Effects of Operating Room Noise on Patient Outcomes and Medical Staff: A Systematic Review

Abstract

Objective:

High noise levels in operating rooms are a common problem in clinical practice. The aim of this study is to review the current study systematically to clarify the effects of operating room noise on medical staff and patients.

Methods:

We searched the studies on operating room noise published in PubMed, Web of Science, and Cochrane Library from 2014 to 2024. The study types included randomized controlled trials, case–control studies, and cohort studies. Study languages were not limited. Two researchers screened the study in accordance with inclusion and exclusion criteria and extracted relevant data for quality evaluation.

Results:

Ten studies were included in this systematic review. They involved 1485 subjects, comprising 888 patients and 597 healthcare workers. In the included studies, the operating room noise level generally exceeded 50 dB, and the recorded highest average noise level was 72.4 dB. Five studies investigated the effects of noise on the psychological state of operating room staff, involving 581 participants, and primarily reported that noise exposure led to adverse psychological effects, such as decreased attention and increased anxiety. Three studies, encompassing 114 participants, examined the physiological effects of noise on operating room staff and found that noise contributed to fatigue, headaches, and increased cortisol secretion. Additionally, five studies explored the influence of noise on surgical patients. Of these studies, four studies documented negative outcomes in patients, including postoperative infections and anxiety, whereas one demonstrated that low-level noise stimulation could beneficially improve postoperative delirium and pain in patients.

Conclusion:

Noise has a potential negative effect on staff and patients, underscoring the importance of implementing noise control measures in the operating room.

KEY MESSAGES

• (1)Operating room noise often exceeds recommended levels; affecting staff and patient well-being
• (2)In medical staff, noise contributes to stress, anxiety, and inattention, affecting cognitive function and performance.
• (3)Patient outcomes may suffer due to noise, with links to increased anxiety, reduced satisfaction, and potential complications.
• (4)This review underscores the need for effective noise control in operating rooms to enhance staff and patient health and surgical outcomes.

INTRODUCTION

Noise pollution is a pervasive global public health challenge with considerable effects on health, well-being, and longevity.[1] Research suggests that constant noise exposure may be a key factor in increased mental and cardiovascular health risks.[2] Noise pollution is prevalent in many densely populated areas and originates from various sources. People may suffer from excessive noise in different places, such as their homes, schools, and workplaces.[3] Hospitals are an easily overlooked noise-exposure environment.

Sound level standards in hospital areas are strictly defined in accordance with the guidelines of the World Health Organization (WHO) to ensure the health and well-being of patients and staff.[4] Specifically, WHO recommends that the average daytime sound level in general hospital areas should not exceed 30 dB to maintain a peaceful environment. At night, the maximum sound level inwards should remain below 40 dB to ensure high-quality rest and sleep. However, hospital noise levels often exceed these standards. A study by Das et al.[5] showed that noise levels in hospitals were 69.5 ± 5.8 dB on 24 h weekdays and 66.2 ± 4.6 dB on weekends, adversely affecting patients.

Noise exposure affects the health of medical staff and patients through multiple pathological mechanisms. It can disturb the REDOX balance of the body, induce neuroinflammation and neuronal apoptosis, and change neurotransmitter transmission in key brain regions, such as the cortex, thalamus–hippocampus, amygdala, striatum, and cerebellum, and eventually lead to tinnitus, anxiety, depression, cognitive and motor dysfunction and other clinical disorders.[6] Notably, the operating room, as a hospital area with a high noise exposure level, has a particularly prominent acoustic environment problem. Liu et al.[7] revealed noise levels of 68.3 ± 14.7 dB in outpatient operating rooms and 45.7 ± 9.6 dB in inpatient operating rooms, which identified noise exposure as a common problem in operating rooms. High noise exposure in operating rooms undoubtedly has adverse effects on the medical staff and patients.[8] With the rapid development of minimally invasive surgery, robot-assisted surgery, and other new surgical methods have been proposed;[9] the noise characteristics of surgical equipment may change drastically, making it urgent to systematically evaluate the effects of operating room noise on the concentration and decision-making ability of medical staff and prognosis of patients. Although previous studies have confirmed the extensive health hazards of noise pollution, the systematic risk analysis and noise control strategies for operating rooms remain insufficient. Through a systematic review of the literatures published over the past decade, our team aims to clarify the specific health risks of noise exposure in operating rooms and provide an evidence-based foundation for formulating precise noise control plans.

METHODS

Search strategy

This review examined relevant literatures published from January 2014 to October 2024 in PubMed, Cochrane Library, and Web of Science. Search terms were (operating room) AND ((noise) OR (noise exposure)). The search strategy used subject words combined with free words. It was supplemented by manual searching and the snowball method to track the references and citations included in the studies.

Inclusion and exclusion criteria

Inclusion criteria

• (1)The study must explicitly report the noise exposure level of the subjects during surgery.
• (2)Prospective (randomized controlled trials [RCTs], quasi-experiments, and other nonrandomized controlled prospective studies), cross-sectional, case–control, and cohort studies were included.
• (3)The study must report clearly the effect of noise on medical staff or patients.

Exclusion criteria

• (1)The case reports, animal tests, conference papers or posters, and low-quality studies.
• (2)The studies that reported only the noise level but not the impact on patients and paramedics.
• (3)The studies only considered music or noise exposure levels below 30 dB.
• (4)The studies accepting noise reduction management did not specify the situation before noise reduction.

Study screening and data extraction

Two researchers independently screened the study on the basis of the exclusion criteria and then extracted data. Duplicate title catalogs were deleted, and obviously, irrelevant study was eliminated by reading titles, abstracts, and full texts. In cases of disagreement between two researchers, the content of an article was evaluated by a third expert with a senior professional title and special training in noise-related knowledge. The data were extracted after a summary analysis of all the studies. Figure 1 was drawn using the PRISMA 2020 (Cochrane, London, UK). Literature management was conducted by EndNote 20 (Clarivate, London, UK).

Figure 1.

PRISMA flow chart of this systematic review.

Bias risk assessment

Two reviewers independently assessed the methodological quality of each included study. If the assessments were contradictory or ambiguous, then a third person made the decision. The quality of RCTs was evaluated by using the Jadad scale, a classic tool for assessing the methodological quality of RCTs.[10] The dimensions “randomization,” “double blinding,” and “withdrawals and dropouts” were used. The total score was 0–5 points, and studies with ≤2 points were considered low-quality studies, and the Jadad score exceeded 3 points, indicating that the study quality was reliable. Non-RCTs were scored by using the Newcastle–Ottawa Scale (NOS), which quantifies the risk of bias by star score.[11] It evaluates nonrandomized studies on the basis of three dimensions, namely, selection (4 stars), comparability (2 stars), and exposure (3 stars), with a total score of 9 stars. A study with less than 4 stars is considered as low quality.

RESULTS

Research selection

A total of 1090 articles were retrieved from three databases. These articles included 130 from PubMed, 125 from the Cochrane Library, and 835 from the Web of Science. Of the articles, 246 were excluded because they were duplicates; 740 were deleted on the basis of their titles and abstracts; 38 were excluded because their full texts could not be found or they were conference papers or posters; and 56 were excluded in accordance with the quality of the study and result extraction. Finally, 10 studies were included in this review [Figure 1].

Study features

The 10 studies were published between 2015 and 2024, involving 1485 subjects, with 888 patients and 597 medical staff. The specific features of the included study are shown in Table 1.

Table 1.

Features of the 10 studies included in this review

Study	Year	Country	Type	Sample size	Subjects	Indicators
Gulsen et al.[12]	2021	Türkiye	Cross-sectional study	92	Medical staff	➀,➁,➂
Kennedy-Metz et al.[13]	2022	United States	Cross-sectional study	16	Medical staff	➀,➂
Idree et al.[14]	2023	India	Cross-sectional study	6	Medical staff	➀,➂
Keller et al.[15]	2028	Switzerland	Cross-sectional study	397	Medical staff	➀,➁
Tseng et al.[16]	2022	China	Quasi-experiment	36	Medical staff	➀,➁
Ukegjini et al.[17]	2016	Switzerland	Quasi-experiment	50/664	Medical staff/patients	➀,➃
Lu et al.[18]	2024	China	Cohort study	71#	patients	➀,➁,➂,➃
Dholakia et al.[19]	2015	Britain	Cross-sectional study	64	patients	➀,➃
Bozych et al.[20]	2024	United States	RCT	64	patients	➀,➁➂
Muzzi et al.[21]	2021	Italy	RCT	25#	patients	➀,➃

Notes: RCT, randomized controlled trial. #, the number of samples affected by noise. Indicator: ➀ noise level, ➁ psychological influence, ➂ physiological influence, ➃ clinical outcome.

Study quality assessment

Of the 10 studies included in this review, two were RCTs. A Jadad score exceeding three points indicates that the study quality was reliable [Table 2].

Table 2.

Study quality assessment (RCTs)

Study	Year	Randomization	Double blinding	Withdrawals and dropouts	Jadad score
Bozych et al.[20]	2024	2	1	1	4
Muzzi et al.[21]	2021	2	1	0	3

Note: RCT, randomized controlled trial.

The NOS was applied to evaluate the quality of eight non-RCTs on the basis of three dimensions: selection, comparability, and exposure. The results showed that the eight studies scored six to eight points, indicating that their quality was reliable [Table 3].

Table 3.

Study quality assessment (non-RCTs)

Study	Year	Selection	Comparability	Exposure	Total quality score
Gulsen et al.[12]	2021	**	**	***	7
Kennedy-Metz et al.[13]	2022	***	**	**	7
Idrees et al.[14]	2023	***	**	**	7
Keller et al.[15]	2018	***	**	**	7
Tseng et al.[16]	2022	**	**	**	6
Ukegjini et al.[17]	2016	***	*	***	7
Lu et al.[18]	2024	***	**	***	8
Dholakia et al.[19]	2015	**	**	**	6

Note: one * stands for one point; RCT, randomized controlled trial.

Qualitative synthesis

All 10 studies recorded detailed noise levels that subjects were exposed to. They covered several surgery types, including orthopedic, heart, and abdominal surgeries. Tseng et al.[16] reported the highest average noise level, which reached 72.4 dB. The lowest average noise level (only 30 dB) was recorded by Muzzi et al.[21], possibly due to its focus on the effects of low-level noise stimulation on patients. Except for three studies (Lu et al.[18], Dholakia et al.[19], and Muzzi et al.[21], all other studies recorded noise levels above 50 dB. Three studies reported noise levels at or above 70 dB. Table 4 shows the specific data.

Table 4.

Noise level and surgery type in 10 studies

Study	Year	Surgery type	Average noise level (dB)
Gulsen et al.[12]	2021	Ten types of surgerya	60.90 (55.5–67.5)
Kennedy-Metz et al.[13]	2022	Cardiovascular surgery	70b
Idrees et al.[14]	2023	Endocrine surgery/thyroidectomy	70 (51.81–90.06)
Keller et al.[15]	2018	Four types of surgery	Upper GI tract 56.00 (55.25–56.75),Hepatobiliary 56.30 (55.83–56.76),Lower GI tract 55.21 (54.56–55.86),Other surgeries 55.44 (54.45–56.42)
Tseng et al.[16]	2022	Three types of surgeryc	72.4 (72.2–75.5)
Ukegjini et al.[17]	2016	General or visceral surgery	61.6 (51.5–76.3)
Lu et al.[18]	2024	Transarterial chemoembolization	42.92
Dholakia et al.[19]	2015	Herniorrhaphy	47.6
Bozych et al.[20]	2024	Tonsillectomy/dental procedures	Before noise reduction 58.53 ± 0.77
Muzzi et al.[21]	2021	Tonsillectomy	30.0 (30.0, 35.0)d

Notes: ^aThe 10 types of surgery included orthopedics, urology, ophthalmology, otorhinolaryngology, plastic surgery, breast surgery, pediatric surgery, cardiovascular surgery, neurosurgery, and gynecology; ^bThe noise range was not clearly reported, and 70 dB was the cutoff value; ^cThe three types of surgery included orthopedic, general, and endoscopic surgeries; ^dThe data refer to the level of auditory stimulation received by the patients.

Effect of operating room noise on medical staff

Psychological effect

Five studies (involving a total of 581 subjects) reported the effects of operating room noise on the psychological state of medical staff, with multidimensional characteristics. First, three studies confirmed that noise exposure could lead to the distraction of medical staff and affect the ability to concentrate on intraoperative processes. Two studies further indicated that noise remarkably increased the stress, anxiety, and irritability experienced by healthcare workers. By comparing different noise interventions, Tseng et al.[16] found that music at volumes of 55–60 dB could substantially reduce stress and anxiety in nurses, with Mozart music being particularly prominent in relieving situational anxiety. However, the stress response increased when the volume of the music exceeded 60 dB. In addition, two studies emphasized that noise had a lower psychological effect on surgeons than on other roles, presumably because surgeons were intensely concentrating on operations. In summary, the negative effects of noise are dependent on intensity and source, and the psychological tolerance of different doctors and nurses varies. Specific data are shown in Table 5.

Table 5.

Psychological effects of operating room noise on medical staff

Author	Year	Sample size	Psychological influence
Gulsen et al.[12]	2021	92	Eighty-six subjects were psychologically affected, with 14 feeling upset, 32 feeling anxious, and 40 feeling distracted
Idrees et al.[14]	2023	6	Noise was proportional to the level of inattention in the medical staff
Keller et al.[15]	2018	397	Noise level had no effect on the attention of the primary surgeon but did affect that of the secondary surgeon and the anesthesiologist
Tseng et al.[16]	2022	36	Noise increased nurses’ stress levels and anxiety, and high-pitched music also increased stress in nurses
Ukegjini et al.[17]	2016	50	Noise interfered with the lead surgeon but had no significant effect on concentration

Physiological influence

Three studies, covering 114 subjects, examined the effects of operating room noise on the physical health of healthcare workers. Gulsen et al.[12] measured the effect of noise on health care workers by assessing subjective symptoms, such as fatigue and headaches, and found that although 84.8% of the subjects were affected. A study by Kennedy-Metz et al.[13] comparing the physiological responses of healthcare workers in a low-noise environment (noise levels of less than 70 dB) and a high-noise environment (noise levels of greater than 70 dB) showed that the heart rate of healthcare workers in a high-noise environment substantially increased. Idrees et al.[14] analyzed salivary cortisol samples before and after noise exposure and found a correlation between noise levels and a considerable increase in salivary cortisol levels after noise exposure. Table 6 provides the specific data.

Table 6.

Physiological effects of operating room noise on medical staff

Study	Year	Sample size	Physiological influence
Gulsen et al.[12]	2021	92	Seventy-eight subjects suffered physical effects, with 47 experiencing fatigue and 31 experiencing headaches
Kennedy-Metz et al.[13]	2022	16	Noise increased the subjects’ heart rates
Idrees et al.[14]	2023	6	Noise levels were significantly associated with increased salivary cortisol in surgeons after noise exposure

Effect of operating room noise on patients

Five studies, encompassing 888 patients, evaluated the influence of operating room noise on patients [Table 7].

Table 7.

Effects of operating room noise on patients

Study	Year	Sample size	Description
Ukegjini et al.[17]	2016	664	The average noise level was higher for operations that lasted for less than 90 min than for operations that lasted longer<breack/>Noise levels were associated with perioperative total inpatient complications (surgical and nonsurgical)<breack/>Noise level was not associated with 90-day mortality or surgery-related complications
Lu et al.[18]	2024	71	Noise level was not related to patients’ blood pressure, heart rate, and complications but was related to anxiety and nursing satisfaction
Dholakia et al.[19]	2015	64	Noise levels were associated with surgical site infections in patients
Bozych et al.[20]	2024	64	Children exposed to noise were more likely to have tantrums seven days after surgery<breack/>Noise was associated with postoperative pain in patients
Muzzi et al.[21]	2021	25	Noise stimulation reduced postoperative pain and postoperative delirium

Two studies reported the association of noise with perioperative complications in patients. Ukegjini et al.[17] found that increased noise was associated with a high incidence of perioperative complications, and further univariate analysis revealed that mortality at 90 days after surgery was associated with attention and communication by the surgical team, and noise may interfere with these factors. Dholakia et al.[19] found that surgical site infection was associated with high levels of noise exposure during daytime hernia repair. These studies showed the importance of noise management for the perioperative health of surgical patients.

Three studies reported the effects of noise on the psychological and physiological states of patients. Lu et al.[18] demonstrated that although routine noise exposure did not remarkably affect the blood pressure, heart rate, or complications of patients undergoing transcatheter chemoembolization compared with noise reduction treatment, it did increase patients’ anxiety and reduce care satisfaction.

The results of two studies on patients undergoing tonsillectomy differed. Bozych et al.[20] found no statistically significant difference in the effects of conventional noise and noise reduction on the behavior of patients during the induction and recovery periods before anesthesia. However, they discovered that compared with other patients, those exposed to conventional noise were more likely to experience restlessness and a higher demand for analgesic drugs 1–2 and 5–7 days after surgery. Muzzi et al.[21] further explored the effects of an auditory intervention and found that low-intensity noise stimulation (30 dB) modestly reduced postoperative pain and delirium but was less effective than music intervention.

DISCUSSION

Noise refers to sound that is not inherent and exceeds a certain limit, and it may affect physical and mental health.[22] As a stressor, noise can increase the activity of the nervous system and levels of stress hormones.[23] It initially causes emotional changes, such as anxiety, fear, irritability, fatigue, and even neurasthenia symptoms, such as dizziness and headache, as well as gastrointestinal problems, including nausea and vomiting. In addition, noise can increase adrenal gland secretion, leading to a fast pulse, high blood pressure, and irritability, which can induce heart disease.[24] Amongst all kinds of noises, medical noise can cause harm to patients and medical staff, leading to the occurrence of various diseases.[25] The operating room, where surgery is performed and intensive care is provided, requires a highly controlled environment. Managing ambient noise is essential to maintaining the physical and mental health of patients and operating room staff. Our team conducted a systematic review to evaluate the effects of operating room noise on medical staff and patients to provide an evidence-based medical foundation for noise management in operating rooms.

First, current noise levels in operating rooms were analyzed. In the 10 included studies, operating room noise levels generally exceeded 50 dB, with those in three studies exceeding 70 dB. This finding indicates that operating rooms remain medical sites with high noise exposure. Operating room noise mainly originates from numerous aspects. The first is the sound of running medical equipment, such as anesthesia machines, monitors, and surgical instruments. The second is human activity, including the communication and walking of medical staff and the sounds generated by surgical operations. Thirdly, environmental factors, like air conditioning systems and door switches, are other sources of noise. Finally, external noise, such as hallway activity and emergency alarms, penetrates into operating rooms. These noise sources superimpose and together constitute a complex acoustic environment in operating rooms.[26] At the same time, noise levels vary from surgery to surgery, with orthopedic surgery having the highest noise levels in terms of available data, likely due to the loud noises generated by the power tools, cast saws, suction, and hammering mallows often used in this type of surgery. Studies have shown that these instruments have noise levels that range between 85 and 120 dB.[27] In a 2020 study, Baum et al.[28] evaluated the noise levels of three adult reconstructive surgeons over a 27-day period. They found an average noise level of 80.64 dB and a peak noise of 103.66 dB. This work and previous studies demonstrate that, over the past decade, operating rooms have been generally exposed to high noise levels. This finding provides basic support for noise control in operating rooms.

We systematically summarized the effect of operating room noise on medical staff. Our summary data showed that operating room noise not only has adverse effects on the psychology of medical staff it also poses a threat to their physiological health. At the psychological level, noise increased the stress and anxiety of medical staff subjectively and objectively. A study by McCullagh et al.[29] showed that nurses subjected to high noise exposure reported poor health status and high stress and burnout scores. Attention is a key factor in achieving good surgical outcomes, and relevant studies have demonstrated that a high level of attention can considerably improve the work performance, communication skills, and safety attitudes of surgeons, helping reduce adverse clinical events likely because attention, an important component of cognitive function, enables filtering out distractions and focusing on work-related problems.[30] However, exposure to harmful noise increases the mental workload and adversely affects cognitive function. This effect, in turn, affects attention.

We also summarized the data on the physiological effects of noise on medical staff in operating rooms. Noise can cause fatigue and headaches, increase heart rate, and elevate cortisol levels in healthcare workers, likely because noise-induced stress activates the hypothalamic–pituitary–adrenal (HPA) axis and raises serum cortisol levels, causing damage to the cardiovascular system.[31] The long-term activation of the HPA axis, especially sustained increases in cortisol levels, may lead to multifaceted health problems, including immunosuppression, insulin resistance, cardiovascular disease, catabolism, and intestinal problems.[32] These findings further highlight the importance of protective measures for healthcare workers regarding noise management.

We systematically analyzed the effect of noise on patient clinical outcomes. We specifically noted that noise may have a negative effect on surgery-related complications. The reasons for this phenomenon are complex and varied. High-intensity noise during surgery can interfere with communication among medical staff. In addition, noise pollution during surgery may distract surgeons and anaesthesiologists, thus affecting the surgical process. This situation may cause surgery-related complications. Noise reduction measures in operating rooms based on the above concept may be an effective way to improve patient clinical outcomes. This hypothesis is supported by the study of Engelmann et al.[33], who found that implementing a noise reduction program in pediatric operating rooms drastically reduced the incidence of postoperative complications in patients.

Our systematic review also revealed two interesting findings. First, low-intensity repetitive noise stimulation may have a positive effect on postoperative delirium in patients, possibly because repetitive noise stimulation helps improve postoperative delirium; however, the specific mechanism has not been fully understood. Another finding is that low-intensity repetitive noise has a positive effect on postoperative pain in patients. A mouse model study by You et al.[34] also reported that mice exposed to noise with levels of less than 40 dB showed low mechanical hyperalgesia. These findings provide a valuable reference for the comprehensive consideration of the effects of different noise levels on patients.

In consideration of the above findings, future operating room noise management should focus on five strategies: (1) Technical upgrades: adopt low-noise devices to minimize equipment-generated noise. (2) Environmental optimization: integrate sound-absorbing materials, strategic layouts, and insulation to dampen noise propagation. (3) Staff training: enforce behavioral protocols to reduce unnecessary conversations and movements while raising awareness of noise effects. (4) Real-time monitoring: implement noise-level alerts and use masking technologies for adaptive control. (5) Personalization: tailor noise reduction measures to surgery types (e.g. strict controls for high-focus procedures) or patient needs. These integrated approaches aim to enhance staff well-being, patient outcomes, and overall surgical safety.

However, this work has limitations. In this study, only a qualitative systematic review was conducted, and quantitative meta-analysis was not possible due to the limitations imposed by the differences in outcome indicators, surgery types, interventions, and observation methods in previously published studies, thus limiting the level of evidence. Future research should prioritize procedure-specific analyses, elucidate molecular pathways, and develop adaptive noise-control technologies. Longitudinal studies are critical to assess cumulative occupational risks for healthcare workers. By fostering interdisciplinary collaboration and innovation, noise reduction in operating rooms can enhance clinical outcomes and occupational safety, ultimately advancing healthcare quality and patient–staff well-being.

CONCLUSION

We systematically reviewed the effect of operating room noise on medical staff and patients, revealing that operating room noise levels (often >50 dB, sometimes reaching 72.4 dB) consistently exceed WHO guidelines, primarily due to equipment, personnel activities, and environmental factors. In staff, noise exposure is correlated with psychological stressors and physiological risks, potentially escalating long-term cardiovascular and immune disorders. Patients face heightened risks of postoperative infections, anxiety, and impaired recovery linked to noise-induced disruptions in communication. Notably, low-intensity noise may alleviate postoperative delirium and pain, although its mechanisms remain unclear.

Our findings underscore the urgency of noise management in operating rooms through integrated strategies. Such strategies include adopting noise-control technologies, optimizing acoustic environments, enforcing behavioral protocols, and implementing real-time monitoring.

However, the limitations of our work include heterogeneity across studies, small sample sizes, and a focus on short-term effects. In the future, surgery-specific noise-related meta-analyses and longitudinal studies can be conducted to obtain highly reliable evidence.

Availability of Data and Materials

The datasets used and/or analyzed during the current study were available from the corresponding author upon reasonable request.

Author Contributions

Xingsun Li and Jiang Li designed the study; all authors conducted the study; Zhihui Xu and Yanfen Shang collected and analyzed the data. Xingsun Li and Haidan Shi participated in drafting the manuscript, and all authors contributed to the critical revision of the manuscript for important intellectual content. All authors gave final approval of the version to be published. All authors participated fully in the work, took public responsibility for appropriate portions of the content, and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or completeness of any part of the work were appropriately investigated and resolved.

Ethics Approval and Consent to Participate

Not applicable.

Conflicts of Interest

The authors declare no conflicts of interest.

Funding Statement

None.