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|Year : 2007 | Volume
| Issue : 35 | Page : 31--34
What do patterns of noise in a teaching hospital and nursing home suggest?
T Bharathan, D Glodan, A Ramesh, B Vardhini, E Baccash, P Kiselev, G Goldenberg
New York Methodist Hospital, Brooklyn, NY, USA
New York Methodist Hospital, 506, 6th Street Brooklyn, NY 11215
Introduction : Noise pollution is known to cause deleterious effects on human health and may especially affect frail elderly patients with poor mental and physiologic reserve. Aims of the study : (i) to learn levels and time- and place-patterns of noise in an urban community teaching hospital (TH) and affiliated urban nursing home (NH); (ii) to compare levels and patterns of noise in both institutions. Results : Recordings were obtained in three areas of the TH: emergency room (ER), intensive care units (ICU), and medical-surgical floors (HF) - nurses' stations and patients' rooms. On nursing home floors (NHF), noise levels were recorded at nurses' stations and in patients' rooms. In all areas of the hospital and NH, noise levels were in range of 55-70 dB and exceeded the 40-50 dB limit recommended by the EPA. In ER and ICU, noise level was higher on weekdays than weekends. In ICU and on HF, noise level was higher during mid-day hours during mornings and evenings. The highest noise level was recorded in ER followed by ICU and HF. On HF, nurses' stations were noisier than patients' rooms. Noise level was higher in the TH than in the NH. On NHF, noise level was similar on weekdays and weekends. Noise was stronger at nurses' stations than in patients' rooms and stronger in the mornings and evenings than during mid-day hours. Patterns of noise followed the human factor activities observed in both facilities. Conclusions : The level of noise in both facilities was above the recommended limit and presents an environmental stressor for a frail elderly patient. With transfer from NH to TH exposure to this stressor is increased. Time- and place-patterns of noise in both institutions suggest that human factor is a major source of noise pollution. This pollution is, therefore, potentially modifiable.
|How to cite this article:|
Bharathan T, Glodan D, Ramesh A, Vardhini B, Baccash E, Kiselev P, Goldenberg G. What do patterns of noise in a teaching hospital and nursing home suggest?.Noise Health 2007;9:31-34
|How to cite this URL:|
Bharathan T, Glodan D, Ramesh A, Vardhini B, Baccash E, Kiselev P, Goldenberg G. What do patterns of noise in a teaching hospital and nursing home suggest?. Noise Health [serial online] 2007 [cited 2020 Jul 12 ];9:31-34
Available from: http://www.noiseandhealth.org/text.asp?2007/9/35/31/36977
Noise is a sound that lacks agreeable musical quality, is noticeably unpleasant, is undesired or interferes with one's hearing of something.  Noise pollution is annoying or harmful noise in an environment.  Noise exceeding a quiet level of 40-50 decibel (dB) is known to cause emotional reactions (annoyance), , disturbed sleep,  delirium, , elevations in blood pressure, tachycardia  and is possibly linked to ischemic heart disease.  Exposure to noise has been shown to have a negative impact on work performance. , A noise level above 55-60 dB is a typical environmental stressor triggering acute and chronic increase in catecholamine levels (fight-and-flight reactions) and cortisol level (defeat reaction). , Although noise affects everyone, people with psychological/mental problems are more prone to experiencing negative effects of noise than people with good mental health. , Therefore, a frail elderly patient with poor physical and cognitive health is more vulnerable to noise pollution. And as was shown in delirium research, even a low intensity stressor can precipitate delirium in a frail elderly patient with multiple morbidities and poor functional and/or mental status. 
In order to minimize the harmful influences of noise, the Environmental Protective Agency (EPA) recommends noise level for hospitals below 45 dB at daytime and below 35 dB at night.  However, excessive noise levels was recorded in hospitals and nursing homes (NH). ,,, Nocturnal awakenings caused by noise in a NH  serve as an example of disturbing effects of noise on NH patients. In the surveyed literature, we did not find patterns of noise pollution in acute care or long-term care institutions.
The aims of our study were:
To learn noise levels and time- and place-patterns of noise in an urban community TH and affiliated NH.To compare levels and patterns of noise in the TH and NH.To learn sources of noise.
We hypothesized that levels of noise in both institutions are above the recommended level and that time- and place-patterns of noise pollution follow staff/human factor activities.
The study was approved by the Institutional Review Board of our hospital.
Materials and Methods
Noise levels were recorded with the Digital Sound Level Meter (Cat. No. 33-2055) in decibel. The levels were recorded by the geriatric team in different areas of the TH and NH and at various times. Both health care facilities are geographically close. Neither staff nor the patients in both institutions were aware of the recordings.
In order to find place-patterns of noise pollution, noise levels were recorded in three areas of the TH: emergency room (ER), intensive care units (ICU) and medical-surgical floors (hospital floors, HF). In the ER and ICU, nurses' stations are close to patients' rooms and noise levels could not be assessed separately. On HF, noise levels were recorded at nurses' stations and in doorways of patients' rooms. In order to establish time-patterns of noise pollution, recordings in all the three hospital areas were obtained at 7 a.m., 11 a.m., 3 p.m. and 8 p.m. In all hospital areas, early morning (7 a.m.) and evening (8 p.m.) recordings were performed during shift changes of nurses and nurse technicians. These staff activities occur mostly at nurses' stations and are of relatively low intensity. Recordings obtained in the middle of the day (11 a.m. and 3 p.m.) coincided with most intense activities such as doctors' rounds, patient care, case management work, nurse-students training, housekeeping, etc. The visiting hours in the hospital are from 11 a.m. to 8 p.m. The early morning, evening and mid-day noise levels were compared. In all hospital areas (ER, ICU and HF), noise levels on weekdays (Monday through Friday) were compared to noise levels on weekends (Saturday and Sunday).
Noise levels on the nursing home floors (NHF) were recorded at the nurses' stations and in the doorways of patients' rooms. Times of the recording were similar to the TH; levels were also compared on weekdays and weekends. Each level was an average of three successive recordings.
The anova model and sas software were used to analyze the collected data and to compare noise levels at different times and in different locations.
Acute care hospital
Areas of the TH [Table 1]: Among three areas of the TH, the highest level of noise was recorded in ER (68.3 ± 2.4 dB), followed by the level in ICU (64.1 ± 2.2 dB) and on HF (63.4 ± 1.9 dB) ( P Areas on HF [Table 1]: As mentioned above, in ER and ICU, nurses' stations are close to patients' rooms and noise levels could not be assessed separately. Hence, no place-patterns could be established. On HF, the noise level was higher at nurses' stations (66.5 ± 2.7 dB) than in patients' rooms (61.2 ± 2.2 dB) ( P Day-by-day pattern [Table 1]: In ER, the level of noise was higher on weekdays (69.5 ± 3.9 dB) than on weekends (67.2 ± 1.5 dB) ( P P Time-of-the-day pattern [Table 1]: In ER, the same levels of noise were registered during early morning, evening (68.0 ± 2.2 dB) and mid-day hours (68.0 ± 2.8 dB). In ICU and on HF, there was a time-pattern of noise: the level was higher in the middle of the day and lower during early morning and evening hours (66.4 ± 1.8 dB vs. 62.2 ± 1.7 dB in ICU, P P Nursing home
The noise level on NHF was lower than on HF: 57.3 ± 2.1 dB vs.63.4 ± 1.9 dB ( P P P Sources of noise
The human factor contributed to noise pollution by conversations between hospital staff, visitors, telephones and overhead pages. Noise pollution from technology originated from various monitors, alarms and from less modern but much noisier cleaning devices. However, sources of noise frequently overlapped and their contribution could not be separated and quantified.
In both settings, acute care TH and NH, noise pollution was above the recommended by the EPA limit of 40-50 dB (level of a moderate rainfall).  The level of noise in both facilities was in the range of 55-70 dB, which is approaching noise in a busy traffic area.  The noise level in the acute care TH was higher than in the NH.
Noise level had certain place- and time-patterns. Thus, among areas of the TH, the highest noise level was recorded in ER followed by ICU and HF (ER > ICU > HF). On HF, nurses' stations were noisier than patients' rooms. In ER, noise level was similar at all times of the day but stronger on weekdays than on weekends. In ICU, noise was greater during mid-day hours and on weekdays. On HF, mid-day hours were noisier than early morning and evening hours but there was no difference between days of the week.
These place- and time-patterns of noise followed staff activities in the TH. The ER was the loudest of all hospital areas, active around the clock but not as busy on weekends. ICU is better organized with lesser number of staff and patients and uses less of overhead paging. A quieter ICU on a weekend is explained by lesser number of doctors working on these days with less teaching activities and fewer procedures performed. On HF, most of the medical staff work is performed near the nurses' stations and in the middle of the day.
The NHF are less noisy than HF because of less medical and non-medical staff and less patient care activities. This time-pattern of noise on NHF was opposite to HF: the level of noise was higher during morning and evening hours, which is the time of shift change. The place-patterns on NHF was similar to HF: nurse' stations were louder than patients' rooms. The noise patterns in the NH again followed the activities of the staff.
Therefore, our recordings show that a frail elderly patient is subjected to excess noise in the NH. And this frail patient is exposed to even higher noise level when being transferred to the acute care hospital. Examples of multiple negative reactions triggered by noise were mentioned earlier. ,,,,,, One very important of these is delirium, precipitated in a physically and/or cognitively impaired patient by such environmental stressor as noise. 
Medical staff in health care facilities is also exposed to noise, although the exposure is limited by shift time. The noise influence on work performance , may again adversely affect patient care.
We could not separately record various sources of noise because of their overlap. However, the time- and place-patterns of noise pollution found in the TH and NH follow activities of the medical staff and strongly suggest that the human factor is a significant and important source of noise. Technology was also a major source of noise pollution by the use of modern as well as quite outdated equipment.
Learning of noise patterns in both acute and long-term care institutions suggests that the noise pollution is potentially modifiable. Noise reduction programs should include staff education,  visiting regulations and respective engineering modifications. Among engineering measures, we would suggest re-designing sounding boards and replacing overhead paging, use of muffling wheels, etc. The noisy behavior of patients  is more difficult to modify but it may improve in a quieter and less irritating environment.
The noise pollution in both acute care TH and NH was in the range of 55-70 dB and exceeded the level recommended by the EPA. The noise level in the TH was higher than noise level in the NH. The higher level of noise in the TH is an additional environmental stressor for a frail elderly patient transferred from the NH to the acute care TH. Potential sequelae of this increased stress, such as delirium, arterial hypertension, cardiac arrhythmias and others, can affect the disease course and prolong hospital stay. Noise pollution can also negatively affect the staff in health care institutions.
Time- and place-patterns of noise in both institutions followed activities of medical and non-medical staff and suggest that the noise pollution is mostly "manmade." Therefore, in both settings, noise pollution is potentially modifiable by staff education, regulatory rules and engineering measures. In our opinion, implementation of noise reduction programs has a great potential and deserves further attention of the medical community.
|1||Merriam-Webster Online Dictionary. Available from: http://www.m-w.com/dictionary. [Last updated on July 19, 2006].|
|2||Bluhm G, Nordling E, Bergland N. Road traffic noise and annoyance: An increasing environmental health problem. Noise Health 2004;6:43-9.|
|3||Persson WK, Bengtsson J, Agge A, Bjorkman M. A descriptive cross-sectional study of annoyance from low frequency noise installations in an urban environment. Noise Health 2003;5:35-46.|
|4||Griefahn B. Sleep disturbances related to environmental noise. Noise Health 2002;4:57-60.|
|5||Hansell HN. The behavioral effects of noise on man: The patient with intensive care unit psychosis. Heart Lung 1984;13:59-65.|
|6||Helton MC, Gordon SH, Nunnery SL. The correlation between sleep deprivation and the intensive care unit syndrome. Heart Lung 1980;9:464-8.|
|7||Kristal-Boneh E, Melamed S, Harari G, Green MS. Acute and chronic effects of noise exposure on blood pressure and heart rate among industrial employees: The CORDIS study. Arch Environ Health 1995;50:298-304.|
|8||Babisch W, Ising H, Gallacher JE. Health status as a potential effect modifier of the relation between noise annoyance and incidence of ischemic heart disease. Occup Environ Med 2003;60:739-45.|
|9||Ouis D. Exposure to nocturnal road traffic noise: Sleep disturbance and its after effects. Noise Health 1999;1:11-36.|
|10||Persson WK, Bengtsson J, Kjellberg A, Benton S. Low frequency noise "pollution" interferes with performance. Noise Health 2001;4:33-49.|
|11||Ising H, Braun C. Acute and chronic endocrine effects of noise: Review of the research conducted at the Institute for water, soil and air hygiene. Noise Health 2000;2:7-24.|
|12||Babisch W. Stress hormones in the research on cardiovascular effects of noise. Noise Health 2003;5:1-11.|
|13||Stansfeld SA. Noise, noise sensitivity and psychiatric disorder: Epidemiological and psychophysiological studies. Psychol Med 1992;22:1-44.|
|14||Belojevic G, Jakovijevic B. Factors influencing subjective noise sensitivity in an urban population. Noise Health 2001;3:17-24.|
|15||Inouye SK. Predisposing and precipitating factors for delirium in hospitalized older patients. Dement Geriatr Cogn Disord 1999;10:393-400.|
|16||Environmental Protective Agency (EPA). Information on levels of environmental noise requisite to protect public health and welfare with an adequate margin of safety. Government Printing Office: Washington; 1974.|
|17||Grumet GW. Pandemonium in the modern hospital. N Engl J Med 1993;328:433-7.|
|18||Kahn DM, Cook TE, Carlisle CC, Nelson DL, Kramer NR, Millman RP. Identification and modification of environmental noise in an ICU setting. Chest 1998;114:535-40.|
|19||Cruise PA, Schnelle JF, Alessi CA, Simmons SF, Ouslander JG. The nighttime environment and incontinence care practices in nursing homes. J Am Geriatr Soc 1998;46:181-6.|
|20||Noise and Hearing Loss. American Speech-Language-Hearing Association. Available from: http://www.asha.org. [Last updated on July 19, 2006].|
|21||Ryan DP, Tainsh SM, Kolodny V, Lendrum BL, Fisher RH. Noise-making amongst the elderly in long-term care. Gerontologist 1988;28:369-71.|