Context
To build capacity for improvement, our parent organization, Hamad Medical Corporation, initiated collaboration with the Institute for Healthcare Improvement. The overall effort came under a value improvement initiative piloted in High Dependency Unit B, which aimed to improve capacity, performance and cost measures.
Measurement Strategy
This study focused on the environmental monitoring of sound and did not involve patient/staff recruitment. It was conducted during a 12-month period, with noise measurements collected in two phases, before and after the interventions. In the pre-intervention phase, the unit’s baseline noise was recorded. Data collection was performed for 2 hours during each shift, 7 days a week (morning, evening and night) and was collected from nursing stations and outside patient rooms. We found that maximum noise levels occurred during rounds at 11 am and on Thursday and Sunday mornings. Fridays and Saturdays were comparatively quiet. In addition, patient-satisfaction scores related to noise levels before and after staff education were collected.
Subsequent to baseline measurements, noise-reduction interventions were tested and implemented (e.g., staff and relatives/patient education, device alarm monitoring, and quiet time implementation).
Interventions to Reduce Noise Levels
The CICU multi-disciplinary team identified the noise problem through patient comments. A task force was formed to address the issue through brainstorming and cause and effect analysis to identify the main reasons for CICU noise and the strategies needed to reduce it (Fig. 1). As this was a unique issue that might require unique inputs, the team developed a Supplier, Input, Process, Output, Customers diagram to further analyse the situation (Fig. 2).
The reasons underlying the high noise levels in the CICU were cardiac monitor alarms, overhead paging, staff conversations, rolling equipment such as procedure carts and housekeeping trollies moving across uncarpeted floors, metal chart holders, and medication and equipment doors, printers, and the phones of physicians and patients’ family members. A Pareto analysis was performed to identify the main causes (Fig. 3) and, based on that analysis, several Plan-Do-Study-Act (PDSA) cycles were tried and tested. We used a model for improvement with rapid cycle PDSA change methodology to guide our work [15].
Strategies to Reduce Noise in the ICU
Different strategies were attempted to reduce unwanted noise in the unit. To that end, a noise-reduction taskforce was formed whose members reminded visitors of quiet time and encouraged the use of whispering and a dedicated area for cell phone use.
A checklist was created and tested that listed tasks to be performed prior to quiet times, such as taking vital signs, blood samples, administering routine medications, dimming the lights, closing the curtains and turning off televisions.
PDSA 1 – Patient Cohort
As the CICU has 2 stations, the critical and non-critical patients were placed in separate cohorts in different areas of the unit to allow for different strategies to be tested and implemented. Patient care was not affected by changing the stations.
PDSA 2 – Quiet Time Implementation
There were challenges involved in devising and implementing quiet time in the ICU. Several time slots were tried over the course of a month, but were unsuccessful. Specifically, it was difficult to align a period that was free from visitation times, medication times, physician rounds, housekeeping rounds and mealtimes.
Multidisciplinary meetings were conducted with the supervisors of security and housekeeping, the catering team, physical therapists and physicians to decide timings and responsibilities. Two blocks of time (3–4 pm and 2–4 am) were designated as quiet times, during which lights were dimmed, noise-reduction strategies were implemented and procedures were minimized. Before the quiet-time period began, nurses (if appropriate) administered pain medication, pre-toilet activities and repositioning of patients to ensure a period of uninterrupted rest. At the commencement of quiet time, a one-on-one announcement was made to every patient and visitor, lights on the unit were dimmed, and visual signage was placed at the entrance to the unit stating: “Quiet Time in Progress” (Fig. 4). The staff made all possible efforts to minimize sources of noise on the unit during this period.
PDSA 3 – Alarm Settings
A tool was developed and tested to monitor alarm sources as well as compliance in setting alarm limits on life-saving equipment. In addition, individualised alarm thresholds, volumes and the use of visual alerts were tested. Unnecessary alarms were removed from monitors.
PDSA 4 – Multidisciplinary Approach
The housekeeping staff agreed to rescheduling the timing of bin changes to avoid disturbing patients during quiet time. In addition, care was co-ordinated to reduce unnecessary entry into patient rooms during quiet time. Furthermore, patient handovers were conducted outside patient rooms during quiet time.
PDSA 5 – Yacker Tracker (Fig. 5)
We used the audio-visual aid Yacker tracker to give alerts if the sound level in the unit was above a set level of 35 db. This audio-visual, noise-signal tool allowed the group to know when noise levels were exceeding set limits. The Yacker tracker resembles a traffic signal with red, yellow and green lights. A green smiley face signified an acceptable sound level. The yellow light signified that levels were rising, and a frowning red face indicated that the volume needed to be lowered. By providing a visual cue, the employees were able to better understand the noise level in the unit and adjust the volume of their voices. Initially, this device was not available in the unit. Therefore, before making a request for its purchase, we tested it by first borrowing a devise for 1 month from a different facility. The initial results were impressive, and it helped to raise awareness regarding noise levels. Based on these results, multiple trackers were purchased for the unit. Two devices were placed at each station and the decibel level was set at 35 dBs (recommended from WHO)
Device Repairs
We worked with the engineering department to change noisy wheel carts, place door stoppers in every room and pad the receiving area for pneumatic systems. These changes resulted in a significant reduction of noise in the unit.
Educational Interventions
Staff Education
Staff and family education played vital role in this initiative. One-to-one and small group educational sessions were conducted for all CICU staff regarding the effects of noise on patients and staff and on noise-reduction strategies. They were informed about the effects of noise on patients and staff, errors associated with noise and current interventions aimed at noise reduction in the unit. The educational sessions were arranged during regular meetings, staff meetings and journal club sessions. Comments by patients and families were shared during those sessions to create a sense of urgency. In addition, results from similar interventions from different facilities were provided to create awareness and motivation amongst the staff.
Posters and signs were placed in the unit and at the entrance of the unit to alert the health-care team and visitors about the noise levels. Posters were placed on ICU doors and hand-outs were distributed to teams and families. In addition, staff was encouraged to keep hallway conversations to a minimum, especially at night. For each shift, a noise reduction champion was assigned to monitor the effective implementation of the noise-reduction strategies and their compliance.
Patient and Family Education
In addition to staff education, all admitted patients and their family members were provided education regarding quiet time during unit orientation. Families were encouraged to bring music, spiritual readings and other items to relax their family member. Hand-outs regarding quiet time were prepared, shared and explained to family members in their preferred language. We used our language bank services for patients who preferred languages other than English or Arabic.
Examination of the Interventions
Apart from the implementation of quiet time, which had a direct effect on the noise levels in the units, a self-reported survey was prepared to study noise-induced effects in the unit. The questions were designed to obtain information on noise sources in the unit, attitudes towards noise and its effects, noise-induced physical and mental effects and the desirability or undesirability of various environmental conditions. Data was collected and statistically analysed to evaluate noise-induced effects. Before the initiation of the project, a taskforce team member designed operational strategies to reduce noise in health facilities, and the team members implemented all possible strategies to reduce noise in the clinical areas.
Outcome Measures
The primary outcome measure was the average noise level during quiet time in the CICU.
Process Measures
Compliance with how often quiet time was interrupted for non-essential reasons was calculated as a process measure.
Balancing Measures
Patient, family and staff satisfaction surveys were conducted for balancing measures. In addition, comment cards were collected to obtain patient feedback.
Analysis
Following the implementation of quiet-time hourly slots, data was collected to evaluate the effectiveness of the interventions.
Welch’s t-test was used in this study. The Welch’s t-test, also known as the unequal variance t-test, is used when the number of samples in each group and the variance of the two data sets are different. We analysed pre and post intervention noise levels in dB using this test.
Compliance to different noise reduction strategies were calculates and analysed by using run chart rules. In addition, for qualitative data, before- and after-intervention percentages of patient and staff satisfaction levels were taken using a survey.
Challenges and Measures to Overcome
There were a number of challenges encountered during this initiative. One of the most important was a lack of awareness or denial regarding the noise problem. Initially, as this was a non-conventional, quality-improvement project, we faced challenges in getting the staff to believe noise was an issue that needed to be addressed. We shared patient and visitor comments to overcome this and convince the team to work on noise reduction. Another challenge was related to the nature of the work conducted in the unit, as the CICU is where emergency tasks and activities are common and continuously changing. Measuring sound and deciding upon improvement strategies was also a challenge, which was addressed through consulting the literature.
In contrast to many other distracting or unpleasant factors in a CICU, excessive noise can be reduced by the implementation of noise-reduction strategies. In our study, we were able to significantly reduce the noise level in the ICU and provide dedicated quiet time for the patients to enable them to have enough rest and sleep. Although these interventions were initially difficult to implement, once staff and patients understood the importance of the initiative, its feasibility improved. We did not attempt patient-specific interventions. Instead, environmental-based changes were tested and implemented. Patient-specific devices such as earplugs and earphones have been tested in past studies to mitigate noise, but their clinical benefit is limited [23–26].