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      An investigation of sound levels on intensive care units with reference to the WHO guidelines

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      Author(s): 1 , , 1 , 2
      Publication date (Electronic):
      Journal: Critical Care
      Publisher: BioMed Central

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          Abstract

          Introduction

          Patients in intensive care units (ICUs) suffer from sleep deprivation arising from nursing interventions and ambient noise. This may exacerbate confusion and ICU-related delirium. The World Health Organization (WHO) suggests that average hospital sound levels should not exceed 35 dB with a maximum of 40 dB overnight. We monitored five ICUs to check compliance with these guidelines.

          Methods

          Sound levels were recorded in five adult ICUs in the UK. Two sound level monitors recorded concurrently for 24 hours at the ICU central stations and adjacent to patients. Sample values to determine levels generated by equipment and external noise were also recorded in an empty ICU side room.

          Results

          Average sound levels always exceeded 45 dBA and for 50% of the time exceeded between 52 and 59 dBA in individual ICUs. There was diurnal variation with values decreasing after evening handovers to an overnight average minimum of 51 dBA at 4 AM. Peaks above 85 dBA occurred at all sites, up to 16 times per hour overnight and more frequently during the day. WHO guidelines on sound levels could be only achieved in a side room by switching all equipment off.

          Conclusion

          All ICUs had sound levels greater than WHO recommendations, but the WHO recommended levels are so low they are not achievable in an ICU. Levels adjacent to patients are higher than those recorded at central stations. Unit-wide noise reduction programmes or mechanical means of isolating patients from ambient noise, such as earplugs, should be considered.

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          Most cited references37

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          Delirium epidemiology in critical care (DECCA): an international study

          Jorge Salluh, Marcio Soares, José M. M. Teles … (2010)
          Introduction Delirium is a frequent source of morbidity in intensive care units (ICUs). Most data on its epidemiology is from single-center studies. Our aim was to conduct a multicenter study to evaluate the epidemiology of delirium in the ICU. Methods A 1-day point-prevalence study was undertaken in 104 ICUs from 11 countries in South and North America and Spain. Results In total, 975 patients were screened, and 497 fulfilled inclusion criteria and were enrolled (median age, 62 years; 52.5% men; 16.7% and 19.9% for ICU and hospital mortality); 64% were admitted to the ICU because of medical causes, and sepsis was the main diagnosis (n = 76; 15.3%). In total, 265 patients were sedated with the Richmond agitation and sedation scale (RASS) deeper than -3, and only 232 (46.6%) patients could be evaluated with the confusion-assessment method for the ICU. The prevalence of delirium was 32.3%. Compared with patients without delirium, those with the diagnosis of delirium had a greater severity of illness at admission, demonstrated by higher sequential organ-failure assessment (SOFA (P = 0.004)) and simplified acute physiology score 3 (SAPS3) scores (P < 0.0001). Delirium was associated with increased ICU (20% versus 5.7%; P = 0.002) and hospital mortality (24 versus 8.3%; P = 0.0017), and longer ICU (P < 0.0001) and hospital length of stay (LOS) (22 (11 to 40) versus 7 (4 to 18) days; P < 0.0001). Previous use of midazolam (P = 0.009) was more frequent in patients with delirium. On multivariate analysis, delirium was independently associated with increased ICU mortality (OR = 3.14 (1.26 to 7.86); CI, 95%) and hospital mortality (OR = 2.5 (1.1 to 5.7); CI, 95%). Conclusions In this 1-day international study, delirium was frequent and associated with increased mortality and ICU LOS. The main modifiable risk factors associated with the diagnosis of delirium were the use of invasive devices and sedatives (midazolam).
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            Monitor alarm fatigue: standardizing use of physiological monitors and decreasing nuisance alarms.

            Douglas K. Graham, Maria Cvach (2009)
            Reliance on physiological monitors to continuously "watch" patients and to alert the nurse when a serious rhythm problem occurs is standard practice on monitored units. Alarms are intended to alert clinicians to deviations from a predetermined "normal" status. However, alarm fatigue may occur when the sheer number of monitor alarms overwhelms clinicians, possibly leading to alarms being disabled, silenced, or ignored. Excessive numbers of monitor alarms and fear that nurses have become desensitized to these alarms was the impetus for a unit-based quality improvement project. Small tests of change to improve alarm management were conducted on a medical progressive care unit. The types and frequency of monitor alarms in the unit were assessed. Nurses were trained to individualize patients' alarm parameter limits and levels. Monitor software was modified to promote audibility of critical alarms. Critical monitor alarms were reduced 43% from baseline data. The reduction of alarms could be attributed to adjustment of monitor alarm defaults, careful assessment and customization of monitor alarm parameter limits and levels, and implementation of an interdisciplinary monitor policy. Although alarms are important and sometimes life-saving, they can compromise patients' safety if ignored. This unit-based quality improvement initiative was beneficial as a starting point for revamping alarm management throughout the institution.
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              The effect of earplugs during the night on the onset of delirium and sleep perception: a randomized controlled trial in intensive care patients

              Bart Van Rompaey, Monique M Elseviers, Wim Van Drom … (2012)
              Introduction This study hypothesised that a reduction of sound during the night using earplugs could be beneficial in the prevention of intensive care delirium. Two research questions were formulated. First, does the use of earplugs during the night reduce the onset of delirium or confusion in the ICU? Second, does the use of earplugs during the night improve the quality of sleep in the ICU? Methods A randomized clinical trial included adult intensive care patients in an intervention group of 69 patients sleeping with earplugs during the night and a control group of 67 patients sleeping without earplugs during the night. The researchers were blinded during data collection. Assignment was performed by an independent nurse researcher using a computer program. Eligible patients had an expected length of stay in the ICU of more than 24 hours, were Dutch- or English-speaking and scored a minimum Glasgow Coma Scale of 10. Delirium was assessed using the validated NEECHAM scale, sleep perception was reported by the patient in response to five questions. Results The use of earplugs during the night lowered the incidence of confusion in the studied intensive care patients. A vast improvement was shown by a Hazard Ratio of 0.47 (95% confidence interval (CI) 0.27 to 0.82). Also, patients sleeping with earplugs developed confusion later than the patients sleeping without earplugs. After the first night in the ICU, patients sleeping with earplugs reported a better sleep perception. Conclusions Earplugs may be a useful instrument in the prevention of confusion or delirium. The beneficial effects seem to be strongest within 48 hours after admission. The relation between sleep, sound and delirium, however, needs further research. Trial registration Current Controlled Trials ISRCTN36198138
              Article 0 comments Cited 73 times – based on 0 reviews     Review now
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                Author and article information

                Contributors
                Julie L Darbyshire
                J Duncan Young
                Journal
                Journal ID (nlm-ta): Crit Care
                Journal ID (iso-abbrev): Crit Care
                Title: Critical Care
                Publisher: BioMed Central
                ISSN (Print): 1364-8535
                ISSN (Electronic): 1466-609X
                Publication date (Print): 2013
                Publication date (Electronic): 3 September 2013
                Volume: 17
                Issue: 5
                Page: R187
                Affiliations
                [1 ]Nuffield Division of Anaesthetics, Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK
                [2 ]Adult Intensive Care Unit, Oxford University Hospitals NHS Trust, John Radcliffe Hospital, Headley Way, Headington, Oxford, OX3 9DU, UK
                Article
                Publisher ID: cc12870
                DOI: 10.1186/cc12870
                PMC ID: 4056361
                PubMed ID: 24005004
                SO-VID: 5afe267b-344d-4fb1-b956-7a9cae53017b
                Copyright © Copyright © 2013 Darbyshire et al.; licensee BioMed Central Ltd.
                License:

                This is an open access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 14 March 2013
                Date revision received : 21 May 2013
                Date accepted : 3 September 2013
                Categories
                Subject: Research

                ScienceOpen disciplines: Emergency medicine & Trauma
                Data availability:
                ScienceOpen disciplines: Emergency medicine & Trauma

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