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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.
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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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CHENBRUECKNIEMEIER
Figure 1. An investigator attaches the dosimeter's remote microphone to the empioyee's scrub ciothes midway
between the ear and outside shouider.
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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
www.aomjoumal.org
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.
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.
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
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CHENBRUECKNIEMEIER
8. Love H. Noise exposure in the orthopaedic operating
theatre: a significant health hazard. ANZ J Siirg. 2003;
73(10):836-838.
9. Nott MR, West PD. Orthopaedic theatre noise: a
potential hazard to patients. Anaesthesia. 2003;58(8):
784-787.
10. Willet KM. Noise-induced hearing loss in orthopaedic
sXa. J Bone Joint Surg 1991;73-B(1):113-115.
11. Mullett H, Synnott K, Quinlan W. Occupational noise
levels in orthopaedic surgery. // J Med Sei. 1999;
168(2): 106.
12. Siverdeen Z, Ali A, Lakdawala AS, McKay C. Exposure
to noise in orthopaedic theatresdo we need protection?
Int J Clin Pract.. 2008;62(ll): 1720-1722.
13. Sydney SE, Lepp AJ, Whitehouse SL, Crawford RW.
Noise exposure due to orthopedic saws in simulated total
knee arthroplasty surgery. J Arthroplasty. 2007;22(8):
1193-1197.
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.
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