1. By Ameya Nerurkar Mandar Samant Chih-Pin Hsiao
NOISE
By Ameya Nerurkar
Mandar Samant
Chih-Pin Hsiao
“Unnecessary noise, then, is the most cruel absence of care which can be inflicted either on sick or well.”
However, until 2005, little work had been done to characterize and improve the acoustic condition in hospitals even though it routinely ranks among the top complaints of hospital patients, visitors and staff (Busch-Vishniac, West, Barnhill, Hunter, Orellana, & Chivukula, 2005) (Johnson & Thornhill, 2006). Busch-Vishniac et al. summarized many studies that indicate noise in hospital will contribute to stress in staff and suggest that noise could cause staff burnout. In addition, some researchers, such as Fife, Minckley, and Wysocki, also believe that noise affects the speed of wound healing according to their studies.
By Florence Nightingale, 1859

2. Causes Of Noise Sound emanating from Equipments
for example, the portable X-Ray machine
Sound made by human beings
House Interiors and furnishing
Sound reflecting surfaces instead of sound absorbing materials
speech intelligibility
Rolling equipments e.g Procedure carts , Housekeeping dollies
Overhead paging

3. Standards and Current Conditions
In 1995, Guidelines for Community Noise from World Health Organization (WHO) recommends an Lmax of no more than 40 dB(A) at night measure on the fast setting. They also suggest patient room Leq of no more than 35dB(A) during the day and 30 dB(A) at night.
Study shows that the average day time sound levels in Johns Hopkins Hospitals are 72 dB(A).
So it leads to privacy problem
The typical speech level for communication between two people
is dB(A) 

4. Busch-Vishniac et al. reviewed the data from 1960 to 2005 and found that the average sound levels gradually increased from Leq 57 dB(A) to 72 dB(A).

5. Effects Of Noise Several adverse effects are associated with noise
increase noradrenalin concentrations in urine, hypertension and myocardial infarction
Sleep disturbance
exposure to sudden, unexpected noise raises patient heart rates
tend to increase blood pressure levels
In a hospital environment, where people are already ill and psychologically stressed, unnecessary noise can be very harmful
Could cause staff stress and burnout
Decreased oxygen saturation,

6. Solutions Assessing and managing Sound Environment
Identify Sources of noise
Maintenance and replacement of Hospital equipments
Layout and acoustic treatment of patients’ rooms and corridors etc
Equipment Repair and Replacement
Scheduling regular maintenance to keep equipments in working order
padding chart holders and pneumatic tube systems, and lowering volume levels on clinical and communication equipment
purchasing choices that are based on auditory performance
Design of Patient rooms and adjacent Areas:
Standardize on single bed private room

7. Solutions
They choose 2-inch fiber-glassed material for their experiment.
Install the panels in the corridor and nurse station.
The result is that the level of noise was dropped by 5 dB(A) and the reverberation time dropped by a factor over 2.

8. Effects of Noise in ICU Experiments Conducted:
The study was conducted with 35 coronary artery bypass graft surgery patients.
The intensive care unit noise level was measured by using Bruel & Kjaer 2144 Model Frequency Analyzer next to the bed of each patient

9. Results
Noise levels ranged between 49 and 89 dB (A) with a mean of 65 dB (A).
Peak noise levels were measured as high as 89 dB (A).
The noise levels measured at different locations in the intensive care unit did not differ significantly.
Noises created by other patients, those who were admitted from emergency room and operating room into intensive care unit, monitor alarms, conversations among staff were the most disturbing noise sources for patients.

10. Conclusions
 The patients who were located in the bed which was closer to the nurses' station were more affected by the intensive care unit noise than other patients.
Having a previous intensive care unit experience also affected the patients' disturbance levels owing to noise.
Relevance to clinical practice:
Nurses are in key positions where they can identify physical, psychological and social stressors that affect patients during their hospital stay. Staff education, planned nursing activities and proper design of intensive care unit may help combat this overlooked problem.

11. ICU Admission and Discharge Criteria
Mengdie Hu, Karsten M. Jensen, Thomas Roh
ICU Admission and Transfer/Discharge Guidelines St. Joseph Hospital 2009
A list of criteria for the admission to ICU
Made to assure the appropriate utilization and resources of the ICU
Karsten
Now we will look at the papers about the ICU admission.
The St. Joseph Hospital have made some guidelines to assure the appropriate utilization and resources of the ICU
It states under which conditions that can get you admitted to the ICU

12. Analysis of indications for early discharge from the intensive care unit  Bone et al. 1993
Patients with moderately severe illness benefit more from ICUs than patients who are severely ill or not very ill.
A predictive model can be developed to determine the mortality risk 24h after admission.
As early as 1993 researchers found that patients with moderately severe illness benefit more from ICUs than patients who are severely ill or not very ill. They also believe a predictive model can be developed to determine the mortality risk 24h after admission.

13. Consequences of discharges from intensive care at night Goldfred et al
Patients who are discharged at night have a much higher risk of dying
Night discharges are more likely to be premature
Insufficiency of intensive-care beds
The observation that patients who are discharged at night have a much higher risk of dying led to the discovery that night discharges are more likely to be premature due to insufficiency of intensive-care beds.

14. Critically ill patients readmitted to intensive care units--lessons to learn? Metnitz et al. 2003
Readmission raises the risk of dying more than four times
Residual organ dysfunctions at time of discharge
Optimizing organ functions in patients before discharge
Premature discharge often lead to readmission which raises the risk of dying more than four times. It's found that organ dysfunctions at the time of discharge is associated with readmission and therefore should be part of the discharge criteria.

15. Triaging patients to the ICU: a pilot study of factors influencing admission decisions and patient outcomes Garrouste-Orgeas et al. 2003
Patients triaged by a senior physician are more likely to be refused admission
Refusal are related to patient age, underlying diseases, self-sufficiency and number of beds available
Karsten

16. The patient-at-risk team (PART): identifying and managing seriously ill ward patients Goldhill et al. 1999
Patients admitted from hospital wards to ICU have a higher mortality then patients admitted from other areas
The PART protocol are a simple way of trying to identify critically ill patients on wards
Karsten

17. Analysis of indications for early discharge from the intensive care unit.  Bone et. al 1993 
Measures: Mortality and Quality of Life
Acute Physiology and Chronic Health Evaluation (APACHE)
Objective methods for determining patient discharge from ICU
Thomas

18. Mortality among appropriately referred patients refused admission to intensive-care units  Metcalfe et al  
UK - excess mortality for those too ill or too well
9% higher rate of mortality
More ICU beds or better admission and discharge criteria
Thomas

19. Guideline on Admission and Discharge for Adult Intermediate Care Units  American College of Critical Care Medicine of the Society of Critical Care Medicine 1998
Admit low risk patients to intermediate care units
List of Requirements
Labor cost reduction
Thomas

20. Discharge Criteria - A new trend Chung 1995
Discharging patients after anesthesia and surgery
Mathematical scoring system for five different areas
Recommends using a numerical system to determine discharging a patient
Thomas