster, 2013). The importance of

noise in healthcare has been recognized for years, and had been described by Florence

Nightingale in 1859 as, “Unnecessary noise, then, is the cruelest absence of care which can

be inflicted either on sick or well” (Busch-Vishniac et al., 2005, p. 3629). Noise pollution

was identified as the third pollution in the operating room after air and water pollution by

Shapiro and Berland (1972). Noise poses several threats to the operating room

environment, including negative physiologic changes resulting in increased cortisol levels,

hearing loss, patient anxiety, and distraction.

The World Health Organization (WHO) describes that hospitalized patients are

more susceptible to the effects of noise because of their diminished capacity to cope during

stressful situations (WHO, 1999). Decibel (dB) is a unit used to express the magnitude of

change in sound frequency (Soucy, Ko, Denstedt, & Razvi, 2008). A weighted scale, dB (A) is

used in clinical practice due to its ability to closely resemble the human ear in the

frequency spectrum (Fritsch, Chacko, & Patterson, 2010). Considerable discrepancy

remains in regards to recommended noise levels in the operating room (OR) by national

regulation agencies. WHO (1999) recommend that OR noise levels should not exceed 30 dB

(A). The Occupations Safety and Health Administration (OSHA) recommend that noise

levels should not exceed 90 dB for an eight-hour time period (OSHA, 1974). The National

Institute for Occupational Safety and Health (NIOSH) of the Centers for Disease Control and


Prevention recommend noise exposure should not exceed 85 dB for an eight-hour time

period (NIOSH, 1970).

Documented noise levels in the operating room range from 55 to 86 dB, depending

upon the surgical procedure performed (Kim, Kil, & White, 2001). Comparison of baseline

noise levels; 20 dB is associated with a quiet environment, 50 dB with normal conversation

and 70 dB is comparable to street traffic (Kurmann et al., 2011). Advancing technology and

enhancements in anesthetic safety have increased the number of auditory alarms,

contributing to growing noise levels amongst operating rooms (Kim, Kil, & White, 2001).

Noise levels in the operating room interfere with the anesthesia provider’s ability to

provide optimal levels of anesthetic care. Elevated noise levels in the OR present as a

hazard and are associated with patient related physiologic responses and alter patient

anesthetic need.

Review of Literature

A literature search was conducted in May 2012. The search for primary research

articles written in English was performed in Medical Literature Online (Medline),

Cumulative Index to Nursing (CINAHL) and Academic Search Premier (ASP) databases

using the following search terms: operating room, noise, sound, physiologic effects,

anesthetic needs and hazards. Abstracts were reviewed for suitable articles and the

reference list of each article was examined for additional sources.

Physiologic Effects of Noise

Noise levels in the operating room have been correlated with patient related

physiologic responses. Studies demonstrate that auditory processing functions remain

intact during anesthesia (Tsuchiya et al., 2003). Manipulation of auditory input the patient


receives during anesthesia may modify their response to surgical stress. Subconscious

memories, with auditory input, during general anesthesia may exist postoperatively. Vivid

memories of noise under propofol anesthesia have been reported. Inhibitory properties of

anesthetics cause the effects of noise to be blunted during the maintenance phase of

general anesthesia.

Physiologic responses originate from the stress response which stimulates the

sympathetic nervous system (Kam, Kam, & Thompson, 1994). Researchers have identified

negative effects of intraoperative noise exposure including tachycardia, hypertension, an

elevation in stress cortisol response and psychological effects (Fritsch, Chacko, & Patterson,

2010). Sympathetic responses also include peripheral vasoconstriction and dilation of the

pupils (Shapiro & Berland, 1972). Elevated noise levels have been identified and remain a

significant concern hospital-wide.

Morrison et al. (2003) studied the effects of elevated noise levels in the intensive

care unit setting. Researchers identified excessive noise levels correlate with patient

annoyance, prolonged length of stay, abnormal sleep patterns, intensive care “psychosis”

and delayed wound healing. Cardiovascular measurements including blood pressure, heart

rate, ectopy frequency, variability and ST segment changes have been evaluated in stress

studies. Researchers have displayed variable results in studies with animals. In human

studies, acute changes in heart rate were noted to be greatest with uncontrollable noise

and specific personality types.

A significant association has been identified between intraoperative noise levels and

the development of surgical site infection (Kurmann et al., 2011). Researchers noted the

median noise levels above baseline were considerably higher in patients that developed a


postoperative surgical site infection. The greater elevation of peak noise levels above the

median in those who developed surgical site infection may have been the result of noise

from various sources. Sources that attribute to the elevation in noise levels include

conversation between individuals, background noise, monitors, alarms, suction devices and

surgical instruments. Intraoperative noise levels may enhance factors including surgical

difficulty, lack of concentration, lack of discipline or stress among the OR leading to surgical

site infection.

Studies have also evaluated the association of noise levels on salivary hormone

release. The measurements of salivary biomarkers have been evaluated in studies as stress

biomarkers (Arai et al., 2008). Levels of salivary alpha-amylase have been associated with

autonomic nervous system changes and are utilized as an index for psychological stress.

The study results identified that intraoperative natural sounds significantly reduce salivary

amylase activity in patients under epidural anesthesia.

Hazardous Effects of Noise

Elevated operating room noise levels increase the risk of hazardous effects on

surgical patients. Operating room sources of noise can be categorized into two primary

groups: sources related to surgical and anesthesia equipment and sources related to

operating room staff conduct (Fritsch, Chacko, & Patterson, 2010). Equipment including

metal tools, suction and anesthesia monitors produce significant noise levels with routine

use. Otolaryngology, orthopedics and neurosurgery commonly use devices that regularly

surpass noise level recommendations. Exposure to elevated noise levels may lead to

hearing loss, tinnitus and noise related physiologic stresses (Love, 2003). Causes of noise

induced hearing loss (NIHL) are related to sound level, frequency, duration and exposure


pattern. Factors that predispose patients to hearing loss include elderly age, comorbid

conditions, medications, substance addiction and previous cumulative exposures. Noise

induced hearing loss remains the most common cause of acquired hearing loss. Nott and

West (2003) identified peak noise levels of 100 dB (A) during orthopedic surgery. Multiple

orthopedic surgeries place the surgical patient at the greatest risk.

Music is frequently played in the OR to provide a comfortable environment for the

patient, to placate the surgeon, and to maintain a pleasurable work environment for the

surgical staff. Music can be a distraction, cause communication breaks and can affect

surgical outcomes. Sanderson et al. (2005) reported that most participants of simulated

anesthesia indicated that monitoring was enhanced without the presence of music and

reported reduced concentration with music.

The ability to communicate effectively in the OR is essential to safely perform

patient care. For speech to be easily understood it needs to be 10-15 dB above the ambient

noise level (Stringer, Haines, & Oudyk, 2008). Operating room noise can quickly rise above

recommended levels and impair communication. This study measured average and peak

noise levels in operating rooms as well as operating room nurse perceptions on speech

interference in a variety of surgical specialties. Results revealed that effective

communication is more difficult to accomplish during times of increased noise levels.

Increased noise levels can also cause the Lombard effect, where speech levels are increased

in order to counteract the background noise (Kam, Kam, & Thompson, 1994).

Effects of Noise on Anesthetic Need

Non-pharmacological interventions such as music, meditation and guided imagery

have all been shown to have a positive impact on patient surgical experience. The use of


peaceful sounds has proven beneficial, while others have speculated the effect may be due

to the suppression of ambient operating room noise. Bispectral index scores (BIS) have

been utilized to determine depth of anesthesia as it demonstrates correlation with the

Observer’s Assessment of Anesthesia Sedation (OAA/S) score in anesthesia with propofol.

The suppression of ambient operating room noise resulted in reduced BIS scores under

combined spinal-epidural and propofol infusion during total knee replacement surgery

(Kang, Lee, Kim, Kim, Kim, Hahm, & Lee, 2008). Ganidagli et al. (2005) noted that reduction

in sedative requirements may be related to elimination of ambient operating room noise.

Hemisync sounds represent a modern approach to the application of sound to assist

in relaxation, meditation, stress reduction, pain management and sleep (Dabu-Bondoc et

al., 2010). Both Kliempt, Ruta, Ogston, Landeck, and Martay (1999) and Lewis, Osborn, and

Roth (2004) reported patients required significantly less intraoperative fentanyl while they

received Hemisync sounds under general anesthesia. Lewis et al. (2004) evaluated the

effects of Hemisync sounds on participants that received bariatric or lumbar surgery under

general anesthesia. The study reported bariatric participants required less fentanyl, while

the lumbar participants required the same amount of fentanyl.

Conclusion

Noise in the operating room is a major challenge that presents as a hazard and is

associated with patient related physiologic responses and affects anesthetic need.

Advancing technology and enhancements in anesthetic safety have increased the number

of auditory alarms that contribute to rising noise levels among the operating room.

Operating room noise levels continue to be measured above recommended guidelines. It is

imperative to acknowledge that noise levels continue to increase in the operating room


environment and implementation of noise reduction protocols are essential to ensure an

optimal surgical environment.

Discussion

Studies have consistently identified the negative effects of elevated noise level

exposure. With the growth of a modern technological age, concerns of noise pollution

continue to arise. Average daytime noise levels have grown from 57 dB, during the 1960’s,

to 72 dB by 2005 in acute care hospitals (AORN, 2009). Noise reduction interventions have

been suggested due to the growing concerns of the hazardous effects of noise.

Recommendations have included the use of soft-soled shoes for staff, elimination of

multiple occupancy patient rooms as well as the introduction of quieter alarms (Morrison,

Haas, Shaffner, Garrett, & Fackler, 2003). It is also suggested that staff set pagers to vibrate,

reduce the amount of overhead pages and limit the amount of unnecessary conversation.

The Association of Perioperative Registered Nurses (AORN) position statement

acknowledges that noise is unavoidable in the perioperative environment and supports

noise reduction measures (AORN, 2009). Identifiable contributing factors of noise include

beepers, cell phones, overhead pages, alarms, electronic music devices, medical devices and

equipment, pneumatic tube systems and communication. AORN suggests that noise

reduction measures in the following domains of administrative, engineering/facilities and

behavioral interventions should be considered when developing an action plan.

Administrative interventions involve promoting a team effort in brainstorming

strategies for noise reduction, evaluating communication methods, muting all nonessential

communication devices, limiting the type of music and specifying a volume level during

procedures (AORN, 2009). Engineering interventions include measuring noise levels,


setting trigger points appropriately on devices, replacing noisy metal carts, using trash and

linen bins that use a damping system to slowly close the lid and investigating less

distracting ringtones. Recommended behavioral interventions consist of assessing one’s

own voice tone and volume, expecting all team members to be personally responsible for

managing the noise they generate, limiting telephone conversations, minimizing the

number of people during the procedure and number of door openings and instituting

specific times when noise levels should be reduced, particularly during induction and

emergence of general anesthesia.

Intraoperative noise is an unavoidable distraction that disrupts patient care and

potentially increases the risk of error (AORN, 2009). Measures can be taken to minimize

the undesirable effects of intraoperative noise. Team development of hospital-wide

protocols is an essential step in noise reduction measures. With the development and

implementation of hospital-wide protocols, excessive operating room noise can be

eradicated.


References

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CE Questions

1. In 1972, Shapiro and Berland identified three pollutants in the operating room:

a. Air

b. Exhaust

c. Water

d. Noise

2. Physiological effects of noise exposure include all of the following EXCEPT:

a. Hypertension

b. Tachycardia

c. Pupil constriction

d. Peripheral vasoconstriction

3. The hazardous effects associated with noise include all of the following EXCEPT:

a. Diminished capacity to cope with stress

b. Emergence delirium

c. Tinnitus

d. Hearing loss

4. According to the Occupational Safety and Health Administration (OSHA), what is the

acceptable amount of noise in operating room suites in an eight-hour period?

a. 70 dB

b. 80 dB

c. 90 dB

d. 100 dB


5. Patients exposed to music intraoperatively experience a ______________ _______________

in the use of propofol.

a. significant reduction

b. significant increase

c. moderate reduction

d. moderate increase

6. Which item is a predisposing factor for hearing loss:

a. Male gender

b. Cardiac conditions

c. Substance addiction

d. Previous exposure to asbestos

7. For speech to be easily understood it needs to be_________ above the ambient noise

level:

a. 5-10 dB

b. 10-15 MHz

c. 10-15 dB

d. 15-20 MHz

8. Which three subspecialties most commonly use instruments that regularly exceed

noise level recommendations?

a. Otolaryngology

b. Neurosurgery

c. Ophthalmology

d. Orthopedics

9. A phenomenon called _____________ ____________occurs when speech levels are

increased in order to counteract background noise.


a. Geneva result

b. Johnson product

c. William’s outcome

d. Lombard effect

10. The effects of Hemisync sounds represent a modern approach to assist in (select 3):

a. Relaxation

b. Alcohol dependence

c. Stress reduction

d. Pain management

11. Studies have demonstrated that auditory processing functions remain intact during

anesthesia:

a. True

b. False

12. Street traffic sound levels have been measured at _______ dB:

a. 70

b. 90

c. 110

d. 130

13. Advances in technology assist in the reduction of operating room sound levels:

a. True

b. False

14. The inhibitory properties of anesthetics most effectively blunt the physiologic

effects of sound levels during _______________________________:

a. monitored anesthesia care


b. induction of anesthesia

c. maintenance of anesthesia

d. emergence of anesthesia

15. Since the mid-1900’s sound levels in operating rooms have?

a. Decreased

b. Remained consistent

c. Increased

16. An administrative intervention in the promotion of effective sound level reducing

measures would include (select 2):

a. Muting all non-essential communication devices during the procedure

b. Measuring sound levels

c. Institute specific times when noise levels should be reduced

d. Promoting a team effort in brainstorming strategies for noise control

17. Recommended engineering interventions in the promotion of sound reduction

consist of _________________:

a. use of trash and linen bins that use a damping system to slowly close the lid

b. evaluating communication methods

c. limiting the type of music and specify a volume level

d. minimize the number of people during the procedure

18. Behavioral interventions that support sound level reduction include (select 2):

a. Setting trigger points appropriately on devices

b. Replacing noisy metal carts

c. Assessing one’s own voice tone and volume

d. Limiting telephone conversations

19. Increased levels of __________________ salivary secretions have been associated with

autonomic nervous system changes as a result of psychological stress.

a. polytene chromosomes


b. amylase chromosomes

c. alpha-amylase

d. beta-amylase

20. A negative effect of intraoperative noise exposure includes an elevated cortisol

response.

a. True

b. False

CE Answers1. a, c, d

2. c


3. b

4. c

5. a

6. c

7. c

8. a, b ,d

9. d

10. a, c, d

11. a

12. a

13. b

14. c

15. c

16. a, d

17. a

18. c, d

19. c

20. a

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