Sunday, July 6

By S. Arun Vijay

A hospital must create a quiet, calm environment for patients by providing a physical setting conducive to recovery and an organizational culture that supports patients and families through the stresses imposed by illness, hospitalization, medical visits, healing and bereavement.

To accomplish this hospital employees must identify internal and external noise factors – is it voices, equipment or the building? The staff must also discern which noise sources are known controllable factors, known uncontrollable factors and unknown uncontrollable factors. The hospital must measure and reduce the noise in patient rooms within defined compliance levels.

Impact of Noise

Noise impacts patients in many ways including:

• Sleep deprivation
• Increased anxiety
• Increase in noise-induced stress
• A “startle reflex” resulting in physiological responses:
  • Facial grimacing
  • Increase in blood pressure
  • Higher respiratory rate
  • Increased heart rate and vasoconstriction

Continuous noise may alter a patient's memory, increase agitation, lower pain tolerance and lead to feelings of isolation.

Noise may also impact hospital employees causing:

• Stress related symptoms.
• Depression.
• Irritability and decreased concentration in the work place.
• Reduced efficiency and decreased productivity.
• Increased medical and nursing errors.

Figure 1: Source of Hospital Noise

Table 1: Priority Matrix – Identify Noise with Respect to Sources
Location	Source: People (Weighted Score, 0.40)	Source: Equipment (Weighted Score, 0.50)	Source: Environment (Weighted Score, 0.10)	Total Weighted Score
Reception (A)
Emergency department (B)
Outpatient departments (C)
Inpatients area (D)
Nursing station (E)
Diagnostic centers (F)
Pharmacy (G)
Operation theaters (H)
Intensive care units (I)
Canteen (J)
Laundry and linen services (K)

Using the Noise/Source Matrix

The matrix shown in Table 1 displays the source of noise in various locations of the hospital and records a mean weighted average, providing a clear picture of the noisiest hospital area and the worst noise source and establishing a clear priority of what to fix first.

Table 1: Noise Location Stratification According to Time of Day
Locations (noise measured in decibels)	A	B	C	D	E	F	G
Time Period
9:00 a.m.–1:00 p.m.
1:00 p.m.–4:00 p.m.
4:00 p.m.–7:00 p.m.
7:00 p.m.–10:00 p.m.
10:00 p.m.–7:00 a.m.
7:00 a.m.–10:00 a.m.

Interpreting the Stratification Technique

By measuring noise during peak and off peak hospital hours, analysts can detect and correct the noise. Noise meter readings established by a pollution control board offer quantitative readings that help predict, and therefore prevent, future noise problems.

Strategies to Solve Noise Pollution

After identifying the primary sources for noise pollution, the following improvement strategies can be implemented:

1. Establish stringent standards impacting patient safety.
2. Evaluate the current hospital noise through patient satisfaction surveys and by measuring the decibel levels.
3. Review the hospital's repair and maintenance policy and ensure it reflects the need for equipment to operate effectively and quietly.
4. Conduct an auditory impact query as part of every remodel and construction project, equipment purchase and staff event.
5. Change the ceiling tiles periodically from sound reflecting to sound absorbing tiles allowing patients to sleep better.
6. Convert a centralized nurse station to a decentralized nurse station.
7. Provide curtains and Plexiglas barriers in multi-bed rooms to provide both visual and auditory protection.
8. Use music therapy to replace noxious sounds with pleasant sounds – music improves restfulness and sleep, and induces relaxation.
9. Provide guidance and instruction during staff education and employee orientation sessions on the importance of maintaining appropriate noise levels.
10. Outline specific procedures regarding:
    • Private discussions in public areas
    • Use of pagers and cell phones
    • Nurse call systems
    • Telephone use
11. Place signs and slogans throughout the hospital – silent hospital help healing (SHHH) – and give patients, staff and visitors buttons that show a nurse with her finger to her lips.
12. Use sound meters to record ambient noise level at periodic times throughout the day.
13. Reduce waiting time in the outpatient departments. Schedule consulting times for the patients and fix appointments with the physicians during registration. Reducing the waiting time in turn reduces noise in the outpatient departments.
14. Display the location of offices and consultants at the reception area, and provide directories on each floor to minimize the need for visitors and patients to ask for directions.
15. Use an individual activity network diagram for each student in the hospital and ensure the faculty oversees the students in the clinical setting. This will minimize overcrowding of students in the clinical setting and streamline student activities.
16. Implement a SHHH program to recognize hospital staff and/or departments that excel at providing and maintaining a noise free environment.

Table 3: Noise Sources
Sources of Noise	Primary Area	Secondary Area	Tertiary	Location
People	• Unwanted movements of people(patients/employees) • Pooling of intermediate customers during consultation timing (representatives) • Exchange of information between employees (human voice) • Too many attenders accompanying the patients	• Frequent visiting of patient’s attenders in the nursing station/laboratory services for enquires • Pooling of students in the nursing station • Mishandling of accessories, which creates excessive noise • Load glucometer carts • Staff tend to have mini-conference in the hallway creating noise	• Frequent movement of people in parking facility creates unavoidable noise • Overcrowding of patient attenders in the canteen • Noise due to renovation/repair work done in the hospital	• Noise created by people from outside the hospital (public meeting announcements)
Equipment	• Ambulance noise • Patient vehicles • Mobility aid sounds • Telephone sounds • Overhead paging systems • Lifts operating noise	• Equipment handling • Noise in laboratories • Mobility aids and wheelchair sounds while transferring patients • Lifts operating noise • Telephones, trip alarms and intercom sound of beepers, bed rails, and ventilators • Portable X-ray machine sounds, blaring T.V. • Buzzers, beepers, multiple monitors, nurse call systems and doors	• Frequent movements of vehicles • Handling of equipment in the laundry and linen services • Noise created during transfer of incoming essential materials in the purchase departments • Utensils handling noise in canteens	• Vehicle sounds
Environment/system	• Improper/confused facility arrangements • Lack of display boards showing facilities available in the hospital leads to unwanted enquires resulting in noise	• Centralized nursing stations • Facility arrangements warranting noise in inpatient wards • Excessive students to patient ratio creates noise during clinical teaching	• Lack of knowledge in handling the equipments by workers involved in maintenance departments • Lack of space required for supportive services	• Hospital floor, wall and ceilings are hard and reflect sound rather than absorb it

Using quantitative and qualitative measures to identify and monitor noise levels in hospitals is critical to hospital efficiency. Reducing noise and maintaining a quiet facility will improve patient care and enhance the reputation of the hospital.

About the Author: Professor S. Arun Vijay is working as a principal physiotherapist at KG Hospital and Post Graduate Medical Institute. He completed his master's degree in Physiotherapy (MPT) and Business Administration (MBA). Mr. Vijay is a certified Six Sigma Green Belt from the Indian Statistical Institute and is currently undergoing Black Belt training. He has done various quality improvement projects in the health care sector using Six Sigma methodologies. Mr. Vijay may be reached at sarunvijay@yahoo.co.in.