By Don Sadler
When you think of noisy environments, you probably think about a rock concert, sports stadium or airport runway. But what about the operating room?
Excessive noise can be a big problem in the operating room (OR) that leads to a number of negative consequences. Given all the different pieces of medical equipment in the OR, and the number of perioperative team members present, this noise can serve as a distraction to team members, which increases the risk of errors and jeopardizes patient safety.
Disrupting and Distracting
“Excessive operating room noise can disrupt communication and distract clinicians during critical patient care activities,” says Emily Jones, MSN, RN, CNOR, NPD-BC, perioperative practice specialist with the Association of periOperative Registered Nurses (AORN).
“The distractions associated with excessive noise in the operating room may interrupt patient care during critical activities,” adds Jones. “Distractions and noise contribute to the complexity of the care environment in the OR.”
Jones points to a systematic review of the perception and attitude toward noise and music in the OR published in 2021. The review concluded that higher levels of noise in the OR can have a negative impact on patient outcomes and adversely affect the performance of team members.
“This review found that excessive noise is often perceived as a source of stress in the OR,” she says.
David Taylor, MSN, RN, CNOR, the president of Resolute Advisory Group LLC, says he has been exposed to loud noise throughout the decades he has spent working in the OR.
“My doctors have always listened to music in the OR, most of the time at high volume,” says Taylor. “This made it difficult to communicate with team members or count instruments, sharps and sponges. And anesthesia always had concerns that they could not hear their patient monitors and manage their patients.”
Taylor says that decades of exposure to excessive OR noise have left him with marked hearing loss. “None of the studies I have read have found excessive OR noise to be beneficial in any way,” he says.
Measuring Distractions During Wound Closure
Barbara L. DiTullio, DNP, RN, MA, CNOR, NEA-BC, senior clinical operations liaison, perioperative services at Beth Israel Deaconess Medical Center in Boston, Massachusetts, completed a study in 2019 focused on distractions that occur in the OR during wound closure and their role in suture needle injuries. In addition to other observable data, she measured OR noise in decibels to understand baseline data.
“I used the NIOSH threshold for noise in hospitals (maintaining a therapeutic environment) of 45 decibels and the WHO threshold of 35 decibels,” says DiTullio. “My baseline for procedures in the study exceeded both.”
The average decibel level DiTullio recorded during wound closure was 62, while the average peak decibel level was 104. In comparison, the average decibel level at a rock concert is between 90 and 120.
“One of the categories of distraction I observed was environmental noise, and this category had the highest number of occurrences observed in all cases,” says DiTullio.
Environmental noise included staff moving in and out of the OR, consolidation and movement of people, equipment and instrumentation, and music.
Technological interruptions were also observed, adds DiTullio, including pagers, telephones, overhead announcements and the like.
The Joint Commission cites another study with similar results to DiTullio’s study that measured noise levels in OR trauma procedures. The average noise level here was 85 decibels, or almost double the NIOSH recommendation, and reached as high as 130 decibels.
Orthopedic and neurosurgery tend to have higher sustained noise levels with intermittent peak levels exceeding 100 decibels more than 40 percent of the time.
“Some the highest levels of OR noise come from powered surgical instruments such as high-speed drills, burs or saws used for bone dissection,” says Jones.
Meanwhile, studies focused on anesthesia have found that the noisiest periods during surgery are associated with induction and emergence of anesthesia. A lab study simulating OR background noise found a 17 percent reduction in the accuracy with which anesthesia residents detected changes in saturation on a pulse oximeter.
“What became clear in my study is that OR noise is distracting,” says DiTullio. “This is true whether it’s essential communication related to the procedure, non-essential communication to help pass the time, or people entering the OR to ask a question or check on case progress.”
“Every incident may not result in a corresponding decibel increase, but each one draws attention away from the task at hand,” says DiTullio. “Even a momentary interruption can cause harm.”
Madhavi Dave, MBA, CPPS, patient safety specialist with the Office of Quality and Patient Safety, Division of Healthcare Improvement, The Joint Commission, says he has encountered times when excessive noise impacted communication while working in the OR.
“Loud music or having many observers in the room (such as medical students and residents) are common sources of noise,” says Dave. “When this occurred, especially during critical phases of the surgery, the circulator typically addressed the situation by either letting the surgeon know that the music needed to be lowered or turned off or asking the observers to leave.”
Categories of OR Noise
The Joint Commission separates common sources of noise in the OR into two categories. The first category includes technological and environmental sources such as:
- Phones and paging systems (personal and overhead)
- Computers
- Wireless communication systems
- Music devices
- Medical equipment/devices
- Monitors and clinical alarms
- Metal equipment and instruments
- Environmental conditions (such as ventilation)
- The second category includes behavioral sources such as:
- Case-related conversations
- Non-case related conversations
- Patient care activities
- Staff entering and leaving the OR suite
“The most commonly cited sources of OR noise are non-case relevant conversations, telephone calls, pagers and music,” says Erin Lawler, MS, CPPS, human factors engineer with the Office of Quality and Patient Safety, Division of Healthcare Improvement, The Joint Commission.
Clinical alarms are important, of course, but excessive alarms in the OR can be distracting and counterproductive.
“It’s important that alarms are kept to the minimum necessary to alert nurses to important changes in patient condition,” says Halley Ruppel, a core faculty member at the Center for Pediatric Clinical Effectiveness (CPCE) in Philadelphia. “Unfortunately, clinical alarms tend to be excessive and frequently not urgent or actionable.”
Ruppel and her team at the Children’s Hospital of Philadelphia Research Institute were recently awarded a $40,000 grant from the AAMI Foundation to explore ways to reduce alarm burdens.
“I’m interested in how we can build sustainable processes for evaluating and improving alarms and alarm management in acute care settings,” says Ruppel.
One way to do this is by giving clinical stakeholders access to up-to-date data analytics on types and frequencies of alarms occurring in their units.
“This could increase awareness and foster engagement in alarm management efforts,” says Ruppel.
Ruppel and her team expect to identify functional specifications for alarm data analytics that can be used to develop an intervention model to test in future work. She hopes the project will optimize how technology functions in clinical care.
“Our ultimate goal is to develop a sustainable process for evaluating the dynamic clinical alarm system that nurses use while caring for patients,” says Ruppel. “Having this process in place will strengthen collaborations between healthcare technology management professionals and clinicians.”
‘Quiet in the Room!’
In 2018, Glendyle Levinskas, BSN, RN, CNOR, a staff perioperative nurse at Vanderbilt University Medical Center Health System in Nashville, Tennessee, launched a project to try to deal with excessive OR noise after experiencing an event. “I was circulating one day when the increased noise level in the OR became a safety concern,” she says.
Levinskas elaborates: “The OR was crowded with multiple ongoing conversations and music when an unexpected difficult intubation caused the anesthesia provider to call out in a loud voice, ‘Quiet in the room!’ Due to the noise distraction, she was unable to concentrate on performing a critical task for patient safety.”
Along with her colleague, research nurse specialist Elizabeth Card, APRN, FNP-BC, CPAN, CCRP, FASPAN, Levinskas wanted to develop evidence-based noise reduction strategies that engaged all team members in shaping sustainable solutions. They formed a task force that made a unified decision on noise reducing interventions to mitigate the increased noise levels in the OR, focusing especially on critical times of surgery.
“The measures begin with staff education, noise awareness and outlined noise reducing behaviors and practices,” says Levinskas. “Specific noise reduction actions include being quiet during critical times by using the safety alert phrase, ‘Sound check.’ This should bring immediate quiet to the OR, including turning off or adjusting music volumes, when a critical task is being performed.”
Levinskas and Card make an important distinction between necessary and distracting noises. For example, an anesthesia machine, alarm or pulse oximeter beep, or movement of carts is a necessary OR noise. Loud music, conversations about non-procedure related topics and unnecessary clanging of instruments are examples of distracting noises.
As part of their project, Levinskas and Card surveyed surgical team members to ask how OR noise was affecting them. Nearly half (47%) said that current noise levels distracted them and caused stress.
Thus began a three-year process to create a culture shift to reduce distracting OR noise. They formed a multidisciplinary OR noise reduction team with 30 members that shaped ongoing education to raise awareness about OR noise risks to health and patient safety.
“Our ultimate goal is to empower everyone in the OR with education and a mechanism to call out when noise levels impair communication and concentration,” says Levinskas. “It has been rewarding to see staff beginning to put the alert phrase into practice.”
Improving Team Communication
The “AORN Guideline for Team Communication” includes recommendations to help decrease noise levels and promote effective communication in the OR to create a safer environment.
“A no-interruption zone should be established during critical phases of surgery where nonessential conversation and distractions are stopped,” says Jones. “Critical phases may include anesthesia induction and emergence, the surgical time-out, medication management, surgical counts, critical dissections or anastomoses and specimen handling.” “To minimize excessive noise during these critical phases, perioperative team members can refrain from non-essential conversations, lower the music volume and silence mobile devices,” Jones adds. “Any team member should feel supported in calling for a ‘safety pause’ if a distraction or interruption occurs that could affect patient safety.”
The “AORN Position Statement on Managing Distractions and Noise During Perioperative Care” contains more detailed strategies for decreasing excessive OR noise. A free PDF may be downloaded at https://www.aorn.org/-/media/aorn/guidelines/position-statements/posstat-safety-distractions-and-noise.pdf.
Meanwhile, the “AORN Guideline for Team Communication” includes recommendations to enhance team communication and the culture of safety in the operating room for the entire perioperative team. It may be purchased at https://www.aorn.org/guidelines/about-aorn-guidelines.
Lawler suggests that health care organizations adopt a systems approach and facilitate conditions that minimize distractions and noise that can impede concentration and communication in the OR. She lists the following recommendations from The Joint Commission:
- Create a no-interruption zone (or a “sterile cockpit”) during critical phases of a procedure during which non-essential conversation and activities are prohibited.
- Measure noise levels in the OR to provide evidence for noise-reduction strategies.
- Provide empirical data reflecting the efficacy of such strategies to the OR team, along with real-time information so they know when noise levels are exceeding recommended levels.
- Educate perioperative team members about the sources of OR noise, its impact on patient and staff safety, and noise reduction strategies.
- Consider equipment alternatives that produce less noise whenever possible.
- Perform simulation and training to model noise reduction strategies.
“We have long since normalized all of the noise and distractions that are experienced in the OR,” says DiTuillio. “Unfortunately, few people realize how much this impacts our daily work or how big a threat it poses to patient safety.”
Levinskas believes that team engagement is the biggest key to reducing OR noise.
“Noise production is caused by everyone, so noise reduction calls for everyone to be involved in addressing the problem,” she says.
