This was a conference presentation I gave on my own at Acoustics 2019: Conference of the UK Institute of Acoustics. The paper, which will be published in conference proceedings, was based on an interdisciplinary project entitled HPNoSS, Hospital Project on Noise and Sleep in Hospitals. Although the presentation was entirely by me, the paper to be published was co-authored by Andreas Xyrichis and other members of the HPNoSS team (see separate item, BMJ article)

Wynne, John

Xyrichis, Andreas

UAL Research Online

Noise pollution in hospitalsExcessive noise is damaging for both patients and staffAndreas Xyrichis senior lecturer 1, John Wynne reader in sound arts 2, Jamie Mackrill freelanceresearcher 3, Anne Marie Rafferty professor of nursing policy 1, Angus Carlyle professor of soundand landscape 21Florence Nightingale Faculty of Nursing, Midwifery, and Palliative Care, King’s College London, UK; 2London College of Communication, Universityof the Arts London, UK; 3Warwick, UKNoise in hospitals is a common grievance among patients,families, and staff.1 In the US, “quietness of hospitalenvironment” is among the lowest scoring items on patientsurveys.2 In the UK, 40% of hospital patients are bothered bynoise at night, a consistent finding of the NHS Inpatient Survey.1Hospital noise is a steadily worsening problem, with levelsregularly exceeding international recommendations.3 4 Noiselevels over 100 dB have been measured in intensive care units,4the equivalent of loud music through headphones and the pointbeyond which damage to hair cells in the ear can occur.Effects on patients and staffExcessive noise in hospitals reduces the intelligibility of speechand impairs communication, causing annoyance, irritation, andfatigue5 and reducing the quality and safety of healthcare. It hasbeen implicated in the development of intensive care psychosis,hospitalisation induced stress, increased pain sensitivity, highblood pressure, and poor mental health.5-7Hospital noise disrupts sleep; machine sounds in particular havea greater negative effect on arousal than human voices.8Post-hospitalisation recovery is also compromised. In one studyfrom Sweden, coronary care patients treated during noisy periodshad a significantly higher incidence of rehospitalisation thanthose treated during quieter periods.9 For hospital staff, highnoise levels can impact negatively on communication,performance, wellbeing, and caring behaviour, and cancontribute to burnout.5 6Patients report being ill equipped and ill prepared to deal withhospital noise.10 Noise can have a cumulative effect: whenhospitalised for several nights, patients can feel trapped in astress inducing soundscape, leading to requests for prematuredischarge and heightened risk of poor recovery and readmission.Slow progressThree key challenges hinder progress in this area. Firstly, noiseis often incorrectly equated with high sound pressure levels. Inphysics, noise and sound are conceptually indistinguishable.With encultured perception, however, noise is defined asunwanted, uncontrollable, or unpredictable sound. Drippingtaps may register low sound pressure levels yet still beconsidered noisy. A narrow focus on sound pressure levels willnot ensure a reduction in noise perception.Secondly, noise is difficult to measure reliably. Materials usedfor hospital floors and walls, ward layout, acoustic propertiesof furnishings, and variables including bed occupancy all affecthow sound is perceived. Published studies of noisemeasurements on wards usually report snapshot recordings overa 24 hour period, and rarely give detailed contextualisation ofthose readings. Validated measurement instruments are alsolacking. One preliminary but promising approach uses a twodimensional plot of patients’ subjective responses to hospitalsounds as a visual tool to evaluate noise reductioninterventions.11Thirdly, there are many potential sources of noise in hospitals.Alarms, televisions, trolleys, and phones, as well as staff, visitor,and patient conversations are reported as common sources ofdisturbance.12 Not all loud sounds are perceived as noise bypatients, however. Some find the sound of the tea trolleypleasing,13 and some intensive care unit patients welcome ringingtelephones as a sign that they are not alone.14Interventions to date have included earplugs, noise warningsystems, sound absorbing panels, educational initiatives, andnoise reduction protocols.15-18 Evidence suggests possiblebenefits, but the lack of randomisation, blinding, control groups,and long term follow up, and the multi-component nature ofmany interventions make it difficult to isolate the effectivenessof a single initiative. Moreover, patients and relatives are rarelyinvolved in this research; they are seen as passive recipients ofthe hospital soundscape rather than active participants in itscreation. In the absence of firm evidence, future solutions shouldbe based on a careful assessment of each hospital environment,and designed with input from all stakeholders, particularlypatients and families.Correspondence to: A Xyrichis andreas.xyrichis@kcl.ac.ukFor personal use only: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribeBMJ 2018;363:k4808 doi: 10.1136/bmj.k4808 (Published 19 November 2018) Page 1 of 2EditorialsEDITORIALS on 18 November 2018 by guest. Protected by copyright.http://www.bmj.com/BMJ: first published as 10.1136/bmj.k4808 on 18 November 2018. Downloaded from Patients and families need clear information about likely noiselevels during admissions so they are better prepared and canconsider simple solutions such as headphones with their ownchoice of audio content. User friendly guides on the potentialsources of noise on wards can also help. Education for staff isalso needed, to encourage a culture that considers noisereduction an integral part of safe high quality healthcare.Finally, early investigations of sound masking and noisecancellation technology suggest potential for use in healthcare.19Sound masking—the addition of background, broadband sound(such as white noise) which can be optimised for particularenvironments to reduce noise induced disturbance—has beenshown in a non-randomised trial to significantly improve sleepin hospitals, for example.20For too long, noise in hospitals has been an intractable problem.Researchers must expand their focus from quantitativereductions in sound pressure levels to broader qualitativeimprovements in hospital soundscapes. Full patient partnershipin this research will help accelerate progress in what has beenan unacceptably slow moving field.Not commissioned, peer reviewedCompeting interests: We have read and understood BMJ policy on declaration ofinterests and declare that AX, JW, JM, AC and AMR received funding from theCultural Institute at King’s as part of the HPNoSS project, which used equipmentdonated by Bose, Sound Directions, and Acoustic Sheep.1 Raleigh V, Thompson J, Jabbal J, et al. Patients’ experience of using hospital services.Picker Institute Europe, 2015.2 Hospital Consumer Assessment of Healthcare Providers and Systems. www.hcahpsonline.org.3 Busch-Vishniac IJ, West JE, Barnhill C, Hunter T, Orellana D, Chivukula R. Noise levelsin Johns Hopkins Hospital. J Acoust Soc Am 2005;118:3629-45.10.1121/1.2118327 164198084 Darbyshire JL. Excessive noise in intensive care units. BMJ 2016;353:i1956.10.1136/bmj.i1956 270596705 Basner M, Babisch W, Davis A, et al. Auditory and non-auditory effects of noise on health.Lancet 2014;383:1325-32. 10.1016/S0140-6736(13)61613-X 241831056 Grumet GW. Pandemonium in the modern hospital. N Engl J Med 1993;328:433-7.10.1056/NEJM199302113280612 84214637 Choiniere DB. The effects of hospital noise. Nurs Adm Q 2010;34:327-33.10.1097/NAQ.0b013e3181f563db 208381788 Buxton OM, Ellenbogen JM, Wang W, et al. Sleep disruption due to hospital noises: aprospective evaluation. Ann Intern Med 2012;157:170-9.10.7326/0003-4819-156-12-201208070-00472 228688349 Hagerman I, Rasmanis G, Blomkvist V, Ulrich R, Eriksen CA, Theorell T. Influence ofintensive coronary care acoustics on the quality of care and physiological state of patients.Int J Cardiol 2005;98:267-70. 10.1016/j.ijcard.2003.11.006 1568677710 King’s College London. Hospital project on noise, sound and sleep. 2017. www.kcl.ac.uk/Cultural/-/Projects/Hospital-Project-on-Noise-Sound-and-Sleep.aspx.11 Mackrill J, Jennings P, Cain R. Exploring positive hospital ward soundscape interventions.Appl Ergon 2014;45:1454-60. 10.1016/j.apergo.2014.04.005 2476809012 MacKenzie DJ, Galbrun L. Noise levels and noise sources in acute care hospital wards.Build Serv Eng Res Tech 2007;28:117-3110.1177/0143624406074468.13 Mackrill J, Cain R, Jennings P. Experiencing the hospital ward soundscape: towards amodel. J Environ Psychol 2013;36:1-810.1016/j.jenvp.2013.06.004.14 Wynne J. ITU: the din of recovery. In: Minevich P, Waterman E, eds. The Art of ImmersiveSoundscapes. University of Regina Press, 2012: 128-41.15 Murphy G, Bernardo A, Dalton J. Quiet at night: implementing a nightingale principle. AmJ Nurs 2013;113:43-51. 10.1097/01.NAJ.0000438871.60154.a8 2428458516 Farrehi PM, Nallamothu BK, Navvab M. Reducing hospital noise with sound acousticpanels and diffusion: a controlled study. BMJ Qual Saf 2016;25:644-6.10.1136/bmjqs-2015-004205 2620853917 Wilson C. Improving the patient’s experience with a multimodal quiet-at-night initiative. JNurs Care Qual 2017;32(2):134-40. 10.1097/NCQ.0000000000000219 2822553218 Richardson A, Thompson A, Coghill E, Chambers I, Turnock C. Development andImproving the patient’s experience with a multimodal quiet-at-night initiative implementationof a noise reduction intervention programme: a pre- and postaudit of three hospital wards.J Clin Nurs 2009;18:3316-24. 10.1111/j.1365-2702.2009.02897.x 1973224219 Gallacher S, Enki D, Stevens S, Bennett MJ. An experimental model to measure theability of headphones with active noise control to reduce patient’s exposure to noise inan intensive care unit. Intensive Care Med Exp 2017;5:47.10.1186/s40635-017-0162-1 2904346220 Farokhnezhad Afshar P, Bahramnezhad F, Asgari P, Shiri M. Effect of white noise onsleep in patients admitted to a coronary care. J Caring Sci 2016;5:103-9.10.15171/jcs.2016.011 27354974Published by the BMJ Publishing Group Limited. For permission to use (where not alreadygranted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissionsFor personal use only: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribeBMJ 2018;363:k4808 doi: 10.1136/bmj.k4808 (Published 19 November 2018) Page 2 of 2EDITORIALS on 18 November 2018 by guest. Protected by copyright.http://www.bmj.com/BMJ: first published as 10.1136/bmj.k4808 on 18 November 2018. Downloaded from 

Noise pollution in hospitals

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Noise pollution in hospitals

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