Noise pollution in pediatric intensive care units (PICU) contributes to poor sleep and may increase risk of developing delirium. The Environmental Protection Agency (EPA) recommends <45 decibels (dB) in hospital environments. The objectives are to assess the degree of PICU noise pollution, to develop a delirium bundle targeted at reducing noise, and to assess the effect of the bundle on nocturnal noise pollution.
Methods:
This is a QI initiative at an academic PICU. Thirty-five sound sensors were installed in patient bed spaces, hallways, and common areas. The pediatric delirium bundle was implemented in 8 pilot patients (40 patient ICU days) while 108 non-pilot patients received usual care over a 28-day period.
Results:
A total of 20,609 hourly dB readings were collected. Hourly minimum, average, and maximum dB of all occupied bed spaces demonstrated medians [interquartile range] of 48.0 [39.0-53.0], 52.8 [48.1-56.2] and 67.0 [63.5-70.5] dB, respectively. Bed spaces were louder during the day (10AM to 4PM) than at night (11PM to 5AM) (53.5 [49.0-56.8] vs. 51.3 [46.0-55.3] dB, P < 0.01). Pilot patient rooms were significantly quieter than non-pilot patient rooms at night (n=210, 45.3 [39.7-55.9]) vs. n=1841, 51.2 [46.9-54.8] dB, P < 0.01). The pilot rooms compliant with the bundle had the lowest hourly nighttime average dB (44.1 [38.5-55.5]).
Conclusions:
Substantial noise pollution exists in our PICU, and utilizing the pediatric delirium bundle led to a significant noise reduction that can be perceived as half the loudness with hourly nighttime average dB meeting the EPA standards when compliant with the bundle.
BerglundBLindvallTSchwelaD. World Health Organization Guidelines for Community Noise. Geneva, Switzerland; 1999. http://whqlibdoc.who.int/hq/1999/a68672.pdf. Accessed March 21, 2016.
2.
Environmental Protection Agency. Information on Levels of Environmental Noise Requisite to Protect Public Health and Welfare with an Adequate Margin of Safety. Washington, DC; 1974. http://www.nonoise.org/library/levels74/levels74.htm. Accessed March 21, 2016.
3.
Al-SamsamRHCullenP. Sleep and adverse environmental factors in sedated mechanically ventilated pediatric intensive care patients. Pediatr Crit Care Med. 2005;6(5):562–567.
4.
Cureton-LaneRAFontaineDK. Sleep in the pediatric ICU: an empirical investigation. Am J Crit Care. 1997;6(1):56–63.
5.
KramerBJoshiPHeardC. Noise pollution levels in the pediatric intensive care unit. J Crit Care. 2016;36:111–115.
6.
MorrisonWEHaasECShaffnerDHGarrettESFacklerJC. Noise, stress, and annoyance in a pediatric intensive care unit. Crit Care Med. 2003;31(1):113–119.
7.
PlayforSThomasDChoonaraI. Recollection of children following intensive care. Arch Dis Child. 2000;83(5):445–448.
8.
AkhtarSWeigleCGChengEYToohillRBerensRJ. Use of active noise cancellation devices in caregivers in the intensive care unit. Crit Care Med. 2000;28(4):1157–1160.
9.
BaileyETimmonsS. Noise levels in PICU: an evaluative study. Paediatr Nurs. 2005;17(10):22–26.
10.
CarvalhoWBPedreiraMLde AguiarMA. Noise level in a pediatric intensive care unit. J Pediatr (Rio J). 2005;81(6):495–498.
11.
BasnerMBabischWDavisA. Auditory and non-auditory effects of noise on health. Lancet. 2014;383(9925):1325–1332.
12.
KudchadkarSRYasterMPunjabiAN. Temporal characteristics of the sleep EEG power spectrum in critically ill children. J Clin Sleep Med. 2015;11(12):1449–1454.
13.
PisaniMAFrieseRSGehlbachBKSchwabRJWeinhouseGLJonesSF. Sleep in the intensive care unit. Am J Respir Crit Care Med. 2015;191(7):731–738.
14.
BerensRJWeigleCG. Noise measurements during high-frequency oscillatory and conventional mechanical ventilation. Chest. 1995;108(4):1026–1029.
15.
SmithHABeruttiTBrinkE. Pediatric critical care perceptions on analgesia, sedation, and delirium. Semin Respir Crit Care Med. 2013;34(2):244–261.
16.
KamdarBBNeedhamDMCollopNA. Sleep deprivation in critical illness: its role in physical and psychological recovery. J Intensive Care Med. 2012;27(2):97–111.
17.
KamdarBBKingLMCollopNA. The effect of a quality improvement intervention on perceived sleep quality and cognition in a medical ICU. Crit Care Med. 2013;41(3):800–809.
18.
PatelJBaldwinJBuntingPLahaS. The effect of a multicomponent multidisciplinary bundle of interventions on sleep and delirium in medical and surgical intensive care patients. Anaesthesia. 2014;69(6):540–549.
19.
LittonECarnegieVElliottRWebbSA. The efficacy of earplugs as a sleep hygiene strategy for reducing delirium in the ICU: a systematic review and meta-analysis. Crit Care Med. 2016;44(5):992–999.
20.
SmithHABoydJFuchsDC. Diagnosing delirium in critically ill children: validity and reliability of the pediatric confusion assessment method for the intensive care unit. Crit Care Med. 2011;39(1):150–157.
21.
SmithHAGangopadhyayMGobenCM. The preschool confusion assessment method for the ICU: valid and reliable delirium monitoring for critically ill infants and children. Crit Care Med. 2016;44(3):592–600.
22.
TraubeCSilverGKearneyJ. Cornell assessment of pediatric delirium: a valid, rapid, observational tool for screening delirium in the PICU*. Crit Care Med. 2014;42(3):656–663.
23.
SilverGTraubeCKearneyJ. Detecting pediatric delirium: development of a rapid observational assessment tool. Intensive Care Med. 2012;38(6):1025–1031.
24.
TraubeCSilverGReederRW. Delirium in critically ill children: an international point prevalence study. Crit Care Med. 2017;45(4):584–590.
25.
MeyburgJDillMLTraubeCSilverGvon HakenR. Patterns of postoperative delirium in children. Pediatr Crit Care Med. 2017;18(2):128–133.
26.
PatelAKBiagasKVClarkeEC. Delirium in children after cardiac bypass surgery. Pediatr Crit Care Med. 2017;18(2):165–171.
27.
SilverGTraubeCGerberLM. Pediatric delirium and associated risk factors: a single-center prospective observational study. Pediatr Crit Care Med. 2015;16(4):303–309.
28.
SmeetsIATanEYVossenHG. Prolonged stay at the paediatric intensive care unit associated with paediatric delirium. Eur Child Adolesc Psychiatry. 2010;19(4):389–393.
29.
ColvilleGKerrySPierceC. Children’s factual and delusional memories of intensive care. Am J Respir Crit Care Med. 2008;177(9):976–982.
30.
KainZNCaldwell-AndrewsAAMaranetsI. Preoperative anxiety and emergence delirium and postoperative maladaptive behaviors. Anesth Analg. 2004;99(6):1648–1654, table of contents.
31.
SchieveldJNLousbergRBerghmansE. Pediatric illness severity measures predict delirium in a pediatric intensive care unit. Crit Care Med. 2008;36(6):1933–1936.
32.
TurkelSBTavareCJ. Delirium in children and adolescents. J Neuropsychiatry Clin Neurosci. 2003;15(4):431–435.
33.
DiMarioFJJrPackerRJ. Acute mental status changes in children with systemic cancer. Pediatrics. 1990;85(3):353–360.
34.
TraubeCSilverGGerberLM. Delirium and mortality in critically ill children: epidemiology and outcomes of pediatric delirium. Crit Care Med. 2017;45(5):891–898.
35.
TraubeCMauerEAGerberLM. Cost associated with pediatric delirium in the ICU. Crit Care Med. 2016;44(12):e1175–e1179.
36.
KudchadkarSRYasterMPunjabiNM. Sedation, sleep promotion, and delirium screening practices in the care of mechanically ventilated children: a wake-up call for the pediatric critical care community. Crit Care Med. 2014;42(7):1592–1600.
37.
HshiehTTYueJOhE. Effectiveness of multicomponent nonpharmacological delirium interventions: a meta-analysis. JAMA Intern Med. 2015;175(4):512–520.
38.
AbrahaITrottaFRimlandJM. Efficacy of non-pharmacological interventions to prevent and treat delirium in older patients: a systematic overview. The SENATOR project ONTOP series. PLoS One. 2015;10(6):e0123090.
39.
SmithHABrinkEFuchsDCElyEWPandharipandePP. Pediatric delirium: monitoring and management in the pediatric intensive care unit. Pediatr Clin North Am. 2013;60(3):741–760.
40.
McAndrewNSLeskeJGuttormsonJKelberSTMooreKDabrowskiS. Quiet time for mechanically ventilated patients in the medical intensive care unit. Intensive Crit Care Nurs. 2016;35:22–27.
41.
TainterCRLevineARQuraishiSA. Noise levels in surgical ICUs are consistently above recommended standards. Crit Care Med. 2016;44(1):147–152.
42.
NannapaneniSLeeSJKashiourisM. Preliminary noise reduction efforts in a medical intensive care unit. Hosp Pract (1995). 2015;43(2):94–100.
43.
ParkMKohlrauschAde BruijnWde JagerPSimonsK. Analysis of the soundscape in an intensive care unit based on the annotation of an audio recording. J Acoust Soc Am. 2014;135(4):1875–1886.
44.
TegnestedtCGuntherAReichardA. Levels and sources of sound in the intensive care unit—an observational study of three room types. Acta Anaesthesiol Scand. 2013;57(8):1041–1050.
45.
ElbazMLegerDSauvetF. Sound level intensity severely disrupts sleep in ventilated ICU patients throughout a 24-h period: a preliminary 24-h study of sleep stages and associated sound levels. Ann Intensive Care. 2017;7(1):25.
46.
ParkMVosPVlaskampBNKohlrauschAOldenbeuvingAW. The influence of APACHE II score on the average noise level in an intensive care unit: an observational study. BMC Anesthesiol. 2015;15:42.
47.
BennettTDSpaederMCMatosRI. Existing data analysis in pediatric critical care research. Front Pediatr. 2014;2:79.
48.
LacroixJCottingJ; Pediatric Acute Lung Injury & Sepsis Investigators Network. Severity of illness and organ dysfunction scoring in children. Pediatr Crit Care Med. 2005;6(3 suppl):S126–S134.
49.
ParuthiSBrooksLJD’AmbrosioC. Recommended amount of sleep for pediatric populations: a consensus statement of the American Academy of Sleep Medicine. J Clin Sleep Med. 2016;12(6):785–786.
50.
HarrisJRameletASvan DijkM. Clinical recommendations for pain, sedation, withdrawal and delirium assessment in critically ill infants and children: an ESPNIC position statement for healthcare professionals. Intensive Care Med. 2016;42(6):972–986.
51.
BarrJFraserGLPuntilloK. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013;41(1):263–306.
52.
JousselmeCVialetRJouveELagierPMartinCMichelF. Efficacy and mode of action of a noise-sensor light alarm to decrease noise in the pediatric intensive care unit: a prospective, randomized study. Pediatr Crit Care Med. 2011;12(2):e69–e72.
53.
CranmerKDavenportL. Quiet time in a pediatric medical/surgical setting. J Pediatr Nurs. 2013;28(4):400–405.
54.
KolEAydinPDursunO. The effectiveness of environmental strategies on noise reduction in a pediatric intensive care unit: creation of single-patient bedrooms and reducing noise sources. J Spec Pediatr Nurs. 2015;20(3):210–217.
55.
KaurHRohlikGMNemergutMETripathiS. Comparison of staff and family perceptions of causes of noise pollution in the pediatric intensive care unit and suggested intervention strategies. Noise Health. 2016;18(81):78–84.
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