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QIPS TIPS #22: The Sounds of Silence

Shari Welch, MD, FACEP

Part 1

Most EDs spend little time planning for the high ambient noise found in the ED and strategies to reduce this ambient noise.  Yet, the data shows that when these efforts are made the efficacy of communication improves.  In an article published by the Joint Commission Journal in June 2013 titled “Strategies for Improving Communication in the ED” Dickson Cheung joined me and our co-authors in discussing ways to reduce ambient noise in the ED. We argued that decreasing ambient noise is a critical strategy for effective communication in the ED.

During periods of reduced noise, speech intelligibility increased, nurses perceived their workloads as less, and social support among staff improved. Reports of efforts to reduce noise in healthcare settings appear in the literature. In one site the unit installed a noise level monitor. As noise on the unit increased, the staff received a real-time signal. When levels were in range, the monitor showed a green light. When the sound exceeded the recommended levels, it went yellow; and when it was in a danger zone, the monitor showed red. Staff identified high sound contributors. For instance, the lids on the rubbish bins were very noisy, so they were replaced; the X-ray machine was revised to be less noisy, and all alarms and phones were programmed to a lower decibel level. In another unit, the overhead paging was reduced and staff was trained to speak more quietly.

Design strategies have been recognized to contribute to noise reduction. Single patient rooms have been shown to be quieter than multiple patient rooms. Noise concerns and concern about hospital-acquired infections (HAI) are seeing an increase in designs of single patient rooms, even in the nursery. Another important and proven design intervention is to install high-performance sound-absorbing ceiling tiles that reduce echoing and reverberation and sharply diminish sound propagation. A key component of quieting facilities is to eliminate noise sources. Even motion sensing paper towel dispensers have been shown to increase the decibel level in a clinical unit!  Every design change must be considered in terms of its contribution to the noise level. Insulating ice machines and pneumatic tube systems can also have a significant effect on noise in the ED Noise reducing panels and wallpaper, strategically placed, were shown to significantly reduce noise in an oncology ward at Johns Hopkins Hospital (60).

Decentralizing workstations on nursing units has been shown to reduce noise in inpatient settings. EDs that are built with large numbers of rooms operating out of a central hub are particularly noisy and the need to involve architects and designers in these efforts is now apparent.  Smaller functioning units (in effect microsystems) are inherently quieter units. 

  STRATEGY
Reducing Ambient Noise

1) Using a sound meter to identify loud noise
2) Pad trash can lids
3) Pad tube system
4) Limit portable X-ray machine use
5) Replace loud paper towel dispensers
6) Limit overhead paging
7) Limit radio use
8) Staff training to decrease speech volume
9) Sound absorbing ceiling tiles
10) Sound absorbing wall paper
11) De-centralized work areas



Part 2
Dickson Cheung and I noted in our article “Strategies for Improving Communication in the ED” that most EDs spend little time planning for and assessing the effectiveness of the communication mediums they employ. We argued that ED clinicians should carefully and thoughtfully plan a communication scheme using several communication mediums to fit the situational complexities of ED interactions. 

By crafting a deliberate scheme with a hierarchy for communications and understanding the affordances of each medium, EDs can improve communication and decrease noise. This can be done in both technology driven and technology independent departments alike. In particular, an emphasis on decreasing overhead paging in the department would be a big step on the road to improved communication. Overall noise levels are a detriment to patient and staff well being and an impediment to effective communication. Through deliberate methods, the noise level of a department can be decreased and the communication model improved. By identifying levels of urgency or emergency in communication content, and then implementing an appropriate communication method, a communication scheme can be designed that is appropriate for a particular department.

For instance, the Communication Scheme could craft rules such as follows:

  1. A physician to physician call is sent to the dedicated phone line
  2. A critical lab value is sent by text to the MD
  3. Routine labs are pushed to the provider through a tracking system cue
  4. A critically unstable patient with pending cardio-respiratory failure is indicated by overhead paging

 

  STRATEGY
Designing a Communication Scheme 

1) Articulate a communication hierarchy using the strategies listed below

  • Whiteboard communication
  • Tracking system communication
  • Text messaging
  • Dedicated cell phones

2) Limit overhead paging
3) Limit radio usage


When the University of Kentucky employed such a system, they went months without any overhead paging and the decrease noise level translated into a calmer work environment!

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