Controlling noise in the OR
Myron Yaster MD and Lynn D. Martin MD MBA
Dr. Christy Crockett of Vanderbilt University is our profession’s ‘go to’ expert on noise and noise reduction in the pediatric operating rooms. In today’s PAAD, we are going to review her team’s recent survey of pediatric anesthesiologist’s perception of noise in the OR1 as well as one of her group’s older quality improvement projects2 that was published 2 years ago. Myron Yaster MD
Original article (letter)
Crockett CJ, Dalal PG, Tjia I, Allen M, Edelstein E, Feng X, French B, Brustowicz RM. A loud call for silence: anaesthesiologists' perceptions of noise in the operating room. Br J Anaesth. 2024 Feb;132(2):444-447. doi: 10.1016/j.bja.2023.11.035. Epub 2023 Dec 15. PMID: 38101964.
Original article
Crockett CJ, Nylander VE, Wooten EJ, Menser CC. The emergence noise reduction quality improvement initiative to enhance patient safety and quality of care. Paediatr Anaesth. 2022 Nov;32(11):1262-1269. doi: 10.1111/pan.14553. Epub 2022 Sep 15. PMID: 36065511.
“It's no secret. When a flight crew's attention is diverted from the task of flying, the chance of error increases. Over the years there have been dozens of air carrier accidents that occurred when the crew diverted attention from the task at hand and became occupied with items totally unrelated to flying. Consequently, important things were missed. Things like setting the flaps prior to takeoff or extending the landing gear before landing. Things like monitoring altitude on an instrument approach or using engine anti-ice for takeoff during a blinding snowstorm. In 1981 the FAA enacted FAR 121.542 and FAR 135.100 to help curb the number of these accidents. Commonly known as the "sterile cockpit rule," these regulations specifically prohibit crew member performance of non-essential duties or activities while the aircraft is involved in taxi, takeoff, landing, and all other flight operations conducted below 10,000 feet MSL, except cruise flight. (Click here to go to FAR 121.542 and 135.100 .)”3
How about the operating rooms? It’s also no secret that operating rooms are noisy, really noisy (commonly reaching 80 decibels, equal to a police siren or a noisy restaurant). Beeping monitors, suction devices, conversational and loud voices, music, and overhead announcements to name just a few. “The Society for Pediatric Anesthesia (SPA) Quality and Safety Committee formed the Noise in the Operating Room Task Force with goals of identifying severity and contributing factors of noise in the operating room across the USA, seeking methods to mitigate its impact. The task force designed a multi-institutional survey that was distributed to SPA members to determine anesthesiologists’ perceptions of noise in the operating room severity, its potential effects on the safety and quality of care, and the effects of various associated factors such as gender, practice type, and years of experience.”
First, like almost all survey studies, the response rate was low, only 407 of 3444 (12%) the survey links had a response. However, this represents a <6% margin of error at 95% confidence interval, so any conclusions made by the authors on the survey results need to be taken with a grain of salt. Indeed, we suspect that this report was published as a letter rather than as an original article because of the low response rate and the subjective nature of the survey. Nevertheless, the 407 people who did respond provide some meaningful insights, so we need to pay attention.
Ok, what did they find? “Most respondents perceived that loud noise can negatively affect communication with the care team (92%) or patient (81%), attentiveness to patient care (64%), and ability to notice alarms (68%).”1 Not surprisingly, noise distraction was most pronounced if loud and during induction and emergence. “Significant differences in provider-reported perceptions of loud noises existed with respect to gender, years of practice, and anesthesia practice type.“1 As discussed in the recent PAAD on hearing loss in the elderly, men are able to tune out and be less distracted than women by OR noise during induction, intraoperatively, and emergence. Where one practiced made a difference. “Compared with academic institutions, participants who worked at private institutions were less likely to report that they noticed loud noises during induction or emergence.”1 Years in practice also made a difference. “Most respondents (85%) reported they feel comfortable asking others to quiet down. Compared with participants with 15 yr in anesthesia practice, participants with <15 yr in practice were more likely to feel comfortable asking others to quiet down in the operating room and more likely to agree that their institution or department had addressed noise in the operating room.”1 Finally, “only a small minority, ~20% of respondents, noted their institutions have implemented some intervention to address noise in the operating room.”
If we agree that noise is a problem and noise reduction should be a quality improvement priority, how can we go about it? Crockett et al’s previous publication2 can serve as a model. As seen in multiple quality improvement studies we’ve highlighted in previous PAADs, success frequently depends on the use of change management principles.4 Start by (1) creating the vision of better by highlighting the need for change, in this case via their survey and published evidence from the literature and (2) the benefits the initiative will achieve (reduced noise during critical periods of time, causing less distraction, thereby improving safety). They directly increased the likelihood of success by using objective (measured noise level) data in the outcomes rather than a subjective assessment of the impacts the noise caused. (3) They engaged staff in development and testing of proposed interventions and used staff meetings to raise awareness and support for these new behaviors and practices. (4) They assured the necessary resources (decimeter with alarm thresholds) were immediately available. (5) They followed an implementation plan that includes clear expectation with ongoing support, coaching, and data sharing in staff meetings to drive towards the sustained success needed. I (LDM) want to particularly call out their use of SMART (Specific, Measurable, Actionable, Reliable, and Time bound) aim for this project. While a reduction of only 2 decibels seems small, being a logarithmic scale, it really represents a power of 2 reduction in volume. Using peer champions to engage staff and continue the learning and improving helps to reduce the sense of loss and increase the likelihood for ultimate success. Process improvement benefits from a defined change management plan to help achieve the necessary buy-in and support from all of the stakeholders needed to insure successful implementation.
The survey results clearly show that noise is a common problems in most ORs and could be a contributor to distractions and possible errors and adverse outcomes. Crockett and colleagues are showing us that there are possible countermeasures to reduce this noise. Due to the rarity of the rate of adverse events in modern anesthesia practice, large scale data would be needed to show a reduction in complications. However, I (LDM) made my career focus on improving care now rather than waiting for the proof that we needed to do something after harm was seen. Anesthesiology needs to join me and others in doing it now!
Let us know what you think and send your thoughts to Myron who will post in a Friday reader response.
References
1. Crockett CJ, Dalal PG, Tjia I, et al. A loud call for silence: anaesthesiologists' perceptions of noise in the operating room. British journal of anaesthesia 2024;132(2):444-447. (In eng). DOI: 10.1016/j.bja.2023.11.035.
2. Crockett CJ, Nylander VE, Wooten EJ, Menser CC. The emergence noise reduction quality improvement initiative to enhance patient safety and quality of care. Paediatric anaesthesia 2022;32(11):1262-1269. (In eng). DOI: 10.1111/pan.14553.
3. Sumwalt RL. The sterile cockpit. In: NASA, ed.1993. https://asrs.arc.nasa.gov/publications/directline/dl4_sterile.htm
4. Rampersad SE, Low DK, Martin LD. Change Management in Modern Anesthesia Practice. International anesthesiology clinics 2016;54(3):83-93. (In eng). DOI: 10.1097/aia.0000000000000101.