By Chase Doyle

Nashville, Tenn.—A nursing initiative to assess noise in the OR has exposed the dangerous decibel levels encountered by surgical staff and patients on a daily basis, according to data presented at the Association of periOperative Registered Nurses 2019 Global Surgical Conference & Expo.

Noise measurements made in real time at randomly selected multisurgery specialty ORs revealed sound levels comparable to a hairdryer or bulldozer during critical times of surgery on both surgical count and anesthesia emergence. The study authors emphasized that these results provide strong evidence to support more restrictive noise policies in the OR.

“We knew the OR was loud, but we’re just now realizing the extent of the problem,” said Glendyle Levinskas, BSN, RN, CNOR, of Vanderbilt University Medical Center, in Nashville, Tenn., and the lead author of the study. “The clinically and statistically significant findings of this study suggest an increased risk of negative health effects on staff and patient safety.”

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As Ms. Levinskas reported, a review of the literature showed that noise can cause distractions to novice surgeons that can affect their performance, may lead to ineffective communication of critical information, and decreases auditory processing functions of surgeons. Noise also can increase risk for surgical site infection in patients. Additionally, according to Ms. Levinskas, noise has been shown to cause stress and heart disease, and increase risk for hearing loss. It wasn’t until she experienced the problem firsthand, however, that these hypothetical risks became real.

“During a difficult intubation, I witnessed a CRNA state very loudly, ‘Quiet please,’” Ms. Levinskas recalled. “The music and conversation among the surgical team was causing a serious distraction and preventing her from performing her job effectively. At that moment, I decided to initiate [a] noise reduction project.”

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Glendyle Levinskas, BSN, RN, CNOR

According to Ms. Levinskas, the volume of music in particular has become one of the staff’s major concerns. While some of the OR staff may be aware of the increasing presence of noise, the extent of the problem remains unknown.

“The staff are unaware of how loud the OR really is or how it’s affecting the communication and focus of providers,” Ms. Levinskas said, who noted that noise in the OR remains unmonitored and unregulated at her academic institution. “Because we don’t have a noise policy in place, I thought it would be beneficial to assess the problem and see how we can intervene.”

For this observational study, Ms. Levinskas and her colleagues used the National Institute on Occupational Safety and Health Sound Level Meter app and an iPhone app, with a calibrated external microphone to measure sound levels during critical times of surgery. In September 2017, the researchers made 60 noise level measurements in randomly selected multisurgery specialty ORs during surgical count (n=30) and anesthesia emergence (n=30). Sound levels were measured at a four-foot perimeter from the OR table, at the foot of the table during surgical count, and at the head of the bed during anesthesia emergence for consistent points of reference of location.

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“There are several critical times in the OR throughout the entire surgical procedure,” Ms. Levinskas explained. “We chose the surgical count because it’s a critical time for the scrub tech and nurse, while anesthesia emergence is a critical time for anesthesia providers.”

A Setting for a Symphony of Noise

As Ms. Levinskas reported, average noise levels in the OR at critical times far exceeded safe sound recommendations for indoor hospitals based on World Health Organization and U.S. Environmental Protection Agency values of 30 and 45 dBA, respectively. According to the real-time data collected, the OR noise level during critical times reached a mean maximum of 86.9 dBA—close to the level of a hairdryer.

“Technology definitely makes our jobs easier in many ways, but it can also be a distraction to the staff,” Ms. Levinskas observed. “Everybody now has electronic devices, and when you combine that with other equipment in the OR as well as background conversation, it’s like a symphony of noise production.”

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Having identified and assessed the problem, Ms. Levinskas and her colleagues are looking to increase staff awareness and strategize solutions for OR noise reduction.

“I believe OR noise assessment is the first step in noise reduction. When we recognize we have a problem we can move forward. We are now hoping to organize a multi-disciplinary team to devise strategies that we can implement to control noise levels. Although noise is unavoidable in the OR, there are certain critical times that really demand quiet.”

Elizabeth Card, MSN, APRN, FNP-BC, CCRP, a nursing research consultant at Vanderbilt University Medical Center and the co-author of the study, said even though certain sounds in the OR are unavoidable, there is still much that can be done to improve the health and safety of the surgical staff and patients.

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“We’re not going to be able to control the sounds of the air exchange, for example, but there are a lot of other things we can control, such as the volume of discussion or the music that goes on,” said Ms. Card, who also praised Ms. Levinskas’s study. “This is a fantastic example of a clinical nurse who is immersed in the work and recognizes that there is a problem, and given the proper support and resources, is able to change practice based on evidence. That’s one of the things we’re so proud of the nurses being able to do at Vanderbilt.”