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Noisy treatment in hospitals

Loud patient rooms and floors can hinder restful recuperations

By Liz Kowalczyk
Globe Staff / October 31, 2011

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For patients recovering from an illness or surgery, doctors first and foremost prescribe rest. But in many hospitals, noise from alarms on patient monitors, other equipment, and conversations is so loud that patients can’t sleep and end up heading home exhausted.

It’s been known for years that hospitals can be loud at night, but evidence is growing that noise on patient floors routinely exceeds the World Health Organization’s recommended maximum of 40 decibels for hospital rooms.

The VA Boston Healthcare System installed noise meters in a nine-bed unit earlier this year and recorded nighttime noise levels up to 66 decibels in hallways - similar to the sound of an alarm clock blaring - and 74 decibels in the loudest patient room. Before improvements on the unit, nurses described it as “extremely noisy’’ and said if they were a patient, they would not be able to heal.

A previous study at Johns Hopkins Hospital in Baltimore found nighttime noise reached 70 decibels in five cancer, pediatric, and medical surgical units.

A leading acoustician who spoke this month at a national health care meeting, where VA staff discussed their findings, said that hospitals are about three times louder at night now than they were when measurements were first taken in 1960.

A lot of the noise is from alarms on monitors that measure heart function and blood oxygen levels, pumps that deliver intravenous medications, and overhead pagers that broadcast alerts. Some of the veterans who filled out questionnaires about the most bothersome noises at the Boston VA simply wrote “alarms,’’ “beeping,’’ or “bells.’’

While monitors can save lives when they alert nurses to dangerous changes in a patient, more than 80 percent of these alarms are false or nuisance alarms, meaning nothing is wrong. The constant beeping desensitizes nurses, causing them to tune out the occasional alarms that turn out to be critical - a phenomenon called “alarm fatigue’’ that is linked to hundreds of patient deaths, according to a Globe investigation published earlier this year.

But the constant beeping - along with noise from staff conversations, ringing telephones, equipment carts with squeaky wheels, and powerful air conditioning systems - may be harming many more patients in subtler ways. Research has shown that depriving people of sleep weakens their immune systems. One study found that healthy adults vaccinated for Hepatitis A produced fewer antibodies to the virus if they were deprived of sleep the night after vaccination.

“Alarms constantly sounding causes problems for every patient in the hospital,’’ said Ilene Busch-Vishniac, provost at McMaster University in Ontario, and a former Hopkins acoustician who presented her findings to a recent “Alarms Summit’’ outside Washington, D.C.

“There are more and more pieces of equipment attached to each patient, so the sheer number of alarms going off has risen exponentially,’’ she said in an interview, calling the noise an “invisible source of trauma’’ in the hospital.

Noise from other sources contributes to the problem, she said, because nurses must turn up the volume on alarms to hear them over the din. Nurses who have lowered the volume to give themselves and patients a break have missed some critical alarms, leading to patient deaths.

Some hospitals, like the Boston VA, Beth Israel Deaconess Medical Center, and Newton-Wellesley Hospital, are taking steps to quiet patient floors - and to lessen nighttime interruptions for taking vital signs and providing other routine care. But the noise problem is still widespread.

Noise studies involving ill patients are rare - primarily because of ethical concerns about purposely keeping a sick person awake. So most of the research has been done with animals and healthy people, said Dr. Randall Friese, a trauma surgeon at the University of Arizona Medical Center. But he monitored intensive care patients and found they slept shallowly and in snippets, rarely reaching deeper levels of restorative sleep, partly because of their underlying illness and partly because of the noise around them.

Beth Leavitt, 51, who lives in Haverhill, was in the intensive care unit at Lawrence General Hospital earlier this month so doctors could monitor her heart.

“They had to watch me and I understand that completely,’’ she said. But after three days, she was exhausted. “The hospital is not a place to rest, I can tell you that,’’ Leavitt said.

Patients leaned on call buttons, supply carts rattled through the corridor, and nurses talked and laughed during shift changes. But among the most regular noises were the alarms on Leavitt’s cardiac and blood pressure monitor and her IV pump - warnings that in her case did not turn out to be serious.

Ellen O’Brien found Children’s Hospital Boston to be noisy, too, when her daughter, Faith, then 2 years old, was admitted in 2008 for serious medical problems including a kidney transplant and pneumonia. O’Brien remembers many sleepless nights for her daughter, when nurses woke her to take vital signs and alarms rang out warning of falling oxygen levels or kinks in her IV tube. With a corridor like “Grand Central Station,’’ O’Brien worried Faith’s body would not heal without sleep.

But looking back, she believes the interruptions and alarms were worth it because in the end they allowed nurses to provide critical care when her daughter needed it and keep her alive.

Still, she wonders if there’s a way to cut noise while keeping patients safe, such as sending alarms directly to nurses’ pagers or cellphones.

Busch-Vishniac said this approach mostly has failed so far because individual nurses become overwhelmed with the sheer volume of alarms. “The first order is to decrease the alarms, then you can talk about sending them just to nurses,’’ she said.

Hospitals are paying more attention to the noise problem since Medicare began publicly posting in 2008 patient satisfaction scores for individual hospitals, including a question about whether the area near their room is always quiet at night. Patients generally score hospitals lower on this measure than any other, and in Massachusetts just half of patients answered yes in 2010.

The VA created a second nurses’ station on its pilot unit so nurses could respond to alarms faster, moved change-of-shift conversations into a break room, and offers foam earplugs to patients. It now plans to focus on reducing nuisance alarms. Executives at Lawrence General, where Leavitt stayed, said they are reducing noise by establishing dedicated quiet hours, regularly asking patients if it’s too loud and installing 200 new televisions with personal headsets - and that patient satisfaction scores have improved.

Beth Israel Deaconess has designated 9 p.m. to 6 a.m. “quiet hours,’’ during which pagers are set to vibrate and nurses use tiny flashlights in patient rooms rather than turn on lights. The hospital has been measuring noise levels and alerting nurses to high readings to encourage quiet.

Friese said his hospital has educated every ICU staff member about the impact of sleep deprivation on the immune system, and made alarms that measure respiratory and heart rates less sensitive at night, so they won’t sound as frequently.

“We need to be able to monitor patients - and not disturb them,’’ he said.

Liz Kowalczyk can be reached at kowalczyk@globe.com.

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