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Evaluation of Potential Noise

Exposures in Hospital Operating


Rooms
LILIA CHEN, MS, CIH; SCOTT E. BRUECK, MS, CIH; MAUREEN T. NIEMEIER, BBA

ABSTRACT

The National Institute for Occupational Safety and Health received a health hazard '
evaluation request from West Virginia University Hospital, Morgantown, to evaluate noise exposures from surgical instruments in the OR. Four surgical technologists, four RNs, and one surgeon wore noise dosimeters to measure full-shift
personal noise exposures during two days while they performed typical daily
activities. Measurements did not exceed Occupational Safety and Health Administration or National Institute for Occupational Safety and Health noise exposure
limits; however, area sound level measurements indicated that some intermittent
activities can generate sound levels above 90 A-weighted decibels. Examples
include surgery preparation, drilling or noise from other powered surgical instruments during surgeries, and clean up. Preventive maintenance of powered surgical
instruments can reduce noise exposures, and noise output should be considered
when selecting replacement instruments. Keeping music at a low level and using *
hearing protection are other interventions to consider to improve noise levels in an
OR. AORN J 96 (October 2012) 412-418. Published by Elsevier, Inc., on behalf of
AORN, Inc. http://dx.doi.Org/10.1016/j.aom.2012.06.001
Key words: operating room noise, drilling, surgical instruments, sound levels.

he National Institute for Occupational


Safety and Health (NIOSH), part of the
Centers for Disease Control and Prevention, conducts research and makes recommendations for the prevention of work-related injury and
illness. When employees, employers, or union
representatives have health and safety concerns,
they can ask occupational health experts from
NIOSH to perform an evaluation as part of the
health hazard evaluation (HHE) program.' The
HHE program responds to these health and
safety requests by sending the requestors usefiil

information; refening them to a more appropriate


agency; or making a site visit, which may include
environmental monitoring and medical testing. If
we make a site visit, we provide the requestors with
a report of our evaluation that includes recommendations specific to any problems found as well
as general guidance for good occupational health
practices.'
This article discusses an HHE performed to
evaluate employees' noise exposures in the ORs at
West Virginia University Hospital, Morgantown.
Although no employees had reported hearing loss.
http://dx.doi.Org/10.1016/j.aoni.2012.06.001

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Published by Elsevier, Inc., on behalf of AORN, Inc.

NOISE EXPOSURES IN OPERATING ROOMS

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members of a hospital management team contacted us because they were concerned about noise
levels, especially during procedures when using
loud surgical instruments.

ASSESSMENT
We evaluated noise exposure of perioperative staff
members during surgeries in several ORs at West
Virginia University Hospital. At the time of our
visit, the hospital had 18 ORs that were used for
a wide variety of surgeries. Managers and employees identified higher noise exposures during
neurosurgeries and orthopedic surgeries, specifically craniotomies, spine discectomies, hip surgeries, and procedures for repairing fractured
bones. Orthopedic surgeries lasted two to four
hours and were reported to create more noise
than other surgeries. Neurosurgeries lasted four
to eight hours, with drilling instruments used
intermittently for several minutes at a time.
We collected noise measurements from nine
employees (ie, four surgical technologists, four
RNs, and one surgeon) who wore noise dosimeters
while performing their daily activities. The monitored employees contributed a total of 11 full-shift
personal noise measures during two days. We
attached a noise dosimeter to each employee's
belt and fastened a small remote microphone to
each employee's scrub clothes at a point midway
between the ear and outside shoulder (Figure 1).
We placed a windscreen over the microphone to
reduce any noise that could have occurred from
objects bumping the microphone. The calibrated
dosimeters averaged noise levels every second for
the employee's full work shift and stored the noise
measurement information, which we later downloaded to a personal computer for analysis. We
used sound level meters (SLMs) to analyze area
noise levels (Figure 2). We placed the SLMs
approximately 3 m from the OR bed because
of space limitations and to keep the equipment
outside of the sterile zone.

BACKGROUND
Perioperative nurses are exposed to noise during surgeries, and repeatedly being exposed to
excessively loud noises could cause noiseinduced hearing loss (NIHL), an irreversible
sensorineural condition that is caused by damage
to nerve cells of the inner ear (ie, cochlea).
Unlike some conductive hearing disorders, NIHL
cannot be treated medically.^ In most cases,
NIHL is insidious, so victims' hearing could be
significantly impaired before they even recognize that they have developed the condition.
After someone's hearing has been permanently
impaired, the ability to hear and understand
speech under everyday conditions is severely
affected. Therefore, it is important that nurses
be aware of noise exposure.
A variety of sources can expose OR staff members to loud noise. Surgical instruments, such as
high-speed pneumatic drills used for bone dissection and accessing neural structures within the
cranial vault, and powered instruments with
sawing, drilling, and cutting attachments used in
orthopedic surgery are loud. Vital sign monitors
and other instruments, such as those used for electrosurgery, also can contribute continuous and
intennittent sounds. Additionally, during surgery
preparation and postsurgery clean up, OR staff
members may hear loud noises from instruments
that accidentally fall to the floor or that have contact
between metal instruments and metal trays and
tables. Unfortunately, many ORs, including those
we investigated at West Virginia University
Hospital, do not contain materials specifically
designed to absorb sound or reduce reverberation.
Furthermore, as the perioperative staff members in
our evaluation reported, loud music, ringing telephones, and pagers can also contribute to noise
exposure in the OR.

Because the energy from noise is widely distributed over many frequencies, the frequency
range is broken into a smaller range of frequencies
called bandwidths, the most common being the
octave band, defined as a frequency band in which
the upper band frequency is twice the lower band
frequency. We also used the SLMs to measure
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Figure 1. An investigator attaches the dosimeter's remote microphone to the empioyee's scrub ciothes midway
between the ear and outside shouider.

octave bands during OR activities that generated


the highest noise levels, such as pneumatic drilling.
Octave band analysis allows us to determine the
dominant noise frequencies, which can be useful
for identifying potential engineering controls. For
example, dominant low-frequency noise is most
likely to be caused by vibration from tools or
equipment and can be reduced by using techniques
to isolate vibration, whereas high-frequency noise
is most effectively reduced by installing noise
enclosures, barriers, or sound absorption systems.
We collected sound level and octave band frequency spectrum measurements every second
during two craniotomies.
NOISE EXPOSURE LIMITS
The noise dosimeters we used in our survey
collect data by using different settings. This allows
us to compare noise measurement results directly
with three different noise exposure limits, which
are the primary noise exposure criteria for assessing workplace noise. These noise exposure
limits are

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the Occupational Safety and Health Administration (OSHA) permissible exposure limit (PEL),^
the OSHA action level (AL), and
the NIOSH recommended exposure limit
(REL).^
Although employers are encouraged to follow the
more protective NIOSH REL, the law requires
them to adhere to the OSHA PEL.
Noise measurement results are reported in units
of A-weighted decibels (dB A). These units are used
because of the very large range of sound-pressure
levels that can be heard by the human ear. Because
the dB scale is logarithmic, increases of 3 dB, 10 dB,
and 20 dB actually represent a twofold, tenfold,
and hundredfold increase of sound energy, respectively. For example, a whisper is 30 dB, a normal
speaking voice is 60 dB, a powered lawn mower
is 90 dB, an ambulance siren is 120 dB, and a jet
engine during take-off is 140 dB.
The OSHA AL standard is specified at 85 dBA
for eight hours per day as a time-weighted average.^ When employees' noise exposures exceed

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TABLE 1. Examples of Balanced NoiseCriterion (NCB) Curve Specifications for


Occupied Activity Areas in Hospitals and
Clinics^
Areas

NCB curve

Private rooms

25-30

Wards

30-35

Operating rooms

25-30

Laboratories

33-43

Corridors

33-43

Public areas

38-43

1. ANSI SI2.2-1995-American National Standard: Criteria for Evaluating Room Noise. New York, NY: Acoustical Society of America,
American Nationai Standards institute: 1995.

Figure 2. The sound level meter analyzes noise


levels.

the AL, an employer is required to implement an


effective hearing conservation program. Such
a program must include monitoring, employee
notification, observation, audiometric testing,
hearing protection devices, training, and record
keeping. When employees' noise exposures exceed
the OSHA PEL, the employees are required to wear
hearing protection. The NIOSH REL for noise is
85 dBA as an eight-hour time-weighted average.
For calculating exposure limits, NIOSH uses a 3-dB
time/intensity trading relationship or exchange rate.
By using this criterion, an employee can be exposed to 88 dBA for no more than four hours,
91 dBA for two hours, 94 dBA for one hour,
97 dBA for 0.5 hours, and so on.
The OSHA noise standard specifies a PEL of
90 dBA as an eight-hour time-weighted average.
When using the OSHA criterion, a less conservative 5-dB exchange rate for calculating the PEL and
AL, an employee may be exposed to noise levels of
95 dBA for no more than four hours, 100 dBA for

two hours, 105 dBA for one hour, 110 dBA for
0.5 hours, and so on.
Occupational noise exposure regulations and
recommendations are designed to prevent hearing
loss from exposures to high noise levels. However, noise exposures lower than those that may
cause hearing loss also can be disruptive to work.
Unwanted noise can interfere with OR staff
members' efficiency, productivity, and ability to
understand others' speech, and can be detrimental
to comfori, health, and the sense of well-being.
In addition to the noise criteria above, another
set of criteria, the balanced noise-criterion (NCB)
curves, has been devised for occupied interior
spaces. This criteria set is designed to limit noise
to levels at which speech can be reasonably
understood.^"' The Acoustical Society of America/
American National Standards Institute (ASA/
ANSI) has recommended specific NCB curve
ranges for steady background noise heard in
various indoor occupied activity areas in hospitals
and clinics (Table 1).^ The ANSI S12.2-1995
Criteria for Evaluating Room Noise specifies that
noise in ORs should not exceed NCB 25 to 30.'
RESULTS AND RECOMMENDATIONS
None of the fiill-shift personal noise dosimetry
measurements that we collected at West Virginia
University Hospital exceeded OSHA or NIOSH
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TABLE 2. Full-Shift Personal Noise Exposure Levels Measured During Two Days
OSHA
permissible
exposure limit
Job title
RN
RN
RN
RN
Surgical technologist
Surgicai technologist
Surgicai technologist

Dose*
(%)

Sterile
zone

Duration
hours:minutes

TWA
(dBA)

Yes
Yes

8:43
8:17
7:05
7:50
7:35
7:44
6:56
7:49
9:07
7:54
1:02

72

7.7

68

4.6

43

0.1
0.2

No
No
Yes

Surgical technologist
Surgical technologist

Yes
Yes
Yes
Yes

Oirouiating nurse

Yes

Surgeon

Yes

Exposure iimits

46
64
55
48
38
55

90

2.8
0.8
0.3

OSHA
action level

NIOSH
recommended
exposure limit

TWA
(dBA)

Dose*
(%)

TWA
(dBA)

Dose*
(%)

76
72
63

15
8.5
2.2

83

60
74

1.6
11

60
44
4.4
3.4

81
71
70
80

77
6.3
73
3.0
68
1.1
58
0.1
maifunctionmicrophone
fauit
Dosimeter
76
5.1
0.8
69
Dosimeter maifunotioniogged data only 1 hour
100

70
65

85

100

85

29
16
6.2
2.2
11

100

==
Occupationai Safety and Health Administration;
dBA =A-weighted decibels; NIOSH = National Institute for Occupationai Safety and Health; OSHA
TWA = time-weighted average.
'The various dose percentages are the amounts of noise accumuiated during a work day, with 100% representing the maximum aiiowabie daily dose.

noise exposure limits (Table 2). Investigators from


NIOSH also observed and recorded times when
noise-producing activities (ie, drill use, music use,
postsurgery clean up) were performed in several of
the ORs. After correlating the observation times
with the results from the employees' dosimeters,
we found that the sound level ranges for specific
activities ranged from
76 dBA to 95 dBA during drill use,
m 67 dBA to 94 dBA during playing of music, and
69 dBA to 90 dBA during postsurgery clean-up
activities.
For all activities observed, sound levels higher than
90 dBA lasted less than 30 seconds and occurred
intermittently. Exposure to sound levels higher than
90 dBA would eventually exceed OSHA limits.
One study of noise levels during total knee
replacement and total hip replacement surgeries
found that average noise levels ranged from approximately 75 dBA to 82 dBA; maximum
A-weighted noise levels reached 108 dBA, and
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peak nonweighted noise levels exceeded 140 dB. A


separate study across 10 different surgeries found
noise levels ranging from 71 dBA to 95 dBA during
use of drills for orthopedic surgeries.^ These researchers also noted that noise levels during set
up of surgical instruments ranged from 94 dBA
to 104 dBA as instruments were placed in surgical
trays.^ Several other noise researchers have found
noise levels during the use of surgical instruments
(eg, drills, saws) exceeding 90 dBA.'"'^ Surgical
procedures in which these instruments are used,
such as craniotomies and orthopedic surgeries,
can last many hours, potentially exposing surgical staff members to long periods of noise.
We used octave band data to compare the room
noise values with the NCB criterion. Results from
octave band noise frequency analysis indicated that
noise levels in the OR were higher than levels recommended by ASA/ANSI, which may cause speech
interference for OR staff.
It should be noted that there were some limitations of our evaluation. At times, the sterile gowns

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worn by staff members in the sterile zone covered


the dosimeter microphone, which may have caused
an underestimation of noise exposure. Also, because
SLMs were placed approximately 3 m from the OR
bed, measurements underestimated sound levels
closer to the source.

instruments, we advised West Virginia University


Hospital that noise levels in their ORs could be
reduced by playing radios at a lower volume. As
a general rule, OR staff members should be able
to speak to one another without needing to raise
their voices when a radio is in use.
Hearing protection is another way to reduce
noise exposure. However, hearing protection
should be chosen carefiilly because hearing protectors that excessively attenuate noise may substantially interfere with communication or the
ability to hear patient-monitoring equipment. One
option is an inseri-type flat attenuation hearing
protector with a low noise reduction rating that
attenuates noise evenly across all frequencies. Flat
response hearing protectors can be found online
by searching for "musician's earplugs."
Despite the inherent challenges to reducing noise
exposures in the OR because of the required noise
from sources such as vital sign monitors, alarms,
and staff communication, there are improvements

FINDING A SOLUTION
Reducing noise exposures in an OR can be
challenging because some sounds are required
during surgery (eg, vital sign monitors, alarms,
staff communication), whereas other sounds,
especially from drilling and sawing instruments,
could be reduced. Our evaluation showed that
pneumatic surgical instruments generated the
highest noise levels in the OR, so we recommended that noise reduction efforis focus on
using surgical instruments that generate less noise.
Noise from powered surgical instruments could
cause speech interference during surgeries, so
using quieter powered surgical instruments is
the most effective way to
reduce noise exposure, to
Recommendations to Reduce Noise
minimize speech interference, and to limit the risk
Consider following these recommendations to improve the noise
of NIHL. We also recomlevel in a facility's ORs:
mended reducing noise ex Ensure existing instruments are operating as quietly as
posure through preventive
possible. Check instruments periodically to maintain the lowest
maintenance of powered
possible noise level. Notify managers if anyone detects a change
surgical instmments and
in an instrument's volume, because such a change may indicate
considering noise output
that the instrument needs servicing or replacement.
when selecting replacement
Investigate surgical instruments that may be quieter than
instruments.
models currently being used. Contact instrument manufacOne study comparing
two different types of
saw blades used for knee
arihroplasty revealed that
a modified saw blade with
an oscillating tip and stationary shaft produced significantly less noise than
a standard design in which
the entire blade oscillated.'^
In addition to using quieter

turers and inquire about noise reduction and experiment with


several different models to assess their noise levels.
Consider wearing hearing protection during loud activities.
Managers can provide optional hearing protection for employee
use. If hearing protection is worn, then it should have a fiat
fi'equency response to reduce the effect on speech communication and the ability of surgical employees to hear patientmonitoring equipment.
Keep music volume low during surgeries. Lower music
volume will help reduce speech interference.

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that can be made. Noise volume from sources such


as drills, saws, and radios can be reduced to create
a more healthfiil workplace. ESM
Aeknowledgment: The authors acknowledge Jay
Bowers, BSN, RN, CNOR, clinical preceptor/
educator at West Virginia University Hospital,
Morgantown, and the OR staff of West Virginia
University Hospitals for their help and cooperation
in this evaluation.
Editor's note: This health hazard evaluation was
completely funded by the National Institute for
Occupational Safety and Health.
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Lilia Chen, MS, CIH, is an industrial hygienist for the Centers for Disease Control and
Prevention, National Institute for Occupational
Safety and Health, in Cincinnati, OH. Ms
Chen has no declared affiliation that could be
perceived as posing a potential confiict of interest in the publication of this article.

Scott E. Brueck, MS, CIH, is an industrial


hygienist for the Centers for Disease Control and
Prevention, National Institute for Occupational
Safety and Health, in Cincinnati, OH. Mr Brueck
has no declared affiliation that could be
perceived as posing a potential confiict of
interest in the publication of this article.
Maureen T. Niemeier, BBA, is a freelance
technical writer. Ms Niemeier has no declared
affiliation that could be perceived as posing
a potential confiict of interest in the publication
of this article.

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