Practice Guidelines
Shh...babies growing: A clinical practice guideline for reducing noise level in the neonatal intensive care unit

https://doi.org/10.1016/j.jnn.2017.02.006Get rights and content

Abstract

This proposed clinical practice guideline addresses the rationale surrounding, and suggests methods to achieve, actual noise levels that are within recommended parameters within the neonatal intensive care unit (NICU) environment. The evidence for this guideline is rooted in review of randomized controlled trials, cohort studies, quantitative study findings, and expert committee opinion.

Section snippets

Objective

The goal of this guideline is to provide tools and motivation for NICU care providers to maintain an environment supportive of premature and term infant development, growth, and neurosensory needs. Infants in the NICU are extremely vulnerable to noxious stimuli, such as loud or high frequency noise, and suffer many ill effects from exposure to such stimuli. Per AAP recommendation, 45 decibels (dB) is the maximum sustained noise level for the NICU environment, 46–50 dB noise level may not occur

Background

According to Fortes-Garrido et al. (2014), average noise levels in the NICU they studied measured 10–40 dB above the AAP recommended level. The main contributing factors to this increase in noise were monitors, alarms, incubators, and conversation. Lasky and Williams (2009) found that respiratory support equipment also contributed to noise levels, especially for those infants who transitioned from an incubator to an open bed. Additionally, Wachman and Lahav (2011) found that an infant's own

Users and setting

This guideline is primarily intended for NICU nurses, as they are the front line caretakers of NICU patients. However, there is also potential benefit for neonatologists, respiratory therapists, radiology technicians, and other care providers in the NICU who follow these recommendations. Essentially any person who spends time in the NICU setting as a care provider or visitor may contribute to the environment in a positive or negative way and this guideline is intended to offer recommendations

Target population

The target patient population affected is NICU patients. These may include premature infants, full term newborns with congenital or perinatal complications, or any infant up to 44 weeks postmenstrual age admitted to the NICU.

Evidence collection methods

Studies included in the evidence base for this guideline were published between 2009 and 2016 with the majority published in 2011–2016. The recommendations were from expert committee statements made in 1997 from the American Academy of Pediatrics who based their recommendations on findings from the Environmental Protection Agency, Office of Noise Abatement and Control (1974). Those committees have not published any new recommendations specific to this subject area since then and the

Recommendations and grading criteria

Rating system for the hierarchy of evidence:

  • Level I: Evidence from a systematic review or meta-analysis of all relevant randomized controlled trials (RCTs) or evidence-based clinical practice guidelines based on systematic reviews of RCTs.

  • Level II: Evidence obtained from at least one well-designed RCT

  • Level III: Evidence obtained from well-designed controlled trials without randomization

  • Level IV: Evidence from well-designed case–control and cohort studies

  • Level V: Evidence from systematic reviews

Method for synthesizing evidence

All evidence was thoroughly examined and evaluated for relevance and applicability. Authors who included a thorough discussion and explanation of their research and findings were included, as long as their articles were published within five years. The two exceptions were for authors who had published multiple articles and were regarded as experts in the subject and the aforementioned expert committee recommendations. Evidence was scoured for specific actions and/or practices, including

Patients' preferences

The authors note that while the patients themselves cannot voice any personal preferences, their parents or post-discharge caregivers can. With this in mind, the authors acknowledge that providers, parents, and post-discharge caregivers have an overarching goal for NICU graduates to have the best possible chance for patient outcomes to be as positive as possible, including neurosensory and auditory status.

Potential benefits and harms

Potential benefits for patients include normalized neurodevelopment, reduced risk to auditory function, fewer episodes of apnea, bradycardia, or oxygen desaturation (A/B/D spells), less stress to infants, increased sleep, and improved weight gain. Potential benefit to caregivers includes reduced risk for alarm or noise fatigue.

Implementation and considerations

Anticipated needs for successful implementation include observation of current practices related to noise levels to identify opportunities for improvement, staff education, signage or handouts for visitors regarding noise reduction, and changing unit culture to value a quieter environment. Anticipated barriers to successful implementation include staff compliance, lack of capital available to replace or repair equipment with noise levels above recommendation, parents and visitors who are

Outcome review criteria

In the short term, observations, noise level measurements, and surveys of staff and visitor attitudes done before and after implementation will determine whether or not the implementation was successful. In the long term, retrospective studies looking at rates of A/B/D spells, neurosensory developmental delays at developmental follow-up, and rates of auditory deficit both before and after practice change implementation may be useful in evaluating the influence of the guideline on patient

Update plan

Due to the potential long-term effects of implementation of this guideline, a review in five years is appropriate to determine if revisions or updates need to be made.

Focus

The main goal of this guideline is to recommend interventions and practices aimed at reducing noise levels from medical equipment, staff and visitors, and ambient environmental noise. Consideration was given to products specifically designed to protect neonates from noise, sources of mechanical and environmental noise, and necessary work flow functions and practices of care providers. Additionally, developmental needs of neonates, both premature and full term gestation, were taken into

Developers

This guideline is based on recommendations made by the American Academy of Pediatrics' (AAP) Committee on Environmental Health in 1997. It remains the current standard of practice as this group has published no new position paper.

No known conflicts of interest exist for either author.

Funding source or sponsor

The authors did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

External reviewers

Alexis Davis, MD, MS Epi.

Clinical Associate Professor, Pediatrics.

Division of Neonatal and Developmental Medicine.

Stanford University School of Medicine.

Kimberly Campisi, BSN RN.

Sarah Howell, BSN RN.

Linda Landof, BSN RN.

Danielle Price, MPH RN.

Gilda Quagliata, BSN RN.

Nicole Rohde, BSN RN.

Jill Silviera, BSN RN.

Brenda Speakman, RN.

Julie Waite, BSN RN.

Lisa Walker, RN.

Christine Weng, BSN RN.

Shelly Claman, NICU Mom.

Lauren Gonzalez, NICU Mom.

Emily Kerrigan, NICU Mom.

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