A Comparison of Sound Levels in Open Plan Versus Pods in a Neonatal Intensive Care Unit

The Neonatal Intensive Care Unit (NICU) Context and the Perceived Soundscape: A Grounded Theory Approach

BACKGROUND

Studies address excessive sound levels and their adverse effects on infants in neonatal intensive care units (NICUs). However, objective measurements represent merely one aspect of the acoustic environment, and investigations into staff's perceptions of the acoustic environment remain scarce in the NICU context. A holistic approach, soundscape, is needed to explore the acoustic environment in-depth.

AIM

This study aims to (1) contribute to indoor soundscape literature and inform decision-makers of future NICU design and research by focusing on staff members' perceptions of the soundscape and (2) explore whether there is a relationship between staff members' perceptions of soundscapes and the built and acoustic environments of one NICU.

METHODS

Following the ISO/TS 12913-2/3 protocols, semi-structured interviews were conducted with 10 NICU staff members and analyzed using the grounded theory to generate a conceptual framework for NICU soundscapes.

RESULTS

The results indicated that the task-related sounds, including false alarms, were neutrally responded to as they evoked acceptance and adaptation behaviors. The sound sources perceived as irrelevant were responded to negatively. NICU staff indicated that although they expect to hear alarms clearly, specific features of alarms caused several physiological and psychological problems.

CONCLUSIONS

The findings of the study revealed the importance of conducting a soundscape approach to investigate NICU acoustic environment in detail. The study showed that staff members' perceptions and responses primarily depend on the context rather than on sound levels.

Analysis of noise levels in the neonatal intensive care unit: the impact of clinical microsystems

Reorganization of neonatal intensive care by introducing clinical microsystems may help to allocate nursing time more appropriately to the needs of patients. However, there is concern that cohorting infants according to acuity may enhance noise levels. This single-center study investigated the impact of reorganization of neonatal intensive care unit by implementing clinical microsystems in a Level III NICU on environmental noise. This prospective study measured 24-h noise levels over a period of 6 months during pre- and post-implementation of microsystems cohorting infants of similar acuity. Comparative analyses of the mixed acuity (i.e., before) and the cohorting (i.e., after) model were performed by creating daily profiles from continuous noise level measurements and calculating the length of exposure to predefined noise levels. Compared to baseline daytime measurements, noise levels were 3-6 dBA higher during physician handover. Noise levels were 2-3 dBA lower on weekends and 3-4 dBA lower at night, independent of the organizational model. The introduction of clinical microsystems slightly increased average noise levels for high-acuity pods (A and B) but produced a much more substantial decrease for low-acuity pods (E), leading to an overall reduction in unit-wide noise levels.    Conclusion: Our data show that noise levels are more driven by human behavior than by technical devices. Implementation of microsystems may help to reduce noise exposure in the lower acuity pods in a NICU. What is Known: • Excessive noise levels can lead to adverse effects on the health and development of premature infants and other critically ill newborns. • The reorganization of the neonatal intensive care unit following the clinical microsystems principles might improve quality of care but also affect noise exposure of staff and patients. What is New: • The transition from a mixed -acuity to cohorting model is associated with an overall reduction in noise levels, particularly in low-acuity pods requiring less nursing care. • Nevertheless, baseline noise levels in both models exceeded the standard permissible limits.

Preventing Excessive Noise Exposure in Infants, Children, and Adolescents

Noise exposure is a major cause of hearing loss in adults. Yet, noise affects people of all ages, and noise-induced hearing loss is also a problem for young people. Sensorineural hearing loss caused by noise and other toxic exposures is usually irreversible. Environmental noise, such as traffic noise, can affect learning, physiologic parameters, and quality of life. Children and adolescents have unique vulnerabilities to noise. Children may be exposed beginning in NICUs and well-baby nurseries, at home, at school, in their neighborhoods, and in recreational settings. Personal listening devices are increasingly used, even by small children. Infants and young children cannot remove themselves from noisy situations and must rely on adults to do so, children may not recognize hazardous noise exposures, and teenagers generally do not understand the consequences of high exposure to music from personal listening devices or attending concerts and dances. Environmental noise exposure has disproportionate effects on underserved communities. In this report and the accompanying policy statement, common sources of noise and effects on hearing at different life stages are reviewed. Noise-abatement interventions in various settings are discussed. Because noise exposure often starts in infancy and its effects result mainly from cumulative exposure to loud noise over long periods of time, more attention is needed to its presence in everyday activities starting early in life. Listening to music and attending dances, concerts, and celebratory and other events are sources of joy, pleasure, and relaxation for many people. These situations, however, often result in potentially harmful noise exposures. Pediatricians can potentially lessen exposures, including promotion of safer listening, by raising awareness in parents, children, and teenagers. Noise exposure is underrecognized as a serious public health issue in the United States, with exposure limits enforceable only in workplaces and not for the general public, including children and adolescents. Greater awareness of noise hazards is needed at a societal level.

Effects of hydrotherapy and tactile-kinesthetic stimulation on weight gain of preterm infants admitted in the Neonatal Intensive Care Unit

OBJECTIVE

The present study aimed to evaluate the effects of hydrotherapy and tactile-kinesthetic stimulation on the birth weight of preterm infants admitted in the Neonatal Intensive Care Unit.

METHOD

It was a randomized controlled trial, without blinding, in which 44 preterm infants of both sexes with gestational age between 32 and 34 weeks were included into two groups: hydrotherapy group (n = = 22) and tactile-kinesthetic stimulation group (n = 22). Weight gain was the parameter assessed daily.

RESULTS

In the tactile-kinesthetic stimulation group there was a variation in weight gain, but without significant difference (p = 0,43). However, in the hydrotherapy group, it was observed that increased weight gain started from the 2nd day (p < 0,001).

CONCLUSIONS

Hydrotherapy group presented significantly increased weight after the interventions, indicating that this technique can interfere with weight gain in preterm infants.

Assessment of Neonatal Intensive Care Unit Sound Exposure Using a Smartphone Application

OBJECTIVE

This study aimed to determine the impact of neonatal intensive care unit (NICU) design and environmental factors on neonatal sound exposures. We hypothesized that monitoring with a smartphone application would identify modifiable environmental factors in different NICU design formats.

STUDY DESIGN

Minimum, maximum, and peak decibel (dB) recordings were obtained using the Decibel X phone app, and the presence of noise sources was recorded in each patient space at three NICUs over a 6-month period (December 2017 to May 2018). Data were analyzed by Student's t-test and ANOVA with Bonferroni correction. Data were collected at the University of Maryland Medical Center single family room (SFR) level IV and St. Agnes Healthcare hybrid pod/single family room level III NICU, Baltimore, MD and at Prince George's Hospital Center open-pod design Level III NICU, Cheverly, MD.

RESULTS

All recordings in the three NICUs exceeded the American Academy of Pediatrics (AAP) recommended <45 dB level. The maximum and peak dB were highest in the open pod format level III NICU. Conversations/music alone and combined with other factors contributed to increased sound exposure. Sound exposure varied by day/night shift, with higher day exposures at the level III hybrid and open pod NICUs and higher night exposures at the level IV SFR NICU.

CONCLUSION

Although sound exposure varied by NICU design, all recordings exceeded the AAP recommendation due, in part, to potentially modifiable environmental factors. A smartphone application may be useful for auditing NICU sound exposure in quality improvements efforts to minimize environmental sound exposure.

KEY POINTS

· Smartphone application was used to assess NICU sound exposure.. · All cases of sound exposure exceed recommendations.. · A smartphone application was used to identify modifiable factors..

Elucidating the context for implementing nonpharmacologic care for neonatal opioid withdrawal syndrome: a qualitative study of perinatal nurses

BACKGROUND

Up to 95% of neonates exposed to opioids in utero experience neonatal opioid withdrawal syndrome at birth. Nonpharmacologic approaches (e.g., breastfeeding; rooming-in; skin-to-skin care) are evidence-based and should be implemented. These approaches, especially breastfeeding, rely on engagement of the neonates' mothers to help deliver them. However, little is known about the structural and social dynamic context barriers and facilitators to implementing maternal-delivered nonpharmacologic care.

METHODS

Using a qualitative descriptive design, perinatal nurses from a Midwest United States hospital family birthing center, neonatal intensive care unit, and inpatient pediatric unit were interviewed. These units were involved in caring for mothers and neonates affected by opioid use. Telephone interviews followed a semi-structured interview guide developed for this study, were audio-recorded, and lasted about 30-60 min. Interviews were transcribed verbatim and independently analyzed by five investigators using the constant comparative method. Themes were discussed until reaching consensus and subsequently mapped to a conceptual model adapted for this study.

RESULTS

Twenty-one nurses participated in this study (family birth center, n = 9; neonatal intensive care, n = 6; pediatrics, n = 6). Analysis resulted in four major themes: 1) Lack of education and resources provided to staff and mothers; 2) Importance of interdisciplinary and intradisciplinary care coordination; 3) Flexibility in nurse staffing models for neonatal opioid withdrawal syndrome; and 4) Unit architecture and layout affects maternal involvement. Minor themes supported each of the four major themes. All themes mapped to the conceptual model.

CONCLUSIONS

This study provides a more comprehensive understanding of the barriers and facilitators affecting implementation of maternal involvement in nonpharmacologic care of newborns with neonatal opioid withdrawal syndrome. Future efforts implementing nonpharmacologic approaches must consider the context factors affecting implementation, including structural and social factors within the units, hospital, and broader community.

Comparing light and noise levels before and after a NICU change of design

OBJECTIVE

To compare light and sound levels before and after a change of design and evaluate these levels considering recommended NICU standards.

STUDY DESIGN

A pre-test/post-test design. Light and sound levels were compared between the former open ward (OW) NICU of 34 beds and the current 40-bed unit composed of both pods and single-family rooms (SFR).

RESULT

Light levels were significantly higher in the pod/SFR unit for all levels of care, days of the week and time of the day. These findings could be attributed to the number and configuration of windows in the new pod/SFR unit allowing for more daylight entry compared to the OW. Sound levels were significantly lower in the current NICU (pod/SFR) compared to the former OW.

CONCLUSION

Following the change of design, the pod/SFR unit are less noisy than the OW, although light levels are higher indicating the necessity to measure light levels.

Auditory exposure of high-risk infants discharged from the NICU and the impact of social factors

AIM

To (a) define the early home auditory environment of high-risk infants within one month of neonatal intensive care unit (NICU) discharge, (b) compare auditory exposures in the home environment to the NICU environment,  and (c) define relationships between maternal/infant factors and auditory exposures within the home.

METHODS

Seventy-three high-risk infants (48 high-risk infants in the NICU at term-equivalent age and 25 high-risk infants in the home following NICU discharge) had auditory exposures measured.

RESULTS

An average of 1.3 hours more noise (P ≤ .001) and 2 hours less silence (P = .01) were observed in the NICU compared with the home, but differences varied based on whether comparing to an open ward or private room. Infants with public insurance, lower household income and mothers without a college education were exposed to an average of 2.8, 3.0 and 2.3 hours more TV/electronic sounds respectively (P < .05). An average of 1744 fewer adult words (P = .03) were spoken in households with public insurance. There was an average of 3.1 hours less silence and 4.5 dB louder stimuli among households with lower income (P < .05).

CONCLUSION

Elucidating differences across environments can lead to interventions to foster appropriate auditory exposures to improve language development of high-risk infants.

Differences in early auditory exposure across neonatal environments

BACKGROUND

To date, no study has compared preterm and full term auditory environments.

AIM

To define differences in auditory exposure for preterm infants at term equivalent age in the neonatal intensive care unit (NICU) compared to auditory exposure in hospital rooms on a labor and delivery ward after full term birth.

STUDY DESIGN

Ninety-eight infants (48 preterm infants born 28 weeks gestation in the NICU at term equivalent age and 50 full term infants in a hospital room on the labor and delivery ward within 4 days of birth) had auditory exposure measured over a single 16-hour period using the Language Environment Acquisition (LENA) device.

RESULTS

More language (p < 0.001) was observed on the labor and delivery ward than in the NICU, with an average of 3.3 h more language in a 16-hour period and an average of 14,110 more words spoken around infants in a 16-hour period on the labor and delivery ward (p < 0.001). More electronic sounds were observed in the NICU, with an average of 2.3 h more in the 16-hour period (p < 0.001). The average decibel level in the NICU was lower than in the hospital rooms on the labor and delivery ward (57.16 ± 2.30 dB, compared to 63.31 ± 2.22 dB; p < 0.001).

CONCLUSION

The NICU auditory environment for preterm infants is different than the auditory environment for full term infants, with less language, more electronic sounds, and quieter stimuli. This understanding can aid in developing appropriate interventions that enhance positive forms of auditory exposures.

Environmental noise levels in hospital settings: A rapid review of measurement techniques and implementation in hospital settings

BACKGROUND

Hospitals provide treatment to improve patient health and well-being but the characteristics of the care environment receive little attention. Excessive noise at night has a negative impact on in-patient health through disturbed sleep. To address this hospital staff must measure night-time environmental noise levels. Therefore, an understanding of environmental noise measurement techniques is required. In this review, we aim to 1) provide a technical overview of factors to consider when measuring environmental noise in hospital settings; 2) conduct a rapid review on the equipment and approaches used to objectively measured noise in hospitals and identify methodological limitations.

DESIGN

: A rapid review of original research articles, from three databases, published since 2008. Studies were included if noise levels were objectively measured in a hospital setting where patients were receiving treatment.

RESULTS

1429 articles were identified with 76 included in the review. There was significant variability in the approaches used to measure environmental noise in hospitals. Only 14.5% of studies contained sufficient information to support replication of the measurement process. Most studies measured noise levels using a sound level meter positioned closed to a patient's bed area in an intensive care unit.

CONCLUSION

: Unwanted environmental noise in hospital setting impacts negatively on patient and staff health and well-being. However, this literature review found that the approaches used to objectively measure noise level in hospital settings have been inconsistent and poorly reported. Recommendations on best-practice methods to measure noise levels in hospital environments are provided.

A Systematic Literature Review of Empirical Studies on Decentralized Nursing Stations

Objectives:

The objective of this systematic review of literature was to critically evaluate peer-reviewed evidence regarding the effectiveness of decentralized nurse stations (DNSs).

Background:

The DNS has become an important topic in healthcare design research and practice over the past decade with aims of improving staff efficiency and patient experience. Research has shown to be inconclusive, with studies reporting an assortment of mixed findings.

Method:

A systematic review of literature was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses search process of electronic databases, citation tracking, and manual searches of references. All authors evaluated the studies independently. Studies included were empirical, peer-reviewed investigations of DNS in hospitals over the past 15 years. Each study was evaluated using an accepted healthcare design evaluation framework.

Results:

Over 200 studies were identified. After exclusions, 21 studies published since 2003 were available for full evaluation. Key findings from this review include (a) there is a positive trend toward patient experience in units with DNS, (b) nursing teamwork was perceived to decline in units with DNS, (c) methodological issues may be responsible for the mixed and inconsistent findings, and (d) there is no consistent categorization of nurse station typology or standard definition for DNS.

Conclusions:

Based on the evaluation framework, DNS are supportive of the patient experience yet have a negative impact on nursing teamwork. Higher quality studies are needed to classify specific typologies of DNS and account for elements such as patient care models, communication, visibility, and other patient care–related factors.

Auditory Exposure in the Neonatal Intensive Care Unit: Room Type and Other Predictors

OBJECTIVE

To quantify early auditory exposures in the neonatal intensive care unit (NICU) and evaluate how these are related to medical and environmental factors. We hypothesized that there would be less auditory exposure in the NICU private room, compared with the open ward.

STUDY DESIGN

Preterm infants born at ≤ 28 weeks gestation (33 in the open ward, 25 in private rooms) had auditory exposure quantified at birth, 30 and 34 weeks postmenstrual age (PMA), and term equivalent age using the Language Environmental Acquisition device.

RESULTS

Meaningful language (P < .0001), the number of adult words (P < .0001), and electronic noise (P < .0001) increased across PMA. Silence increased (P = .0007) and noise decreased (P < .0001) across PMA. There was more silence in the private room (P = .02) than the open ward, with an average of 1.9 hours more silence in a 16-hour period. There was an interaction between PMA and room type for distant words (P = .01) and average decibels (P = .04), indicating that changes in auditory exposure across PMA were different for infants in private rooms compared with infants in the open ward. Medical interventions were related to more noise in the environment, although parent presence (P = .009) and engagement (P  = .002) were related to greater language exposure. Average sound levels in the NICU were 58.9 ± 3.6 decibels, with an average peak level of 86.9 ± 1.4 decibels.

CONCLUSIONS

Understanding the NICU auditory environment paves the way for interventions that reduce high levels of adverse sound and enhance positive forms of auditory exposure, such as language.