Impact of Noise in Operating Theater: A Surgeon's and Anesthesiologist's Perspective.

BACKGROUND AND AIMS: Noise is often considered as an undesirable sound. Excess noise is a health threat that deteriorates one's concentration and communication. Noise in the operating theater can be disturbing, impairs communication, and can lead to stress. The aim of this survey was to assimilate information about the perspective of surgeons and anesthesiologists regarding noise in the operating theater and whether it affects their work atmosphere.
METHODS: A questionnaire consisting of 15 closed-ended questions excluding one open-ended question was given to surgeons from various specialties and anesthesiologists. The subjective response were analyzed and documented. Data analysis was done using descriptive statistics. Association was found out using Chi-square test.
RESULTS: We collected a total of 290 responses, of which 87.6% (n = 254) considered noise to increase the stress level and deteriorates the quality of teamwork (83.8%, n = 243). Noise affects communication among the staff (86.2%, n = 250) and decreases their concentration level (85.5%, n = 248) which could be harmful in view of the patient's safety. 87.9% (n = 255) of the participants were in favor of limiting the number of people in the operating theater. Nonetheless, 73% (n = 211) considered music has a calming effect and were in favor of music in the operating theater.
CONCLUSION: Noise in the operating theater can have distressing effects on surgeons, jeopardizing the patient's safety. However, a flip side to this is that music is considered to have a calming and soothing effect decreasing the anxiety and stress levels. Copyright:

INTRODUCTION

Noise is often perceived as an undesirable sound.[1] We often complain about noise, but rarely, we are aware of its detrimental effects. Noise is a health threat and a cause of anxiety as it deteriorates concentration and communication leading to impaired cognition. Rightly quoted by Dr. Wolfgang Babisch, noise puts a burden on our heart, brain, and ears.[2] Adding further to this is the nonspecific response to ambient noise called Lombard effect. It is an increase in the suprasegmental speech parameters of vocal intensity, duration, and fundamental frequency in the presence of noise.[3] White noise, on the other hand, is a random signal having equal intensity at different frequencies, giving it a constant power spectral density. It enhances mental cognition and alleviates the mood of the individual. It has numerous other therapeutic benefits such as relieving sleep disorders, gives relaxation, and escalates attention span and productivity.[4] Ever since the 1960s, there has been an alarming rise in noise pollution at health centers, more so in the operating theater.[5] Noise in the operating theater has an adverse impact on the mindset of health-care professionals leading to insulation of thoughts. The working conditions in the operating theater are critical, taxing the brain function; hence, there should be a good coordination and communication among surgeons, anesthesiologists, and other health-care staff.[6] Intrusive background noise in the operating theater can be distracting, jeopardizing communication leading to a perceived increase in stress. According to the WHO, the noise in operating theaters must not increase beyond 30 dB (A), comparable to whispering inaudibly in a library.[7] In the operating theater where battery- and motor-driven appliances, surgical drills, intercom, and monitor alarms are installed in a major proportion, a noise-free environment is inescapable. Obnoxious noise levels ringing from our devices while carrying out the surgical procedure may violate the norms set by the Occupational Safety and Health Administration and National Institute for Occupational Safety and Health (NIOSH) recommendation for hearing safety.[6]

The aim of this survey was to obtain information on the perspective of the surgeons and anesthesiologists regarding noise in the operating theater and its impact on their working. The key objective of this survey was to identify whether noise can lead to an increase in the level of stress and human errors, tracing the area of the operating theater that emanates the loudest noise, impact of noise and music while working, and finally, whether noise can lead to hearing impairment.

METHODS

A questionnaire consisting of 15 questions was given to surgeons from various specialties and anesthesiologists. Informed written consent was taken from all participants before distributing the questionnaire. The response was analyzed and documented. Data analysis was done using descriptive statistics, and the association was found out by Chi-square test. The Statistical Package for the Social Sciences (SPSS) Windows, version 17.0 Chicago: SPSS INC. software was used for the study.

After approval from the Institutional Ethics Committee, a total of 290 participants were enrolled for this prospective study. The study design was cross sectional, and a total number of 290 samples were collected. Surgeons from specialties such as oral and maxillofacial surgery, orthopedics, ENT, general surgery, neurosurgery, and anesthesiologist were included in the study. The participants who have not responded to all the questions in the survey were excluded from the study. The study duration was 2 months (February 1 to March 31, 2017).

RESULTS

A total of 290 responses were received. Table 1 shows the percentage of respondents involved in the study. Table 2 describes the perspective of the participants on noise hazards in the operative theater. Table 3 shows the source of noise pollution. Graph 1 shows the preference of music among the participants. Table 4 represents the type of music preferred by the participants. Graph 2 shows the nosiest area in operating complex.

Table 1

Percentage of respondents involved in the study (n=290)

Specialty	n (%)
Oral and maxillofacial surgery	62 (21.4)
Anesthesiology	61 (21)
Orthopedics	59 (20.3)
ENT	56 (19.3)
General surgery	45 (15.5)
Neurosurgery	7 (2.4)

ENT; Ear, nose, and throat

Table 2

Perspective on noise hazards by the participants (n=290)

Noise hazards	n (%)
Communication	250 (86.2)
Stress level	254 (87.6)
Chances of human error	251 (86.6)
Quality of teamwork	243 (83.8)
Hearing deficits	0 (0)
Concentration level	248 (85.5)

Table 3

Source of noise pollution (n=290)

Source	n (%)
Suction	66 (22.7)
Surgical drills	58 (20)
Monitor alarms	40 (13.8)
All of the above	126 (43.5)

Graph 1

Preference of music among the participants (n = 290)

Table 4

Type of music preferred by the participants (n=264)

Type of music	n (%)
Pop	31 (11.7)
Contemporary	97 (36.8)
Classical	73 (27.7)
Devotional	42 (15.9)
Others	21 (7.9)

Graph 2

Nosiest area in operating complex (n = 290)

DISCUSSION

The literature characterizes noise from various perspectives. The simplest definition of noise is any undesirable sound.[1] Shapiro and Berland defined noise as an undesirable sound that causes disturbance and diminishes the effectiveness.[8] Szalma and Hancock opined regarding the detrimental impact of noise on intelligibility of speech, speed of response, accurateness, and acoustic and cognitive impairment.[9] McNeer et al. assessed the impact of noise on individuals and opined that, in a replicated situation applying validated psychometric analysis tools, noise intensifies the perceived burden of the assignment and extent of exhaustion.[10] The need of the study was to highlight the role of noise as one of the confounding factors in human error keeping aside the age-old adage “To err is human.”

Noise levels in operating theater

NIOSH recommends the noise safety threshold of 85 dB for an 8-h period or 91 dB for over 2 h.[11] Noise levels in working rooms more often violate the points of confinement setup by government administrative agencies.[7] In 1972, Shapiro and Berland reported noise levels as high as 85 dB in the operating room during a routine cholecystectomy.[8] Hodge and Thompson decades later reported intermittent sounds up to 108 dB during a “typical major surgical procedure.”[12] Noise increases substantially with the inflow of individuals in the operating theater. The start and termination of the surgical procedure, often considered as the loudest phase, exceeds the maximal limit of 120 dB.[11]

Effect of noise

A survey was conducted on surgeons from various specialties and anesthesiologists with varying work experience. Majority (86%) of the participants considered the background noise, a negative effect on their working.

Noise can cause miscommunication in the working theater which can prompt adverse consequences on the patient's safety, increasing the anxiety level, diminishing the harmonious coordination of teamwork. All this inculcates a risk of human error.[13] Diversions, lack of concentration, and poor correspondence frequently prompt complications inside the operating theater. Noise can be disturbing, primarily during crucial tasks such as chalking out the WHO safety check and swab counts.[7] A majority of the participants (85.5%) considered that the ongoing conversations among the colleagues hinder the concentration level. This impedance is significant when an individual is subjected to “redundant conversations” which affects their working style and multitasking.[7] The effect of this impeding impact of surrounding noise on anesthesiologists was discussed in a review which concluded that the surrounding noise hampers the mental productivity and lack of concentration.[10] The surgeons, anesthesiologists, and other working staff are vulnerable to occupational noise-induced hearing loss. It is an occupational hearing deficit hazard to unavoidable noise in the working area. Although none of them reported any hearing deficit, it may be a possible sequela.

Noise in the operating theater is inevitable. Surgical procedures rely on complex monitors and surgical devices to enable the surgeons to perform fruitful fruition of their procedures. However, the noise generated by the device dampens the concentration and coordination, as reported by 79.7% of our participants.

Music in operating theater

Most respondents (72.9%) felt that music did not have an adverse impact on their tasks. A miniscule proportion of our participants (7.9%) considered that music can be a source of distraction while a critical communication among the colleagues. This can mask the warning bells of the alarms and can also be a source of noise pollution. The rest of the participants (9.3%) were in a state of dilemma of the pros and cons of music. There is currently insufficient evidence to support or refute this finding due to contradicting results published in the literature. Few studies claim that music can deteriorate communication among the team. It can violate the stipulated time period allotted to the surgical procedure primarily by repeated request and absent-mindedness. Furthermore, there can be long-term physiological sequelae such as noise-induced hearing loss and stress. Contrary to this, there are studies that highlight the beneficial effects of music which includes calming effect on individuals in the operating room by decreasing the anxiety and stress while multitasking.[6] Weldon et al. conducted a study on music and communication in the operating theater and suggested that the choice of music should be decided by the entire staff and ought to be played low in the background.[14]

Number of people in operating room

A study by Shital et al. analyzed the operating room human traffic as a cause of surgical site infection.[15] Derek et al., in their study, recommended to limit the number of staff handling instrument and the number of handoffs along with minimizing the people working in the operating room, so as to decrease any event of instruments miscount.[16] The number of people in the operating room should also be limited to regulate redundant conversations and distractions for working staff. In view of our study, it was recommended by majority of surgeons and anesthesiologists to minimize the number of footprints or human traffic congestion by adopting the latest digital trends.

In an open-ended question concerning measures to be taken to decrease noise in the operating theater, the various suggestions put forth by our participants included: limiting the number of people, case history of a patient should be discussed prior so as to minimize the group discussion in the operating room, briefing themselves of the safety checklist, and protocol well in advance to the surgical procedure and installation of soundproof walls. The operating theater should have alarm bells that ring up when there is a breach in the safety threshold limit.

Engineered solutions are the need of the hour that can curtail the obnoxious sounds emanating from the suction pumps. Noise-free monitors with color indicators that would make the anesthesiologists more watchful seem to be promising in the near future. Standard guidelines to be espoused delineating the nature of music permissible in the theater which could probably soothen the mind with its calm and a composing effect. Noise apps would soon be ubiquitous among the health-care professionals, enabling them to create an accurate record of noise nuisance. These apps would turn our smartphones into a mobile sound-level meter. NIOSH sound-level meter app developed by NIOSH is one such unique app, and there would be many more in the pipeline aiming to measure and reduce the level of ambient noise in the operating theater.

The literature is scant on the role of music in the operating theater with no specific guidelines of its influence on the work of operating theater personnel. Further research is warranted in this field so that adequate measures can be taken to optimize the sound level in the operating theater and minimize the adverse effects on staff and patients. The current study was adequately buttressed to observe the noise exposure. It can raise the participant's cognizance about the noise levels in their workplace, guide them about their hearing concerns, and probably necessitate the use of a hearing protection aid as a precautionary measure.

CONCLUSION

We have envisaged the perspective of surgeons and anesthesiologists regarding adverse impact of noise in the operating theater. Future research should embark on analyzing the implications of noise (and/or music) on specific tasks such as dexterity, coordination, memory, ergonomics, and chalking out differences between the impact of noise and that of music.

A major limitation of the study that can be egged on is the lack of numerical data evaluating the intensity of noise, a potential source of distraction in our setup. Some of the deep-seated questions such as objective assessment of cognitive skills of an individual, disruption in the synthesis, and processing of information under the influence of noise or music still remain unanswered.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.