Patients' perception of sound levels in the surgical suite

Noise, Distractions, and Hazards in the Operating Room

Anesthesiologists are perioperative leaders of patient and health care team safety. The anesthesiologist needs to remain vigilant in the perioperative setting and while caring for patients. The ability to navigate increased noise levels, distractions, and hazards is crucial for maintaining a safe environment. While some noise, such as music, can have benefits, overall noise levels can distract from patient care and have adverse effects on patient care and intraoperative staff. This study provides an overview of noise, distractions, and hazards in the perioperative environment.

Effect of intraoperative noise on postoperative pain in surgery patients under general anesthesia: evidence from a prospective study and mouse model

BACKGROUND

Most patients are in a noisy environment during abdominal surgery under general anesthesia. This study included patients who underwent abdominal surgery under general anesthesia and established an animal model to determine whether intraoperative noise affects postoperative pain.

MATERIALS AND METHODS

This prospective study included 200 patients who underwent abdominal surgery under general anesthesia. Intraoperative noise and electroencephalograms were continuously recorded, and the mean level and time proportion of noise intensity of greater than 70 dB were calculated. Maximum postoperative pain was assessed using a numerical rating scale at 0-12 h and 12-24 h after surgery, and postoperative analgesia consumption in patients receiving patient-controlled intravenous analgesia was recorded. Postoperative pain intensity and electroencephalogram amplitude were compared between patients with high-noise exposure (time proportion of noise intensity greater than 70 dB ≥40%) and low-noise exposure (<40%). Mechanical pain sensitivity was tested in two groups of mice with plantar incisions exposed to 40 dB or 70-100 dB.

RESULTS

The time proportion of noise intensity greater than 70 dB was identified as an independent risk factor for postoperative pain intensity ( P <0.001). P ain numerical rating scale 0-12 h (4.5±1.5 vs. 3.7±1.3, P =0.001) and 12-24 h (3.9±1.5 vs. 3.2±1.1, P =0.004) after surgery in patients with high-noise exposure was significantly higher than in patients with low-noise exposure. The electroencephalogram amplitude of patients with high-noise exposure was significantly lower than that of patients with low-noise exposure ( P <0.05). In the mouse model, mechanical hyperalgesia in the 70-100 dB group was significantly greater than that in the 40 dB group ( P <0.001).

CONCLUSION

High-level intraoperative noise exposure aggravates the degree of postoperative pain and analgesic needs of patients undergoing abdominal surgery, which may be related to the impact of noise on the neurophysiological activity of the brain and postoperative hyperalgesia.

Background Music's Impact on Patients Waiting in Surgery and Radiology Clinics

OBJECTIVES

To assess the impact of different types of background music on patients' anxiety and perceptions in a healthcare setting.

BACKGROUND

An overwhelming number of studies in the West have been conducted on the use of background music in reducing patients' anxiety and their perception of hospitals. Despite the optimism for Western classical music in such settings, evidence documenting the successful use of this genre of music in waiting rooms across other people groups has, thus far, been inconclusive.

METHOD

A single-blind randomized study in which a total of 303 participants were recruited from both surgery and radiology clinics using a between-groups experimental design. Patients were seated in the waiting room for at least 20 min while music (Western classical, lo-fi) or no music was playing in the background. Participants were then required to complete a questionnaire that consisted of a shortened 6-item State Trait Anxiety Inventory (STAI-6), and eight questions relating to overall perceptions of the hospital.

RESULTS

The results from both clinics revealed that patients in the no music condition rated themselves as feeling significantly less anxious than those in either of the two music conditions. Patients' perceptions of the hospital's overall service and expectations were higher in the no music condition.

CONCLUSIONS

Firstly, the choice of background music should match the differing pace of the day; for example, a more upbeat song would better fit the mood of a busy clinic, leading to a more "congruent" atmosphere. Secondly, playing background music in a "task-oriented" and highly charged/anxious environment may increase arousal levels, which in turn could result in negative perceptions of the hospital and an increase in anxiety among patients. Finally, music is a cultural product and music that primes certain beliefs in one culture may not have similar effects among other people groups. Hence, specific curated playlists are necessary to convey "intentions" to different people groups.

The Effect of an Educational Intervention on Nurses' Knowledge, Perception, and Use of Nursing Presence in the Perioperative Setting

PURPOSE

Explore the effect of a nursing presence educational intervention on nurse circulators' perceptions, knowledge, and use of nursing presence with patients undergoing surgical procedures.

DESIGN

One group, pretest-posttest design.

METHODS

Nursing presence is an intentional-reflective way of being with patients that was operationalized using four domains (Attention-to-Environment, Interaction Quality, Focus-of-Energy, and Active Engagement). Data collection involved observations of participants in practice and completion of surveys to examine 34 randomly selected nurse circulators' knowledge, perception, and use of nursing presence before and after participating in a nursing presence educational intervention. Dependent t tests and McNemar tests were used to examine relationships between the independent and three dependent variables - knowledge, perceptions, and use of nursing presence.

FINDINGS

The educational intervention significantly enhanced participants' nursing presence knowledge, but not perceptions, which were very high at baseline. Participants' significantly increased their use of 3 of 4 nursing presence domains with the exception of the Attention-to-Environment domain, which is related to promoting a healing environment.

CONCLUSIONS

Lack of attention to promoting a healing environment by the surgical team created a barrier to circulators' ability to successfully use all four nursing presence domains. Embracing nursing presence as a practice framework involves cooperation from the surgical team and a shift in perioperative environment from a chaotic to healing one.

Noise in cesarean deliveries: a comprehensive analysis of noise environments in the Labor and Delivery operating room and evaluation of a visual alarm noise abatement program

BACKGROUND

Cesarean delivery is the most common major surgery worldwide. Noise in healthcare settings leads to impaired communication and concentration, and stress among healthcare providers. Limited information is available about noise at cesarean delivery.

OBJECTIVE

This study aimed to achieve a comprehensive analysis of noise that occurs during cesarean deliveries. Sound level meters are used to determine baseline noise levels and to describe the frequency of acute noise generated during a cesarean delivery that will cause a human startle response. Secondarily, we aimed to evaluate the effectiveness of a visual alarm system in mitigating excessive noise.

STUDY DESIGN

We completed a preintervention/postintervention observational study of noise levels during cesarean deliveries before and after introduction of a visual alarm system for noise mitigation between February 15, 2021 and August 26, 2021. There were 156 cases included from each study period. Sound pressure levels were analyzed by overall case median decibel levels and by time epoch for relevant phases of the operation. Rapid increases in noise events capable of causing a human startle response, "startle events," were detected by retrospective analysis, with quantification for baselines and analysis of frequency by case type. Median noise levels with interquartile ranges are presented. Data are compared between epochs and case characteristics with nonparametric 2-tailed testing.

RESULTS

The median acoustic pressure for all cesarean deliveries was 61.8 (58.8-65.9) (median [interquartile range]) dBA (A-weighted decibels). The median dBA for the full case time period was significantly higher in cases with neonatal intensive care unit team presence (62.1 [60.5-63.9]), admission to the neonatal intensive care unit (62.0 [60.4-63.9]), 5-minute Apgar score <7 (62.2 [61.1-64.3]), multiple gestations (62.6 [62.0-64.2]), and intraoperative tubal sterilization (62.8 [61.5-65.1]). The use of visual alarms was associated with a statistically significant reduction of median noise level by 0.7 dBA, from 61.8 (60.6-63.5) to 61.1 (59.8-63.7) dBA (P<.001).

CONCLUSION

The noise intensities recorded during cesarean deliveries were commonly at levels that affect communication and concentration, and above the safe levels recommended by the World Health Organization. Although noise was reduced by 0.7 dBA, the reduction was not clinically significant in reaching a discernible amount (a 3-dB change) or in reducing "startle events." Isolated use of visual alarms during cesarean deliveries is unlikely to be a satisfactory noise mitigation strategy.

Noise in the operating room during induction of anesthesia: impact of a quality improvement initiative

PURPOSE

Noise in the operating room (OR) is common and associated with negative effects on anesthesiologists, surgeons, and patient outcomes. Induction of anesthesia is among the loudest perioperative periods. Despite its critical nature, there is little data on noise levels during induction, associated patient and anesthesiologist satisfaction, and the effects of noise reduction strategies.

METHODS

We conducted a two-part prospective interventional quality improvement project on the care of adult patients receiving general anesthesia for elective noncardiac surgery. For part A, we measured average and peak noise (dB[A]) levels during anesthesia induction in N = 100 cases and administered a satisfaction questionnaire to anesthesiologists. We then applied a multidisciplinary educational program to OR personnel on active noise reduction strategies and subsequently collected data during N = 109 cases in a post-intervention phase. For part B, we administered satisfaction questionnaires to N = 100 patients pre- vs postintervention, respectively.

RESULTS

Median [interquartile range] noise levels throughout induction were 66.0 [62.5-68.6] dB(A) preintervention vs 63.5 [60.1-65.4] dB[A] post-intervention (Hodges-Lehmann estimator of the difference, - 2.7 dB[A]; 95% confidence interval [CI], - 4.0 to - 1.5; P < 0.001). Peak noise levels during induction were 87.3 [84.0-90.5] dB(A) preintervention and 86.2 [81.8-89.3] dB(A) postintervention (Hodges-Lehmann estimator of the difference, - 1.8 dB[A]; 95% CI, - 3.3 to - 0.3; P = 0.02). Noise-related anesthesiologist satisfaction postintervention was significantly improved in multiple domains, including assessment of noise having distracted anesthesiologists. Patient satisfaction was high pre-intervention and did not significantly improve further.

CONCLUSION

In this quality improvement project, average noise levels during induction of anesthesia, anesthesiologist satisfaction, and anesthesiologists' perceived ability to perform were improved following a multidisciplinary educational program on noise reduction in the OR.

STUDY REGISTRATION

www.ClinicalTrials.gov (NCT04204785); registered 19 December 2019.

Influence of Anesthetic Techniques on Perioperative Outcomes after Endovascular Aneurysm Repair

BACKGROUND

The purpose of the study was to explore the influence of anesthetic techniques on perioperative outcomes after endovascular aneurysm repair (EVAR) for infrarenal abdominal aortic aneurysm (AAA) in a Chinese population.

METHODS

A retrospective review was performed in patients after elective EVAR for infrarenal AAA at our single center. Patients were classified into general anesthesia (GA), regional anesthesia (RA), and local anesthesia (LA) groups. The primary outcomes (30-day mortality and morbidity) and secondary outcomes [procedure time, mean arterial pressure (MAP), and length of hospital stay (LOS)] were collected and analyzed.

RESULTS

From January 2006 to December 2015, 486 consecutive patients underwent elective EVAR at our center. GA was used in 155 patients (31.9%), RA in 56 (11.5%), and LA in 275 (56.6%). The GA patients had fewer respiratory comorbidities, shorter and more angulated proximal necks, and more concomitant iliac aneurysms. LA during EVAR was significantly associated with a shorter procedure time (GA, P < 0.001; RA, P < 0.001) and shorter LOS (GA, P = 0.002; RA, P = 0.001), but a higher MAP (GA, P < 0.001; RA, P < 0.001) compared with GA and RA. LA was associated with a significantly lower risk of cardiac (odds ratio (OR) 4.27, 95% confidence interval (CI) 1.21-15.04), pulmonary (OR 5.37, 95% CI 1.58-18.23), and systemic complications (OR 4.15, 95% CI 1.85-9.33) compared with GA. RA was also associated with a decreased risk of systemic complications (OR 4.74, 95% CI 1.19-18.92) compared with GA. There was no difference in the 30-day mortality, neurologic complications, renal complications, and intraoperative extra procedures among the 3 groups.

CONCLUSIONS

Anesthetic techniques for EVAR have no influence on the 30-day mortality. LA for EVAR appears to be beneficial concerning the procedure time, LOS, and 30-day systemic complications for patients after elective EVAR for infrarenal AAA in the Chinese population.

"Noise Factory": A qualitative study exploring healthcare providers' perceptions of noise in the intensive care unit

OBJECTIVES

This study aimed to explore healthcare providers' perceptions of noise in the intensive care unit.

DESIGN

A qualitative exploratory study was conducted using group interviews.

SETTING

The setting comprised a total of 15 participants (five physicians and ten registered nurses) working in an 18-bed medical surgical intensive care unit at a teaching hospital in Istanbul, Turkey. Semi-structured questions were formulated and used in focus group interviews, after which the recorded interviews were transcribed by the researchers. Thematic analysis was used to identify significant statements and initial codes.

FINDINGS

Four themes were identified: the meaning of noise, sources of noise, effects of noise and prevention and management of noise. It was found that noise was an inevitable feature of the intensive care unit. The most common sources of noise were human-induced. It was also determined that device-induced noise, such as alarms, did not produce a lot of noise; however, when staff were late in responding, the sound transformed into noise. Furthermore, it was observed that efforts to decrease noise levels taken by staff had only a momentary effect, changing nothing in the long term because the entire team failed to implement any initiatives consistently. The majority of nurses stated that they were now becoming insensitive to the noise due to the constant exposure to device-induced noise.

CONCLUSION

The data obtained from this study showed that especially human-induced noise threatened healthcare providers' cognitive task functions, concentration and job performance, impaired communication and negatively affected patient safety. In addition, it was determined that any precautions taken to reduce noise were not fully effective. A team approach should be used in managing noise in intensive care units with better awareness.

Preoperative calming effect of melatonin and its influence on propofol dose for anesthesia induction in healthy dogs

OBJECTIVE

To investigate the preoperative calming effect of melatonin and its influence on propofol dose for anesthesia induction in dogs.

STUDY DESIGN

Prospective, randomized, blinded, placebo-controlled clinical study.

ANIMALS

A total of 50 healthy, adult, client-owned dogs scheduled for elective surgery.

METHODS

Dogs were equally divided into treatment group M, which received 5 mg kg^-1 melatonin, and placebo-control group P (sucrose), both administered orally 2 hours prior to induction of anesthesia. Dogs were subjectively characterized and further designated as skeptical (group S; n = 18) or trustful (group T; n = 32). Behavior, calming effect and vital parameters (pulse rate, respiratory rate, blood pressure, rectal temperature) were evaluated before and after treatment. Propofol dose [mg kg^-1 intravenously (IV)] to allow endotracheal intubation and anesthesia induction quality was documented. Data were analyzed using a general linear model and Mann-Whitney U tests.

RESULTS

Dogs in group MS (n = 10) were calmer than those in group PS (n = 8) at 90 minutes after drug administration (p = 0.047). Group MT (n = 15) required less propofol (5.98 ± 0.96 mg kg^-1) than group PT (n = 17; 7.04 ± 1.82 mg kg^-1 IV; p = 0.048) and group MS (9.48 ± 3.22 mg kg^-1 IV; p = 0.007). Group PS required 7.69 ± 2.71 mg kg^-1 IV. Skeptical dogs showed more reactions during induction (p = 0.013). Vital parameters were within physiological ranges before and after treatment.

CONCLUSION AND CLINICAL RELEVANCE

Results showed that melatonin may be used to reduce propofol dose for anesthesia induction in trustful dogs. Skeptical dogs benefitted from the calming properties. Potentially, melatonin could be used to minimize the level of excitement before general anesthesia and to reduce the required propofol dose for induction.

A cross-sectional study in a tertiary care hospital in China: noise or silence in the operating room

OBJECTIVES

This study aims to provide a comprehensive description of noise levels in operating rooms (ORs) in a tertiary care hospital in China. Additionally, the study aims to examine the deviation in noise levels from international and internal standards as well as the differences in noise levels by category of surgery and day of the week.

METHODS

We monitored noise levels in 23 ORs in a tertiary care hospital in China between August 2015 and March 2016. Dosimeters were used to determine noise levels. The noise data collected in the dosimeter were downloaded to an IBM computer for subsequent analysis. One-way analysis of variance and Student's t-test were used to examine the differences in noise levels.

RESULTS

The noise level in the ORs ranged between 59.2 and 72.3 dB(A), with 100% of the measurements exceeding the recommended hospital noise standards. There was substantial similarity in noise levels from Monday to Friday (F=1.404, p=0.234), with a range between 63.7 and 64.5 dB(A). The difference in noise levels by category of surgery was significant (F=3.381, p<0.001). The results of the post hoc analysis suggested that ophthalmic surgery had significantly higher noise levels than otolaryngological surgery or general surgery.

CONCLUSIONS

Ophthalmic surgery had significantly higher noise levels than otolaryngological or general surgeries. High noise levels were identified in all evaluated ORs during weekdays, and these levels consistently exceeded the currently accepted standards. These findings warrant further investigation to determine the harmful effects of noise on both patients and staff in ORs..

Sound as a supportive design intervention for improving health care experience in the clinical ecosystem: A qualitative study

PURPOSE

Most prior hospital noise research usually deals with sound in its noise facet and is based merely on sound level abatement, rather than as an informative or orientational element. This paper stimulates scientific research into the effect of sound interventions on physical and mental health care in the clinical environment.

METHODS

Data sources comprised relevant World Health Organization guidelines and the results of a literature search of ISI Web of Science, ProQuest Central, MEDLINE, PubMed, Scopus, JSTOR and Google Scholar.

RESULTS

Noise induces stress and impedes the recovery process. Pleasant natural sound intervention which includes singing birds, gentle wind and ocean waves, revealed benefits that contribute to perceived restoration of attention and stress recovery in patients and staff.

CONCLUSIONS

Clinicians should consider pleasant natural sounds perception as a low-risk non-pharmacological and unobtrusive intervention that should be implemented in their routine care for speedier recovery of patients undergoing medical procedures.

Evaluation of noise pollution level in the operating rooms of hospitals: A study in Iran

INTRODUCTION

Noise pollution in the operating rooms is one of the remaining challenges. Both patients and physicians are exposed to different sound levels during the operative cases, many of which can last for hours. This study aims to evaluate the noise pollution in the operating rooms during different surgical procedures.

MATERIALS AND METHODS

In this cross-sectional study, sound level in the operating rooms of Hamadan University-affiliated hospitals (totally 10) in Iran during different surgical procedures was measured using B&K sound meter. The gathered data were compared with national and international standards. Statistical analysis was performed using descriptive statistics and one-way ANOVA, t-test, and Pearson's correlation test.

RESULTS

Noise pollution level at majority of surgical procedures is higher than national and international documented standards. The highest level of noise pollution is related to orthopedic procedures, and the lowest one related to laparoscopic and heart surgery procedures. The highest and lowest registered sound level during the operation was 93 and 55 dB, respectively. Sound level generated by equipments (69 ± 4.1 dB), trolley movement (66 ± 2.3 dB), and personnel conversations (64 ± 3.9 dB) are the main sources of noise.

CONCLUSION

The noise pollution of operating rooms are higher than available standards. The procedure needs to be corrected for achieving the proper conditions.

Safety, Performance, and Satisfaction Outcomes in the Operating Room: A Literature Review

OBJECTIVE

This review of empirical literature focuses on the design of operating rooms (ORs) by investigating the physical environmental features of ORs associated with patient and staff outcomes.

BACKGROUND

Many ORs built more than 30 years ago remain operational today. However, most are inadequately designed to handle the equipment, processes, and people that a contemporary OR needs to accommodate. However, the evidence base for designing ORs has been sorely lacking, and little guidance exists on how OR design can improve safety and performance outcomes.

METHOD

A literature search was conducted using PubMed and the university's linked databases. The inclusion criteria included peer-reviewed journal articles that reported some aspect of the physical environment of ORs along with outcomes. The study included empirical studies as well as nonempirical best practice papers.

RESULTS

This literature review uncovered 211 articles. The main themes that emerged include OR design-related factors, ventilation, temperature and humidity, acoustical environment, lighting, and materials. Some environmental threats to patient safety in the OR include frequent door openings, clutter, poor air quality, surface contamination, and noise. Further, staff performance and satisfaction were impacted by factors such as the OR layout and equipment and furniture ergonomics.

CONCLUSION

This literature review provides an overview of the research organized into design-focused topic areas to support decision-making by architects and designers. This article highlights gaps in the research and identifies areas where best practice and design assumptions need to be evaluated using rigorous design research.

Exploring the effect of sound and music on health in hospital settings: A narrative review

BACKGROUND

Sound in hospital space has traditionally been considered in negative terms as both intrusive and unwanted, and based mainly on sound levels. However, sound level is only one aspect of the soundscape. There is strong evidence that exploring the positive aspect of sound in a hospital context can evoke positive feelings in both patients and nurses. Music psychology studies have also shown that music intervention in health care can have a positive effect on patient's emotions and recuperating processes. In this way, hospital spaces have the potential to reduce anxiety and stress, and make patients feel comfortable and secure. This paper describes a review of the literature exploring sound perception and its effect on health care.

DATA SOURCES AND REVIEW METHODS

This review sorted the literature and main issues into themes concerning sound in health care spaces; sound, stress and health; positive soundscape; psychological perspective of music and emotion; music as a complementary medicine for improving health care; contradicting arguments concerning the use of music in health care; and implications for clinical practice. Using Web of Science, PubMed, Scopus, ProQuest Central, MEDLINE, and Google, a literature search on sound levels, sound sources and the impression of a soundscape was conducted. The review focused on the role and use of music on health care in clinical environments. In addition, other pertinent related materials in shaping the understanding of the field were retrieved, scanned and added into this review.

RESULTS

The result indicated that not all noises give a negative impression within healthcare soundscapes. Listening to soothing music was shown to reduce stress, blood pressure and post-operative trauma when compared to silence. Much of the sound conveys meaningful information that is positive for both patients and nurses, in terms of soft wind, bird twitter, and ocean sounds.

CONCLUSIONS

Music perception was demonstrated to bring about positive change in patient-reported outcomes such as eliciting positive emotion, and decreasing the levels of stressful conditions. Whilst sound holds both negative and positive aspects of the hospital ecosystem and may be stressful, it also possesses a soothing quality that induces positive feelings in patients. Conceptualizing the nature of sound in the hospital context as a soundscape, rather than merely noise can permit a subtler and socially useful understanding of the role of sound and music in the hospital setting, thereby creating a means for improving the hospital experience for patients and nurses.

The therapeutic impacts of environmental design interventions on wellness in clinical settings: A narrative review

PURPOSE

The aim of this review is to document the role of physical environmental factors in clinical environments and their impact on patients and staff wellness with a particular focus on physical and mental healthcare.

METHODS

Data sources comprised relevant English language articles and the results of literature search of ISI Web of Knowledge, PubMed, Scopus, ProQuest Central, MEDLINE, and Google.

RESULTS

Incorporating physical environmental factors into hospital design can facilitate better user satisfaction, efficiency and organisational outcomes. Many of the design interventions convey positive distractions for patients and staff, in terms of views of pleasant outside vistas, soothing sound, artwork and music.

CONCLUSIONS

Well-designed physical settings play an important role in the healing process of patients in health care facilities. The challenge then is to fully understand that role in the ecological context of health care. Other contributors are possible and should be explored in further research.

Exploring positive hospital ward soundscape interventions

Sound is often considered as a negative aspect of an environment that needs mitigating, particularly in hospitals. It is worthwhile however, to consider how subjective responses to hospital sounds can be made more positive. The authors identified natural sound, steady state sound and written sound source information as having the potential to do this. Listening evaluations were conducted with 24 participants who rated their emotional (Relaxation) and cognitive (Interest and Understanding) response to a variety of hospital ward soundscape clips across these three interventions. A repeated measures ANOVA revealed that the 'Relaxation' response was significantly affected (n(2) = 0.05, p = 0.001) by the interventions with natural sound producing a 10.1% more positive response. Most interestingly, written sound source information produced a 4.7% positive change in response. The authors conclude that exploring different ways to improve the sounds of a hospital offers subjective benefits that move beyond sound level reduction. This is an area for future work to focus upon in an effort to achieve more positively experienced hospital soundscapes and environments.

Noise levels in a burn intensive care unit

INTRODUCTION

Increased noise levels in hospitals, critical care units, and peri-operative areas have been associated with higher levels of sleep deprivation and patient stress. The World Health Organization (WHO) guidelines stipulate a limit of 35 decibels (dB(A)) equivalent continuous sound level (LEq) during the day and 30 dB(A) LEq at night in patients' rooms. To date, no quantitative studies of noise levels have been performed in burn units. The objective of this study was to quantify noise levels in a burn critical care unit to ascertain compliance with guidelines in order to minimize this potential insult.

METHODS

An A-weighted sound pressure level meter was used to measure the ambient noise levels in a burn intensive care unit. Maximum and minimum sound pressure levels were measured at 30-min intervals on 10 days over a 1 month period. Measurements were obtained during shift changes and random times during the day and night-time. Descriptive statistical analyses were performed, to calculate means and standard deviations. Noise measurements at specified times were compared using analysis of variance (ANOVA).

RESULTS

Mean dB(A) LEq values for shift changes, day, and night-time were 65.9 ± 2.8, 65.7 ± 2.6, and 60.9 ± 5.2 dB(A), respectively. There was no significant difference in dB(A)(max) or dB(A)(min) between shift changes, day or night-time (p>0.05). However, night-time minimum values were consistently lower. There was no significant difference between sound pressure level (SPL) inside and outside patients' rooms (p>0.05) at any time.

CONCLUSIONS

Irrespective of time or location, the mean dB(A) LEq in the burn unit was significantly greater than World Health Organization (WHO), National Institute for Occupational Safety and Health (NIOSH), and the Environmental Protection Agency (EPA) recommendations. Guidelines for decreasing noise exposure are necessary to reduce potential negative effects on patients, visitors, and staff.

The power of words: sources of anxiety in patients undergoing local anaesthetic plastic surgery

INTRODUCTION

With local or regional anaesthesia being employed for more as well as more complex surgical procedures, an increasing number of patients remain fully conscious during their operation. This is generally perceived as being advantageous to the patient as less time is spent in hospital and the side effects of general anaesthesia are avoided. However, there is no direct measure of the patient experience during 'awake surgery', in particular of which aspects of the process may be distressing.

METHODS

Seventy patients undergoing day case plastic surgery under local anaesthesia were asked to complete a short questionnaire immediately following their operation. This was designed to identify specific factors likely to either increase or reduce anxiety during surgery. The questionnaire was initially validated on a pilot group of ten patients.

RESULTS

Unsurprisingly, painful stimuli such as injections were identified as potential stressors. More interestingly, the data highlighted that some commonly used surgical terms such as 'knife' and 'scalpel' provoke considerable anxiety in the conscious patient. This varied according to age and sex with younger and female patients being most vulnerable. Other events identified as potential stressors, such as casual conversations and movements among theatre staff, were actually shown to be non-stressful and, in some cases, stress relieving.

CONCLUSIONS

Technical jargon used by surgical staff can elevate anxiety levels among patients who are awake for their operation. Careful consideration of the words we use may reduce this, particularly in female patients.

Evaluation of the Built Environment: Staff and Family Satisfaction Pre- and Post-Occupancy of the Children's Hospital

Objective:

To evaluate and compare the impact of an existing and newly built hospital environment on family and staff satisfaction related to light, noise, temperature, aesthetics, and amenities, as well as safety, security, and privacy.

Background:

The United States is engaged in an unprecedented healthcare building boom driven by the need to replace aging facilities, understand the impact of the built environment on quality and safety, incorporate rapidly emerging technologies, and enhance patient- and family-centered care. More importantly, there is heightened attention to creating optimal physical environments to achieve the best possible outcomes for patients, families, and staff.

Methods:

Using a pre-post descriptive survey design, all nursing, social work, therapy staff, and families on selected inpatient units were invited to participate. A demographic form and Family and Staff Satisfaction Surveys were developed and administered pre- and post-occupancy of the new facility.

Results:

Pre/post mean scores for staff satisfaction improved on all survey subscales with statistically significant improvement ( p < .05) in most areas. The most improvement was seen with layout of the patient room, natural light, storage and writing surfaces, and comfort and appeal. Family satisfaction demonstrated statistically significant improvement on all subscales (p ≤ .01), especially for natural light, quiet space, parking, and the child's room as a healing environment.

Conclusions:

Families and staff reported greater satisfaction with the newly built hospital environment compared to the old facility. Study results will help guide future architectural design decisions, attract and retain staff at a world-class facility, and create the most effective healing environments.

The effect of distractions in the operating room during endourological procedures

Background

Professionals working in the operating room (OR) are subject to various distractions that can be detrimental to their task performance and the quality of their work. This study aimed to quantify the frequency, nature, and effect on performance of (potentially) distracting events occurring during endourological procedures and additionally explored urologists’ and residents’ perspectives on experienced ill effects due to distracting factors.

Methods

First, observational data were collected prospectively during endourological procedures in one OR of a teaching hospital. A seven-point ordinal scale was used to measure the level of observed interference with the main task of the surgical team. Second, semistructured interviews were conducted with eight urologists and seven urology residents in two hospitals to obtain their perspectives on the impact of distracting factors.

Results

Seventy-eight procedures were observed. A median of 20 distracting events occurred per procedure, which corresponds to an overall rate of one distracting event every 1.8 min. Equipment problems and procedure-related and medically irrelevant communication were the most frequently observed causes of interruptions and identified as the most distracting factors in the interviews. Occurrence of distracting factors in difficult situations requiring high levels of concentration was perceived by all interviewees as disturbing and negatively impacting performance. The majority of interviewees (13/15) thought distracting factors impacted more strongly on residents’ compared to urologists’ performance due to their different levels of experience.

Conclusion

Distracting events occur frequently in the OR. Equipment problems and communication, the latter both procedure-related and medically irrelevant, have the largest impact on the sterile team and regularly interrupt procedures. Distracting stimuli can influence performance negatively and should therefore be minimized. Further research is required to determine the direct effect of distraction on patient safety.

Anxiety in the operating theatre: a study of frequency and environmental impact in patients having local, plexus or regional anaesthesia

AIMS

To estimate the frequency of intraoperative anxiety, the influence of environmental factors on intraoperative anxiety and to study the relationship between intraoperative anxiety and generalised anxiety and depression.

BACKGROUND

Previous research has documented that surgery is associated with increased stress and anxiety, which have an adverse effect on patient outcomes. Few studies have been conducted to obtain patients' perspectives about the influence of the operating theatre environment on anxiety.

DESIGN

The study used a survey design including questionnaires.

METHOD

Clinical variables were noted from the anaesthesia medical records. The sample (n = 119) comprised patients undergoing elective surgery and emergency operations within 24 hours of admission. Anxiety was assessed by the Jakobsen's questionnaire and the Hospital Anxiety and Depression scale.

RESULTS

Twenty-three per cent felt anxious on arrival at the operating theatre, 35% were anxious at induction of anaesthesia, while 12% felt anxious after induction. At start of surgery 15% experienced anxiety and during surgery 9% were anxious. Continuous information reduced the experience of anxiety in 49% of the patients and the opportunity to ask questions during the intraoperative period reduced anxiety in 55%. The sight of technical equipment and surgical instruments was reported to increase anxiety in 9% and 6% of the sample, respectively. Patients with higher levels of general anxiety and depression also experienced significantly higher levels of anxiety in the intraoperative period.

CONCLUSIONS

In this study patients experience highest level of anxiety at induction of anaesthetics. The operating theatre environments impact on patients' anxiety are in less degree influenced by the sight and hearing of the technical equipment and the surroundings. Continuous information and opportunity to ask questions reduces patients' anxiety. Results indicate that there is a significant positive relationship between generalised anxiety and depression prior to admission and anxiety experienced during the intraoperative period.

RELEVANCE TO CLINICAL PRACTICE

Generalised anxiety and depression prior to surgery should be identified to implement nursing interventions to reduce anxiety in the operating theatre.

Conscious surgery: influence of the environment on patient anxiety

AIMS

This paper is a report of a study: (i) to investigate anxiety arising from the experience of the clinical environment during surgery under local/regional anaesthesia and (ii) to uncover the specific aspects patients find anxiety provoking and possibly dissuade them from opting for such anaesthesia.

BACKGROUND

Operating theatre staff have focused historically on conducting safe, efficient surgery with unconscious patients and not primarily on the care of 'awake' patients. However, with the rise in day surgery, the volume of surgery performed under local or regional anaesthesia is increasing.

METHOD

As part of a larger study investigating anxiety in elective day surgery, a questionnaire was given to 523 patients on the day of surgery to adult patients undergoing surgery with local or regional anaesthesia between 2005 and 2007. They were asked to return this by mail 24-48 hours following surgery and 214 completed questionnaires were returned (response rate 41%).

FINDINGS

The experience of being awake, possibly feeling the surgeon's touch, seeing their body cut open or surgery being more painful than expected were anxiety-provoking aspects. Using factor analysis, 'intra-operative apprehension', 'anaesthetic information provision' and 'health control' were identified as central features. Multiple regression showed that apprehension associated with the intra-operative experience and anaesthetic information provision were statistically significantly associated with an increase in overall level of anxiety.

CONCLUSION

Focusing care on managing the intra-operative experience and providing anaesthetic information in advance might help limit anxiety and expel the apparent misapprehensions associated with conscious surgery.

Noise exposure due to orthopedic saws in simulated total knee arthroplasty surgery

In some orthopedic procedures, including total knee arthroplasty (TKA), surgeons are exposed to noise generated by powered instruments, with a risk of developing occupational hearing loss. A new saw design, the Stryker Precision system (Stryker, Kalamazoo, Mich), has been developed that may reduce noise during TKA surgery. The new system was tested against a standard Stryker System 5 sagittal saw in simulated TKA surgery using porcine cadaveric femurs, and noise levels from the cuts were measured. The average noise level of the Precision system, L(Aeq) = 81.6 dB(A), was significantly lower than that of the System 5 saw, L(Aeq) = 88.9 dB(A) (P = .003). Calculated 8-hour values for both blade systems were within Health and Safety guidelines. It was concluded that the Precision system produced a lower risk of noise-induced hearing loss than the System 5 saw.

Communication devices in the operating room

PURPOSE OF REVIEW

Effective communication is essential to patient safety. Although radio pagers have been the cornerstone of medical communication, new devices such as cellular telephones, personal digital assistants (PDAs), and laptop or tablet computers can help anesthesiologists to get information quickly and reliably. Anesthesiologists can use these devices to speak with colleagues, access the medical record, or help a colleague in another location without having to leave a patient's side. Recent advances in communication technology offer anesthesiologists new ways to improve patient care.

RECENT FINDINGS

Anesthesiologists rely on a wide variety of information to make decisions, including vital signs, laboratory values, and entries in the medical record. Devices such as PDAs and computers with wireless networking can be used to access this information. Mobile telephones can be used to get help or ask for advice, and are more efficient than radio pagers. Voice over Internet protocol is a new technology that allows voice conversations to be routed over computer networks. It is widely believed that wireless devices can cause life-threatening interference with medical devices. The actual risk is very low, and is offset by a significant reduction in medical errors that results from more efficient communication.

SUMMARY

Using common technology like cellular telephones and wireless networks is a simple, cost-effective way to improve patient care.

Evaluation of a Hands-Free Wireless Communication Device in the Perioperative Environment

The objective of this study was to evaluate the efficiency and reliability of a hands-free voice over Internet protocol (VOIP) communication system in the perioperative environment. Two surveys were administered to anesthesiologists and operating room (OR) nurses working at an academic medical center. Providers were queried by alphanumeric pages or VOIP queries during OR work shifts to measure communication response times. Providers, responding to the query, were asked to verbally complete a system performance survey to capture information regarding their workload and work environment at the time of the query. A user feedback survey was independently administered in writing to a convenience sample of OR providers to obtain information regarding provider communication preferences, concerns, and recommendations. OR providers responded to communication queries four times faster when using VOIP compared to alphanumeric pagers. Providers found VOIP to be much less reliable than conventional pager-telephone systems. Dead spots in the 802.11b network and errors in speaker recognition were frequently cited as sources of system failures. Providers also expressed concern in maintaining confidentiality of patient data or other clinical data communicated using this system. The results of this study suggest that VOIP is still a developing technology but one that is currently viable in the clinical setting. The technology can be used efficiently and securely in health care if users are given the proper training its functions and capabilities.

Noise levels in Johns Hopkins Hospital

This article presents the results of a noise survey at Johns Hopkins Hospital in Baltimore, MD. Results include equivalent sound pressure levels (L(eq)) as a function of location, frequency, and time of day. At all locations and all times of day, the L(eq) indicate that a serious problem exists. No location is in compliance with current World Health Organization Guidelines, and a review of objective data indicates that this is true of hospitals throughout the world. Average equivalent sound levels are in the 50-60 dB(A) range for 1 min, 1/2, and 24 h averaging time periods. The spectra are generally flat over the 63-2000 Hz octave bands, with higher sound levels at lower frequencies, and a gradual roll off above 2000 Hz. Many units exhibit little if any reduction of sound levels in the nighttime. Data gathered at various hospitals over the last 45 years indicate a trend of increasing noise levels during daytime and nighttime hours. The implications of these results are significant for patients, visitors, and hospital staff.

Surveying Patients as a Start to Quality Improvement in the Surgical Suites Holding Area

The holding area, as the patient's first introduction to the surgical suites, has the potential to set the tone for the entire surgical experience. To identify targets for improvement efforts in the holding area, a convenience sample of 51 surgical patients completed a 12-item patient satisfaction survey developed using Androfact before discharge from hospital. Results reveal 5 aspects that fall below the desired benchmark satisfaction rate of 80%: staff holding personal conversations in the patients' presence, being offered distraction materials while waiting, pleasantness of the physical environment, reassurance that family members would be kept up-to-date during the surgical procedure, and comfort to provide personal information without worrying that others were listening. Discussion of findings indicates priorities for improvement efforts in the holding area.

Analgesia following music and therapeutic suggestions in the PACU in ambulatory surgery; a randomized controlled trial

BACKGROUND

This study was designed to determine whether music (M), or music in combination with therapeutic suggestions (M/TS) could improve the postoperative recovery in the immediate postoperative in daycare surgery.

METHODS

One-hundred and eighty-two unpremedicated patients who underwent varicose vein or open inguinal hernia repair surgery under general anaesthesia were randomly assigned to (a). listening to music (b). music in combination with therapeutic suggestions or (c). blank tape in the immediate postoperative period. The surgical technique, anaesthesia and postoperative analgesia were standardized. Analgesia, the total requirement of morphine, nausea, fatigue, well-being, anxiety, headache, urinary problems, heart rate and oxygen saturation were studied as outcome variables.

RESULTS

Pain intensity (VAS) was significantly lower (P = 0.002) in the M (2.1), and the M/TS (1.9) group compared with the control group (2.9) and a higher oxygen saturation in M (99.2%) and M/TS (99.2%) group compared with the control (98.0%), P < 0.001, were found. No differences were noted in the other outcome variables.

CONCLUSION

This controlled study has demonstrated that music with or without therapeutic suggestions in the early postoperative period has a beneficial effect on patients' experience of analgesia. Although statistically significant, the improvement in analgesia is modest in this group of patients with low overall pain levels.

Noise in the postanaesthesia care unit

BACKGROUND

Although the postanaesthesia care unit (PACU) can be noisy, the effect of noise on patients recovering from anaesthesia is unknown. We studied the sources and intensity of noise in the PACU and assessed its effect on patients' comfort.

METHODS

We measured noise in a five-bed PACU with a sound level meter. Noise levels were obtained using an A-weighted setting (dBA) and peak sound using a linear scale (dBL). Leq (average noise level at 5-s intervals), maximum Leq (LeqMax), minimum Leq (LeqMin) and noise peaks (Lpc) were calculated. During recording, an independent observer noted the origin of sounds from alarms and noise above 65 dB intensity (P65dB). Two hours after leaving the PACU, patients were asked about their experience and to rank their complaints on a visual analogue scale (VAS) using unstructured and structured questionnaires.

RESULTS

We made 20,187 measurements over 1678 min. The mean Leq, LeqMax and LeqMin were 67.1 (SD 5.0), 75.7 (4.8) and 48.6 (4.1) dBA respectively. The mean Lpc was 126.2 (4.3) dBL. Five per cent of the noise was at a level above 65 dBA. Staff conversation caused 56% of sounds greater than 65 dB and other noise sources (alarm, telephone, nursing care) were each less than 10% of these sounds. Five patients reported disturbance from noise. There was no significant difference in Leq measured for patients who found the PACU noisy and those who did not [59.5 (3.1) and 59.4 (2.4) dBA respectively]. Stepwise multiple logistic regression indicated that only pain was associated with discomfort.

CONCLUSIONS

Even though sound in the PACU exceeded the internationally recommended intensity (40 dBA), it did not cause discomfort. Conversation was the most common cause of excess noise.