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 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 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 SANSCESSE DERANGEANT MANQUE DE SOMMEIL SANS REPOS ENVIRONNEMENT POUR GUERIR ALARMES BRUITS VOIX FORTES SANS CESSE DERANGEANT MANQUE DE SOMME SANS REPOS ENVIRONNEMENT POUR GUERIR alarmsnon stop talking loud noises no rest disruptions no healing environment loud alarms ringing beeping talking RESTINGloudly constant noise no rest disruptions healing environment 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 disuptions healing environment loud 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 alarms beeps loudNESS

talking loudly constant noise no rest disruptions healing environment nonstop loud alarms ringing beeing talking loudly consTant HEALING REST noise non stop no rest disruptions healing environment loud alarms ringing beeping talking loudly constant noise no rest disRuptive non stop no rest healing environment loud alarms ringingeeping talking loudly constant noise non stop 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 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 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 SANSCESSE DERANGEANT MANQUE DE SOMMEIL SANS REPOS ENVIRONNEMENT POUR GUERIR ALARMES BRUITS VOIX FORTES SANS CESSE DERANGEANT MANQUE DE SOMME SANS REPOS ENVIRONNEMENT POUR GUERIR alarmsnon stop talking loud noises no rest disruptions no healing environment loud alarms ringing beeping talking RESTINGloudly constant noise no rest disruptions healing environment 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 disuptions healing environment loud 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 alarms beeps loudNESS talking loudly constant noise no rest disruptions healing environment nonstop loud alarms ringing beeing talking loudly consTant HEALING REST noise non stop no rest disruptions healing environment loudalarms 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 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 SOMMEIL 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 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 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 SANSCESSE DERANGEANT MANQUE DE SOMMEIL SANS REPOS ENVIRONNEMENT POUR GUERIR ALARMES BRUITS VOIX FORTES SANS CESSE DERANGEANT MANQUE DE SOMME SANS REPOS ENVIRONNEMENT POUR GUERIR alarmsnon stop talking loud noises no rest disruptions no healing environment loud alarms ringing beeping talking RESTINGloudly constant noise no rest disruptions healing environment 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 disruptions healing environment loud alarms ringing beeping talking loudly constant noise no rest disruptions healing environment loud alarms beeps loudNESS talking loudly constant

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Stop the Noise : A Quiet Environment Promotes Healing MAI NGUYEN RN, BScN, CCRN, CNRN, CNCC(c) , JULIE KINNON BScN, MScN, BEA KRISTINE CANAPI RN, BScN , MARTIN DARBOUZE RN, BScN , JOSIE DEL CAMPO RN, CNCC(c) , WINSOME WRIGHT RN, BScN

INTENSIVE CARE UNIT - MONTREAL GENERAL HOSPITAL, MCGILL UNIVERSITY HEALTH CENTRE

References* 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.

Acknowledgements MAI NGUYEN JULIE KINNON

main13@videotron.ca julie.kinnon@muhc.mcgill.ca

Further Information Affiliations

. . . W H A T W E D I D . . .I N T R O D U C T I O N

L I T E R AT U R E R E V I E W

M ET H O D

Most ICU environments have noise levels far above the World Health Organization (WHO) recommendations. Excessive noise in ICU has been found to have negative impacts on the physiological and psychological health of patients. Important links between error rate and environmental noise have been established. Noise reduction strategies aimed at behaviour change have revealed a reduction in environmental noise in hospitals. This quality improvement project sought to raise awareness of noise in our unit and test out strategies to create a quiet healing environment for our patients and families.

[1] WHO states that hospital noise levels should not exceed 45dB(A) during the day and 30 dB(A) during the night. [2] Studies in ICUs reported average noise levels of 60-70 dB(A) with peaks over 90dB(A). [3] Negative effects of noise on patients include: sleep disturbance, increased stress response, immunosuppression, delirium, and delayed healing.[4] Equipment alarms ringing near ICU patients’ heads contributes to interruption of sleep.[5] Patients and families felt private rooms were quieter but hallway noise continued to be a problem.[6] Measured noise levels before and after an educational and awareness campaign indicated noise reduction.[7] Earplugs could be a reasonable noise-reduction strategy for improving sleep in certain ICU patients.

• Sound meter measurements before and after the project.

PHASE ( 3 ) IMPLEMENTING STRATEGIES TO REDUCE NOISE LEVELS

“Stop the Noise - A Quiet Environment Promotes Healing” was a project pioneered by ICU nurses to highlight the issue of excessive noise in the ICU. This quality improvement project was successful in raising the nurses’ awareness of noise in our unit. Results of our surveys and sound measurements established that noise is disturbing and that some simple strategies can make a difference in the “health” of our environment.

We look forward to future developments of this project in order to sustain this change. We aim to continue developing new signage and awareness strategies, to include ancillary and profes-sional staff in the project and to consider a “noise policy” in our unit. Finally, we would like test the use of earplugs on appropriate patients and consider conducting a formal research project.

CONCLUSION

L I M I TAT I O N S•Projectwasdirectedmostlytowardsnurses.• Low survey response rate (patient & family survey, post-intervention nursing survey).• Environmental variability during sound measurements.

O U T C O M E S

PHASE ( 2 ) IS NOISE AN ISSUE IN OUR UNIT?

SOUND LEVEL COMPARISON

• Survey (before project): - staff perception - patient & family perception•Survey (after project):

staff perception & behavioral change

O B J E C T I V E S

• 14 Staff Nurses - volunteers.• Task division: survey & intervention groups.• Communication via monthly meetings & e-mail.

•Explorenurses’perceptionsofnoiseanditsimpactonpatients.•Sensitizenursestothenegativeimpactofnoiseonpatients,familyandstaff.•Identifysourcesofnoiseinourunit.•Developunit-basednoisereductionstrategies.•Evaluatetheimpactoftheprojectonstaffandtheenvironment.

PHASE ( 1 )FORMING THE PROJECT COMMIT TEE

SOUND MEASUREMENTS

STAFF SURVEY

PATIENT & FAMILY SURVEY

EDUCATION ACTIONS

•University-affiliatedteachinghospitalinMontreal(~500beds)• ICU staff with variable levels of experience.• Staff and patients from a culturally diverse population.

SETTING

[1]Dennis,C.M.etal(2010).BenefitofQuietTimeforNeuro-IntensiveCarePatients,JournalofNeuroscienceNursing,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

MEDICATION PREPARATION AB OVE LI G HT SWITCH ES

AB OVE VENTI LATO RN EAR M O N ITO R / IV PU M PS

• Poster emphasizing negative impact of noise.• Presentation &

discussion during AM Nursing Rounds• Posting of current

journal articles• Distribution of

handouts >>>

A Quieter Environment - One Voice at a Time

Why reducing unnecessary noise is

important to our patients?

* 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.

• Reducing volumes on phones and IV pumps.• Adjusting music volume to

patients’ preference.• Closing doors during

rounds & at night.

• Lowering alarm monitor volumes.• Individualizing alarm

parameters.• Responding quickly to

alarms, call bells & phones.• Sound level measurements in patient rooms

and the hallways were taken during day, evening and night.• The following were also measured:

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)

0   10   20   30   40   50   60  

Health-­‐care  

Housekeeping  staff/

Medical  devices  

Phones  rings  

Footsteps  

Noise  Contributors  

[%]  0   10   20   30   40   50  

Very  Fast  

Fast  

Slow  

Very  Slow  

Not  at  All  

Patient  Survey  on  RNs'  Alarm  Response  Rate  

[%]  

SIGNAGE QuotestoRememberandMakePartofourCare

EveryoneCanHelpPromoteaQuiet,HealingEnvironment

Reminding&EncouragingChangeinPractice

Random sound level measurements before and 8 months after project implementation revealed some noise reduction.

STAFF SURVEY RESPONSES Nurses answered a survey with open-ended questions 8 months after the project.

Nurses were able to identify safe dB(A) levels.

Nurses identified noise-reduction strategies they had used.

“ I now try closing patient room doors more often.”“ I speak more quietly outside patient rooms. ”“ I avoid crushing pills when I can.”

Nurses described important risk factors of noise.

“ Sleep deprivation ” “ Increased error rate ”“ Psychosis & restlessness”

Nurses are thinking about future strategies.

“ Music therapy ”“ Place sound measuring devices in the unit. ”“ Establish non-disturbance periods. ”“ Involve others in the project (e.g. housekeeping, physicians) ”

Nurses felt positively about the signage.

“ 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. ”

Nurses felt families were impacted

by noise.

“ Noise can be perceived as unprofessional. ”“Noise added to their stress level. ”

M ed I CAL/SU RG I CAL/T R A U M A I C U : 2 2 B E D S , H A L LWAY D E S I G N

IN FRONT OF PATIENT ROOMS

UNIT MAIN ENTRANCE0   20   40   60   80   100  

Are  you  often  awoken  by  excessive  noise  in  the  ICU?  

Do  monitoring  alarms  interfere  with  your  sleep?  

Will  music  in  your  room    help  you  sleep?  

Yes   No   [%]  

0 20 40 60 80 100

Do  frequent  warning  alarms  interfere  with  care  delivery  to  patients?  

Do  you  experience  "alarm  fatigue"  when  working  in  the  ICU?  

Do  patients  develop  anxiety,  panic,  or  paranoia  from  overhearing  conversations  between  staff?  

Yes No [%]  

0   10   20   30   40   50   60   70   80   90   100  

Recurrent  warning  alarms  can  reduce  trust  in  seriousness  of  the  call  

Excess  noise  and  monitor  alarms  have  a  substantial  impact  on  patients'  sleeping  pattern  

Excess  noise  and  alarms  can  increase  stress,  anxiety  and  confusion  in  ICU  patients  

Strongly  Agree   Agree   Disagree   Strongly  Disagree   [%]  

0  10  20  30  40  50  60  70  80  

Before   A1er   Before   A1er   Before   A1er  

DAY   EVENING   NIGHT  

Noise  Levels  in  the  ICU  Before  and  After  Applying  Noise  Reduction  Measures  

[dB]  

QUANTITATIVE

QUALITATIVE