Operating in the Cacophony: A quasi-experimental exploration of noises in the orthopedic surgery setting





Abstract


Purpose


The purpose of this study was to determine if an interactive educational program regarding noise reduction would reduce noise levels in an orthopedic OR setting.


Methods


A quasi-experimental design was used for this study.


Findings


Results from pre-intervention were lower than post intervention. The pre-intervention mean was 73.4 dB where the post-intervention was 74.1 dB. There was no statistically significance between pre- and post- intervention results ( t = -1.292, p = 0.099). The results were in alignment with previous studies conducted on noise levels in the OR.


Conclusions


Staff in the OR should work to minimize noise and distraction which they can control, such as music levels and non-patient care conversations. Noise should be kept to an absolute minimum during critical phases of the intraoperative procedure such as time out periods, surgical counts, critical dissections, medication administration/graft preparations, confirming/opening of implant, induction and emergence from anesthesia, and care and handling of specimens.


Noise can be considered unwanted or disruptive. Noise in the health care setting, especially in the operating room, can be not only distracting but detrimental to proper communication amongst team members. Examples of such operating room noise include anesthesia machine alarms, operating room equipment, background small talk among staff, music, and instrumentation movement. Noise from various sources in the operating room can lead to poor communication, possible increased error, substandard job performance and increased stress. Excessive noise (noise pollution) in the OR can lead to increased levels of physical and emotional tension, exhaustion and decreased cognitive function, which can negatively affect patient care. The World Health Organization recommends noise levels stay below 35 dB in bedrooms at night when sleeping and should not exceed 70 dB over a 24-hour period or >85 dB over an hour. The Researchers have documented noise levels in the operating room (OR) that range between 58 dB and 120 dB. , To put it in perspective, the Defense Health Agency’s Hearing Center of Excellence reports that a hair dryer, blender, or a subway train is about 85–100 dB; a rock concert, auto racing or a hammer pounding a nail is approximately 120–140 dB, whereas fireworks or a jet engine produces about 125–155 dB of sound. Normal conversation is about 60dB


1


Review of literature


Health care workers who work daily in the intraoperative setting are a part of the work environment and are affected by surrounding distracting factors such as noise. When healthcare workers perform patient care in this highly complex work environment, they are affected by these environmental conditions, whether good or bad. Some nurses and other health care personnel have suffered from “high burnout levels” due to negative stressors of noise pollution in the OR. Noise pollution disturbs the ability to perform tasks and affects general well-being. About 50 % of OR personnel who worked in orthopedic surgery reported hearing loss caused by excessive noise.


Individuals can often become “blind” to noise, much like a sense of smell. The noise one hears every day does not have the same effect on a person who does not hear it daily. There are many studies regarding noise in the operating room and its effects on staff, performance, and patient care, however, not much literature examines the possible difference made if an interactive educational program was implemented to make health care staff more aware of said adverse effects of unwanted noise in the OR. , , Much of the literature examined perceptions, attitudes and the stress impact noise pollution in this complex environment caused for mainly health care professionals, but patients as well. Healthcare workers in the OR know about the noise in the OR, but they may not have been made aware of the unhealthy effects of the prolonged, continuous, background unwanted noise in a highly complex health care setting where good communication is crucial. There are gaps in the research regarding the value of awareness of the untoward effects of noise in the OR. Understanding the noise level in the OR is not the only important aspect of mitigating noise levels, but it is also important to make those who work in the OR aware of such an unwanted nuisance and ramifications of noise pollution. The goal of this awareness and education would hopefully lead to a more conscious contributor or limiting factor to the noise in this complicated area, therefore improving communication among team members, cutting down on distractions, and possibly reducing anxiety in patients and health care providers. Awareness and education can also help one understand how overwhelming and intimidating an operating room setting can be. This study’s purpose was to determine if an interactive educational program regarding noise reduction would reduce noise levels in an orthopedic OR setting.


2


Research question


The research question this study addressed was “what are the differences in noise levels in an orthopedic OR setting before and after an interactive educational program regarding noise reduction?” The hypothesis for this study is noise will be significantly lower post intervention, was rejected as decibel readings post intervention were higher than pre-intervention.


2.1


Operational definitions


Noise in the OR was operationally defined as sound levels in the OR as measured by a decibel meter during orthopedic operative cases.


2.2


Methods


The study design utilized to examine this question was a quasi-experimental design. To prevent threats to internal validity, data were collected before and after the educational program with subject blinding as subjects were not aware of the decibel meters in the operating rooms. STROBE guidelines were used to report the research study and subsequent findings.


2.3


Study population/subject selection


The study setting included nine operating rooms within the Main OR of a 200-bed hospital level 2 trauma center in central Texas, the four operating rooms of an ambulatory surgery center, and four operating rooms of a second ambulatory surgery center. All of the above ORs are located on the same medical campus and are managed by the same administration. For this study, the focus was on orthopedic procedures, such as total joint replacements, foot/ankle and podiatry cases, and sports medicine surgeries. The health care staff within these areas will include surgeons, anesthesiologists, certified registered nurse anesthetists (CRNAs), Anesthesiologist assistants (AAs), nurses, Physician assistants (PAs), and surgical technicians.


2.4


Study procedures


Following Institutional Review Board approval, Data collection for this study began with the use of a decibel/sound level meter, purchased from a nonaffiliated entity. The meter was placed in one of the operating rooms randomly for a designated period to capture noise levels during orthopedic cases. The health care workers working in the OR were not aware of the meter’s presence or of its location. Each operating room was assigned a number to identify the room throughout the study. The meter measured the sound levels in these ORs only during orthopedic cases for the duration of the case from in room time to out of room time, and the data collected during the designated time were entered on a spreadsheet which was stored on a password protected USB flash drive. The data were collected over 30 days with each operating room observed/examined for equal amounts of time.


At the end of this pre-intervention of data collection, an interactive presentation was provided by the research team to health care staff working in the intraoperative setting. The educational presentation consisted of information from Association of periOperating Nurses (AORN), Joint Commission and the Environmental Protection Agency (EPA) on noise reduction in the surgery environment. The presentation was consisted of a powerpoint presentation with a lecture style format that included audio examples of noise levels and interaction between the presenter and the audience related to staff experience with noise level during cases. The interaction allowed for a robust discussion around myths or misconceptions of noise levels in the OR. The presentation gave an overview of sources noise levels in the OR, such as alarms, equipment, instrumentation, phone calls, and communication/conversation between person within the OR. Furthermore, this presentation included potential consequences of excessive noise in the OR such as reducing the staff’s ability to communicate appropriately, and the potential for errors to occur due to ineffective communication. Potential untoward effects of working in a noisy environment were reviewed such as hearing loss, fatigue, job dissatisfaction, and other physical effects. Decreasing noise during critical phases of a procedure through intentionally limiting excessive noise such as pausing to communicate with full attention by all team members were reviewed. The presentation took place during meetings to all health care staff that work in the intraoperative setting with a majority of the staff in attendance. An email was also sent to all the healthcare staff to ensure all have received the educational materials in addition to the presentation.


After the educational program had been presented, a post-implementation collection of data was done. All the ORs observed in the first data collection were submitted to the same sound level detection as before. For thirty days, the same sound level meter was placed in the ORs for a designated period and equal amounts of time. The data collected during this time were recorded on a spreadsheet. Following completion of the data collection, descriptive statistics were analyzed and compared between the pre-intervention and post-intervention decibel readings. A paired t -test was used to analyze difference between pre- and post-intervention decibel readings.


3


Results


Descriptive statistics were used to analyze the data ( table 1 ). Results from pre-intervention were lower than post intervention. A majority of cases both before and after the intervention were knee and hip arthroplasties and podiatry cases leading to a similar case mix pre- and post- intervention. The pre-intervention mean was 73.4 dB where the post-intervention was 74.1 dB. Noise levels at the beginning and end of cases was the lowest with ranging from 43.7 dB to 60 dB pre- and 45.3 dB to 59.9 dB post-intervention reflective on conversational and ambient noise. Noise levels were highest during the middle of the cases when instrumentation was being used ranging from 61 dB to 115.8 pre- and 61 dB to 122.6 post-intervention. A paired t -test was conducted to examine the differences before and after the intervention ( table 2 ). There was no significant difference in pre- and post-intervention decibel readings ( t = −1.292, p = 0.099). The hypothesis, noise would be significantly lower post intervention, was rejected.


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May 22, 2025 | Posted by in ANESTHESIA | Comments Off on Operating in the Cacophony: A quasi-experimental exploration of noises in the orthopedic surgery setting

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