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Not exactly a quiet zone

Times Staff Writer

After eight nights in the hospital for debilitating headaches, Laurel Carpenter was ready to go home and finally get what the doctor ordered — a good night's sleep.

From a private room in a Los Angeles hospital last summer, Carpenter had endured a torrent of interruptions and noise that could wake even the sedated. The cacophony — screeching cart wheels, telephones, shouts from the hallway — coupled with the frequent rousings for meals, medication and vital-signs checks made continuous rest virtually impossible. And then there was the fire drill.

"I was asleep and I came out of my pain-medicated stupor, trying to get out of bed, wondering what in the world was going on," said the 48-year-old Los Angeles resident. "The alarm rang for 15 or 20 minutes. I thought I was going to go crazy."

Carpenter's experience is far from uncommon. Hospitals that take patient satisfaction surveys find that noise levels and lack of sleep regularly top the complaint list. And a sizable body of research over the last dozen years bears out what many overnight patients already know — the hospital is a lousy place to sleep.

"Noise is a problem inherent in every major hospital in the United States," said Dr. Mathew Lee, medical director of the Rusk Institute of Rehabilitation Medicine at New York University Medical Center. "Its impact on patients is almost always underestimated."

The clamor of hospitals is more than a mere annoyance — its negative effect on sleep appears to slow the healing process. Excessive noise and sleep deprivation are believed to diminish the strength of the immune system, lower pain tolerance levels and extend hospital stays. A lack of sleep also may retard the body's ability to generate new cells to repair damaged tissue.

Researchers have yet to produce a comprehensive examination detailing the clear connection between hospital noise, sleep loss and healing. However, when existing studies are reviewed as a whole, they make a powerful argument about the need to reduce noise in hospitals.

"We need more hard data, it's true," said Lee, who wrote about the effects of hospital noise on patients in the April 2000 issue of Preventive Medicine Magazine. "But it's common sense. It's a no-brainer."

Some hospitals have taken steps to turn down the noise, but most are busy tending to higher priorities, from tight budgets and staffing shortages to bioterrorism threats.

"Hospitals have a very Band-Aid approach to noise," said Susan E. Mazer, president of Healing HealthCare Systems, which develops noise reduction plans for hospitals. "Unless the problem is life-threatening, it's probably not going to make their to-do list."

A new study published in last month's American Journal of Nursing shows why the problem strikes such a harshly discordant note with patients — hospital sounds can be as loud as jackhammers. The researchers, a team of Mayo Clinic nurses, found that during the hustle and bustle of a morning shift change at Saint Marys Hospital — a Mayo Clinic-affiliated hospital in Rochester, Minn. — the blare reached 113 decibels.

Furthermore, the average nighttime sound level in a private room was several times greater than the maximum recommended by the federal government for hospitals. Nighttime averages for a semiprivate room were worse.

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High-tech din Technology is widely blamed for disturbing the library-like quiet that prevailed in the nation's hospitals almost a half-century ago. Intercoms, pagers, televisions and a host of sophisticated medical monitoring equipment — all outfitted with their own array of beepers, buzzers and alarms — have gradually raised the base level of noise.

The high-tech advancements have desensitized the medical staff to bothersome sounds, while forcing them to communicate more loudly simply to be heard. To patients, already in an anxious, if not pained state, the unfamiliar noises can be, at the very least, irritating. "I realize you have to work at work," said Carpenter, whose room was close to a nurses' station. "But you should have heard the joking and laughing going on. I can't tell you how many times that woke me up."

As part of their study, two Mayo Clinic nurses spent the night — as if they were patients — in the thoracic surgery unit of the hospital. They kept personal journals, noting noise and interruptions, and placed sensitive sound-measuring equipment in several rooms throughout the floor. They discovered no shortage of sounds at odds with a good night's rest.

In addition to an array of technological bells and whistles and human chatterboxes, they were awakened by the bang of unpadded clipboards, the sound of a roommate flushing the toilet, the clank of a door latching shut and the rattle of an IV pole.

"It was a real eye-opener," said Cheryl Cmiel, the study's lead author. "We hardly got any sleep and we were a lot better off than patients who are hooked up to more invasive and anxiety-producing equipment."

The Mayo Clinic nurses learned their medical facility didn't satisfy federal guidelines for hospital quiet. During the night, the Environmental Protection Agency recommends keeping noise averages below 35 decibels, roughly the sound of a computer quietly humming. But the nighttime average in one of the Mayo Clinic's semiprivate rooms registered 53 decibels, roughly the sound of a bathroom exhaust fan.

Those readings are probably typical for most big-city hospitals. A 1995 study of an urban hospital published in the Archives of Environmental Health found noise levels exceeded 55 decibels throughout much of the day. Dr. Gerald Grumet, who wrote about hospital noise for the New England Journal of Medicine in 1993, estimates that most big hospitals average between 50 and 70 decibels (the latter akin to a noisy office).

"I wear earplugs in the hospital," said Grumet, a psychiatrist in Rochester, N.Y. "It was bad a decade ago, and it's not much better today."

Noise, even if one is not sick, has been shown to raise blood pressure, increase stomach acid and boost stress and anxiety. But if one is ill, the lack of sleep could interfere with the immune system, affecting a patient's ability to battle infection, according to a study published last year in Psychosomatic Medicine.

German researchers found that a well-rested person's immune system is stronger than a sleep-deprived person's, even after a single night of being kept awake. Of 19 men and women vaccinated against hepatitis A, those who were well-rested averaged twice the antibodies of the sleep-deprived.

The restorative theory, cited by some researchers, contends that sleep preserves energy and promotes rejuvenation within the body. The state of sleep stimulates a protein synthesis and cell division that is essential for tissue renewal, they say, while a lack of sleep can produce hormones that slow recovery.

Those hospitals that have attacked the noise problem successfully have improved patient satisfaction. At Northside Hospital, a 450-bed facility in suburban Atlanta, a committee of employees from throughout the hospital (even accounting) studied ways to reduce noise. In two years, the committee was able to drop the decibel level by as much as 40% in some hospital areas.

Pagers were set to vibrate instead of ring, bright yellow signs reading "Quiet Please, Healing in Progress" were posted throughout the hospital, and the hospital staff was urged to speak quietly when possible and conduct long conversations in private. "We have the happiest bunch of people I've ever worked with in my life," said nurse June Morrison, who headed the committee. "And happy people are loud and carry on. We wanted them to be aware of that."

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Quieter equipment The biggest noise reduction came from the repair and replacement of heavy rolling equipment. One cart, regularly wheeled down hospital hallways, registered 90 decibels or about the same output as a hair dryer next to one's ear.

The Mayo Clinic staff, which also created its own sound committee, has taken similar steps. Employees replaced paper towel dispensers with simple towel holders, installed padding on doors and around clipboards — and managed to lower the average nighttime decibel levels from 53 to 41 for a semiprivate room.

To minimize patient interruptions, nurses rescheduled several nighttime tests and checkups to an hour more convenient for patients. Nighttime X-rays were changed from 3 a.m. to 10 p.m., for example. And staff members were urged to refrain from using direct light, telephones, intercoms, televisions and radios between 11 p.m. and 5 a.m.

More than 170 hospitals in 41 states are combating the noise problem with music designed to cover up or distract the patient from existing noises. The hospitals, among them the Mayo Clinic, subscribe to the Continuous Ambient Relaxation Environment Channel, or CARE, from Healing HealthCare Systems, which broadcasts quiet instrumental music and restful nature scenes around the clock.

Officials at Sutter Solano Medical Center in Vallejo, Calif., have plans to alleviate their noise problem in the coming year, said Jan Boller, director of clinical outcomes and healing practices. They've already cautioned their staff against loud talking and reduced the use of an overhead paging system, and will soon begin playing restful music during nursing shift changes.

"We didn't have to make big sacrifices or spend large amounts of money to make some effective changes," said Cmiel. "We just had to do it."

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