FOREWORD: Noise as a Hazard in Emergency Medicine
In this foreword to observation articles by Barnette and Chandler, Colin Langfeldt examines how noise pollution affects conditions in emergency departments.
Over the last century, technology, efficiency, and overall success in the field of medicine have followed a general trend of improvement. However, often overlooked is that with the improved technology and machinery in hospitals, namely emergency departments, noise pollution has significantly and continually increased. This noise is described by Khademi, Roudi, Farhat and Shahabian (2011) as “an accidental sound wave without any rhythm or harmony which can interfere with hearing” (p. 142). They further describe noise pollution as “the level of environmental noise that is annoying”. With other more salient issues having to be dealt with, noise, or at least tolerable noise is often left unstudied and untreated. Consequently, high noise levels remain potentially damaging to both the state of the patients as well as the concentration and mood of medical professionals. Furthermore, the high levels of stress already present on many healthcare providers make effectively diagnosing and resolving the issue of noise that much more important.
What is surprising, is that contrary to what one might initially expect, one study found that having some noise, rather than none, actually led to faster completion of tested tasks. However, it should be noted that the quality of work being done did not vary, but merely that it was completed faster. Additionally, post-screening concluded that though the quality of work was not affected initially, there were heightened work stressors. These stressors mainly consisted of fatigue, mood changes, and absenteeism (Folscher, Goldstein, Wells &Rees, 2015, p. 470). Additionally, another study found that elevated levels of noise may not affect the quantity of work completed but rather the quality of care being provided. It was found that as the number of decibels increased, workers reported greater levels of subjective distress.
The prolonged exposure to these subjective stressors can lead to problems at work as well as potential dangers to providers heath. This information is especially concerning due to the nature of how those in emergency medicine are taking on shifts. It is not uncommon for providers to work 8 or more hours on a single shift with little breaks. Furthermore, If the fatigue of quickly moving from patient to patient is not enough, there is also potential for excess stress and stagnation due to distraction and an altered mood.
To make matters worse, many working in the emergency department have reported difficulty communicating as a consequence of elevated noise pollution. Furthermore, alternate cases have measured noise to have an effect on the hypothalamus and pituitary. This in turn raises epinephrine, norepinephrine, and corticosteroids levels along with increasing blood pressure and changing heart rate and peripheral vasoconstriction (Filus, Lacerda, & Albizu, 2015, p. 208). Clearly, with the myriad of potential dangers as a result of excessive noise exposure, it appears preventative action should be taken. The problem, however, is that this issue is simply being documented without proper processionary measure being taken, that is in some cases. Getto, Marco, Papas, Fort, and Fredette (2016) affirm this in saying that “It is well documented that noise levels in the ED exceed EPA standards on a regular basis, and this is likely contributing to provider performance” (p. 117).
What may be causing the discrepancy in prevention, is the severity. Despite the high levels of noise pollution in hospitals currently, some believe the issue is not significant enough to be highly dangerous. With that said, one physician says “there is growing concern over high noise levels in hospitals and their effects on patients and staff. Hospital noise levels have been shown to exceed the recommended limit in psychiatric hospitals, intensive care units, surgical wards, operating rooms, recovery rooms, neonatal intensive care units, and pediatric intensive care units and in children’s wards” and they are not alone (Ratnapalan, Cieslak, Mizzi, McEvoy & Mounstephen, 2011, p. 826). To say that these findings are concerning would be, to many, both patient and provider, an understatement. Both the performance and health of medical professionals are on the line as well as the comfort and wellbeing of those being treated. Additionally, it is reported that many currently working in emergency medicine complain of the noise as both distracting and annoying. However, these concerns are being analyzed and addressed. Filus et al (2015) point out that, “the occupational risk due to high levels of noise in the hospital environment has been recognized, and at the suggestion of the National Agency of Sanitary Surveillance of the Ministry of Health, evaluation, and control of noise in hospital areas is recommended” (p. 205). With technology in medicine only progressing more and more, it is unlikely that the issues caused by noise will simply take care of themselves. Consequently, more attention is being brought to working towards solutions.
Another problem is presented in that even with accounting for all the potential consequences of additional noise as well as noise that is above healthy levels, it is expected that health care providers are adept at handling stress. With that said, it does not mean that this stress is being handled as expected. Tijunelis, Fitzsullivan, and Henderson (2005) suggest that “initially, this stress can be invigorating and challenging, but over time, it often becomes a source of dissatisfaction” (p. 334). Often times, there is such an emphasis on caring for patients and ensuring that their health is a priority, that those working to do so are often left neglected and not being cared for properly.
Often much of the stress placed on providers is simply from sources that are out of the control of the departments themselves rather than being a result of their environment. The chief sources were found to be “patient load, difficult/hateful patients, and malpractice liability” but no real emphasis on stress from environmental factors (Tijunelis et al, 2005, p. 334). He further states that the primary hazards to the health of these workers likely comes from “infectious diseases, latex allergies, radiation exposure, violence, nitrous oxide, rotating shift work, burnout, and emergency physician attrition.”. Yet, there is again no mention of noise. It is mentioned though, that specifically measuring the root causes and effect of stress is not an exact science and as a result is not concrete.
One idea as to why noise might not be a significant contributor to performance (at least in some cases studied) is that these residents have becoming used to such levels of noise and as a result can “Block out” said noise (Getto et al, 2016, p. 116). It could also be attributed to the fact that, often times, the procedures performed during these studies are quite common and therefore familiar to those performing them. As a result, the procedures do not present a real challenge, nor do they put a great mental load on the provider. An example of such a procedure is intubation. It should be noted, however, that these findings do not support the majority of other studies and as a result are not conclusive. With so many differing opinions, the data is certainly mixed, to say the least. There are several studies citing both that too much noise truly is hazardous and should be dealt with, as well as many that say that noise isn’t as significant as initially thought. However, generally, most agree that subjectively health care providers at the least experience irritation and a lack of focus from excess noise.
Due to the large variance in methods used of measuring noise levels and in turn their negative effects, it is difficult to find a singular root cause and consequently to offer a universal solution. Flius et al (2015) suggest that there isn’t a singular step that can be taken to fix the blanket hazard of noise, but rather many (p. 208). While lacking on the specifics, he believes that educational workshops and ear protection in some environments are necessary for proper protection and long-term health. On the other hand, Tijunelis et al (2005) believes that the most effective path to a solution is simply awareness and conscientiousness of personal noise output and making sure to reduce what is controllable (p. 334). This idea is reaffirmed by Ratnapalan et al (2011) who cite that “A study in an intensive care unit showed that almost 50% of sound peaks were due to television (23%) and staff talking (29%) and were amenable to behavior modification” (p. 831). He points out that by simply paying attention and actively taking measures to reduce noise levels can have a significant impact overall. These solutions certainly make sense, but it seems like too simple of a solution for a complex problem.
With moments of boredom and stagnation being a rarity in emergency departments, it can often be hard to find time for everything. Between taking care of caring for patients, communicating information, filing data and all the other responsibilities of providers, finding the time to ensure all excess noise is being reduced can present a challenge. To further this dilemma, it requires a constant and active awareness on the part of the staff, which in these tense and busy settings is not always a possibility. On top of this, the previously mentioned stress and weight of working in such an environment only adds to the distraction at hand, potentially leading to moments of intensity becoming quite loud and as a result hectic and only more stressful.
To address these issues, other preventative solutions have been offered. These include steps such as “soft-soled shoes for staff, abolishing multiple patient rooms, quieting alarms, and restricting overhead paging” (Zun & Downey, 2008, p. 665). Taking such actions certainly could make sense, however, they could lead to other issues, such as further difficulty communicating. One group, in an effort to reduce noise, actively worked to keep patients’ doors closed, however, the effect only shifted overall noise levels by 6 decibels, and in some cases actually increased noise. While this amount is certainly better than nothing, it likely is not enough of a change to have a significant effect.
According to the World Health Organization it is recommended that the noise levels not exceed 30 dB during the day, as well as the EPA setting the safe limit at 40 dB (Tijunelis et al, 2005, p. 334). However, in several cases recorded amongst multiple studies, the average levels of noise were significantly higher than this and, in some moments, more than double these suggested levels. It is likely that if measures were taken by these institutions, these numbers would change. He goes on to say that somewhere around 51 percent of the noise levels in ICU’s were able to be altered. He states that simply examining and evaluating behavior and the environment could have a significant effect. In one case, significant contributors such as “slamming of doors and drawers and conversations among attending physicians, staff, and medical students” could easily be lessened (Tijuenlis et al, 2005, p. 335). Even something as simple as replacing metal trashcans with plastic ones had a measurable effect.
Clearly, noise as a hazard in the emergency department is not a simple issue to tackle. It is multifaceted and presents multiple sub-contributors when analyzed more in-depth. Whether the real danger of high noise levels lies in its inhibition to communication, its annoyance, its contribution to stress, or all three is up for debate and is continuing to be studied. The articles that follow further showcase how these effects are present and dealt with in different emergency department settings. The exact amount of danger presented by noise, and how prevalent the issue is, changes depending on where it is measured, how it is measured, and by who it is measured. If one thing is for sure, it is that there certainly are issues that come along with excess noise and they could be done without, especially in a place as high stakes as the emergency room. If it is at all possible, for the sake of the providers and patients both, it would be beneficial to conduct further research into the subject and take as many preventative measures as possible. At the end of the day, the purpose of medical care is to help ensure good health, and it seems that taking action against excess noise would only further aid that goal.
Filus, W., Lacerda, A., Albizu, E. (2015). Ambient noise in emergency rooms and its health hazards. Thieme E-Journals. 19(3). Retrieved From https://www.thieme-connect.com/products/ejournals/abstract/10.1055/s-0034-1387165
Floscher, L., Goldstein, L., Wells, M., Rees, D. (May 2015). Emergency department noise: mental activation or mental stress. Emergency Micine Journal. 32(6). Retrieved from https://emj.bmj.com/content/32/6/468
Getto, L., Marco, D., Papas, M., Fort, C., Fredette, J. (2016, March). The effect of noise distraction on emergency medicine resident performance during intubation of a patient simulator. The Journal of Emergency Medicine. 50(3). Retrieved from https://www.sciencedirect.com/science/article/pii/S0736467915010471
Khademi, G., Roudi, M., Farhat, A. S., & Shahabian, M. (2011). Noise pollution in intensive care units and emergency wards. Iranian journal of otorhinolaryngology, 23(65), 141. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3846184/
Ratnapalan, S., Cieslak, P., Mizzi, T., McEvoy, J., & Mounstephen, W. (2011). Physicians’ perceptions of background noise in a pediatric emergency department. Pediatric emergency care, 27(9), 826-833. Retrieved from https://oce.ovid.com/article/00006565-201109000-00007/HTML
Tijunelis, M., Fitzsullivan, E., Henderson, S. (May 2005). Noise in the ED. The Journal of Emergency Medicine. 23(3). Retrieved from https://www.sciencedirect.com/science/article/pii/S0735675705000872#!
Zun, L. S., & Downey, L. (2005). The effect of noise in the emergency department. Academic emergency medicine, 12(7), 663-666. Retrieve from https://onlinelibrary.wiley.com/doi/abs/10.1197/j.aem.2005.03.533