SHHH, SURGERY IN PROGRESS Staff members who are able to concentrate, communicate and work well with one another will provide safer care.

Ever been in a really noisy OR? The surgeon's rock anthem blares, nurses discuss their weekends and the vital signs monitor beeps proof of life — it's so chaotically loud that it's hard to think straight. Yet this sounds like a typical OR, right? That's the problem. You might think excess noise during surgery is normal and acceptable, but just 45 decibels can impact what's heard and communicated among surgical team members. The Joint Commission thought the problem was enough of a concern to issue a recent safety alert centered on eliminating noise distractions in the OR.

The noisiest periods of surgery occur during anesthesia induction and emergence, according to the alert. Orthopedic surgery and neurosurgery are among the noisiest procedures with intermittent peak levels exceeding 100 decibels more than 40% of the time. A prospective study of hernia repairs found that noise levels were substantially higher during the incision closures of patients who developed surgical site infections, suggesting the surgical teams were distracted enough to be noncompliant with aseptic processes. High noise levels in the OR have also been associated with ineffective communication, diminished speech intelligibility, poor performance of complex tasks, poor cognitive function and concentration, stress, fatigue and anxiety.

Turning down the volume
Noise levels can also be a contributing factor to a number of patient safety events, including wrong-site surgery and retained surgical objects. Escalating noise is a pervasive problem in today's ORs and an underrated contributing factor to the never events that continue to happen, so you need to develop a total systems approach to turning down the volume during surgery.

Get a baseline measurement. You can use sound level meters and noise dosimeters to generate empirical data about the sound levels in your ORs. One staff member might not even notice the sounds of her working environment while another might not be able to concentrate in the "din." Noise that's pleasant to one person — AC/DC blasting over the OR's sound system — might be unbearable to someone else. Objective data can help you decide if noise levels are exceeding a safe threshold and determine if you need to address the issue.

VOLUME CONTROL
Common Sounds Can Jeopardize Patient Safety

Try limiting the disruptions caused by these sources of noise and distraction in the OR.

Technological and environmental

DISRUPTIVE TECHNOLOGY Cell phones in the OR are a potential source of noise distraction.

• phones
• paging systems (personal and overhead)
• computers
• wireless communication systems
• music devices
• medical equipment/devices
• monitors, clinical alarms
• metal equipment, instruments
• environmental conditions (ventilation, for example)

Behavioral

• case-related conversations
• non-case-related conversations
• patient care activities
• staff entering and leaving the OR

SOURCE: The Joint Commission

Some noise meters alert staff with visual reminders when levels reach a point that is unsafe or not conducive to communication and concentration. Placing the meters in ORs and other patient care areas is an effective way to provide staff with real-time feedback about the noise they're producing and can help them grasp the importance of reducing distractions during the care they provide.

Address noise producers. Minimize conversations about other patients and other procedures or subjects that are unrelated to surgery. It's also important to discuss only essential aspects of the current surgery. Be mindful of the amount of noise surgical equipment makes, especially when purchasing new platforms. The whir of an arthroscopy burr and the suction of a smoke evacuator might not sound disturbing when heard alone, but they contribute to the overall cacophony of noise in the OR. Whenever possible, prioritize equipment that's less noisy than competing brands.

Abrupt noise can be quite startling and disruptive to other team members in the room. You might not be able to eliminate or even turn down the noise equipment makes, but you can carefully place metal instruments into metal trays so they don't clatter and close drawers gently instead of slamming them with your hip. Replace carts with squeaky wheels or squirt a little WD-40 on the axels. Every little bit helps when it comes to reducing noise disruptions during surgery.

Create "no interruption zones." These are times when surgical team members must remain quiet to allow nurses, surgeons or anesthesia providers to focus on the critical stages of surgery — anesthesia induction and emergence and surgical counts, to name a few. At these important moments — actually, at all times during surgery — every team member should feel empowered to ask for quiet when noise levels begin to exceed the safety threshold or simply when they become an annoyance or disturb their abilities to perform essential tasks. OSM