The research team, led by Kawthar Jaber Fadlallah and colleagues at the Center for Collaborative Research Initiatives in Public Health and Saint-Joseph University of Beirut, used an explanatory sequential mixed-methods design, a two-stage approach that pairs breadth with depth. First, they surveyed 228 intensive care nurses across Lebanon between March and June 2025, asking them to rate noise sources and the perceived impact of noise across four domains: subjective perception, emotion, physiology, and performance. Then, between September and October 2025, they conducted semi-structured interviews with 20 nurses purposively selected from the survey respondents, analyzing the transcripts thematically to explain what the numbers showed.

The survey results paint a picture of an environment saturated with machinery. Most noise sources were rated as moderate, but monitor alarms and ventilators stood out as the leading high-level source, cited by half of the nurses. Alarm fatigue, the desensitization that develops when clinicians hear hundreds of alerts per shift, is a well-documented safety concern in critical care, and this study confirms that in Lebanese ICUs the alarm-ventilator duo dominates the soundscape that nurses cannot escape.

Perhaps the most technically interesting finding lies in the impact scores. Across all four domains, the mean scores fell below the midpoint of the scale: subjective perception at 11.0 plus or minus 3.4, emotion at 13.8 plus or minus 4.4, physiology at 14.2 plus or minus 4.3, and performance at 10.6 plus or minus 4.2. On the surface, that might suggest noise is not a severe problem. But the qualitative interviews revealed a subtler and more troubling interpretation. Nurses described getting used to the noise while simultaneously reporting impaired concentration, having to repeat tasks, tinnitus, and headaches that persisted after their shifts ended. Their adaptation, the authors conclude, reflected endurance rather than relief.

This distinction matters scientifically. Habituation to noise is often assumed to be protective, a form of resilience in which the nervous system learns to filter out irrelevant stimuli. But psychophysiological research has long suggested that even when people report no longer noticing a noise, their bodies may still be responding, with elevated stress hormones, disturbed sleep, and cardiovascular strain. The Lebanese nurses’ accounts of tinnitus and post-shift headaches are consistent with that literature: subjective adaptation can coexist with objective wear.

Geography added another layer to the story. In bivariate analysis, the perceived impact of noise varied significantly by region across all four domains, with p-values at or below 0.017. Impact was highest in the Beqaa region and lowest in North Lebanon. The authors link this pattern to the strained context in which Lebanese nurses work, a health system under chronic economic and institutional pressure in a low- and middle-income country setting, where resources for noise mitigation, alarm management technology, and staff support may be scarce or unevenly distributed.

Experience also shaped perception. The perceived impact in the subjective perception domain increased with longer hospital tenure (r = 0.17, p = 0.009) and longer ICU experience (r = 0.13, p = 0.046). That correlation is counterintuitive at first glance: surely veterans should be least bothered by noise. But it aligns with the endurance interpretation. The longer nurses work in the unit, the more they become aware of what the noise is doing to them, even as they learn to function through it. Accumulated exposure appears to sharpen awareness of the toll rather than dull it.

Burnout emerged as a central thread. The mean burnout score of 3.5 plus or minus 1.2 fell exactly at the lower boundary of the band indicating the presence of burnout, meaning a substantial share of the surveyed nurses were already experiencing the emotional exhaustion and reduced professional efficacy that define the syndrome. The interviews connected this to the noise environment indirectly but persuasively: nurses coping with constant auditory stress, cognitive disruption, and physical symptoms described informal, individually driven coping strategies, while institutional responses were inconsistent at best.

That last point may be the study’s most actionable insight. Where hospitals failed to provide systematic noise management, nurses managed noise on their own, improvising solutions that the researchers linked to the broader LMIC context of systemic strain. The authors argue that this pattern supports system-level mitigation rather than reliance on individual habituation. In practice, that could mean alarm customization and tiered alerting to reduce false alarms, sound-absorbing architectural materials, designated quiet periods, staff education on noise behavior, and acoustic monitoring integrated into unit quality metrics, all interventions that have shown promise in critical care research worldwide.

The study has limits worth noting. It measured perceptions rather than objective sound levels, and its cross-sectional design captures a single moment in time, so causal claims about noise causing burnout cannot be firmly drawn. The sample, while geographically broad within Lebanon, reflects one national context during a period of exceptional strain. Still, by combining quantitative scores with the lived accounts of 20 nurses, the research captures something numbers alone cannot: the quiet resignation of professionals who have learned to keep working through a hazard their institutions have not yet learned to control. For intensive care units everywhere, and especially in resource-constrained settings, the message is that adaptation is not a solution. It is a symptom.

Subject of Research: Nurses' perceptions of noise pollution and its health effects in intensive care units in Lebanon

Article Title: Noise pollution in the intensive care unit: a mixed − methods exploration of Lebanese nurses’ perceptions

Article References: Noise pollution in the intensive care unit: a mixed − methods exploration of Lebanese nurses’ perceptions. (n.d.). https://doi.org/10.1186/s12889-026-29813-9

Image Credits: AI Generated

DOI: 10.1186/s12889-026-29813-9

Keywords: noise pollution, intensive care unit, nurses, burnout, occupational health, alarm fatigue, Lebanon, mixed methods, LMIC, tinnitus, ventilators, monitor alarms

The central finding across all three investigations is that well-constructed clinical decision support tools can nudge clinicians toward evidence-based decisions without slowing them down. In the emergency department study, the research team evaluated a tool designed to help clinicians select an appropriate dose of an intravenous loop diuretic for patients arriving with acute decompensated heart failure. This class of medication removes excess fluid that accumulates when the failing heart cannot maintain adequate circulation, allowing the heart to pump more effectively and relieving the profound shortness of breath that drives these patients to seek emergency care in the first place. Clinical guidelines recommend that patients with acute decompensated heart failure receive at least twice the dose of diuretics they take at home when they arrive in the emergency department, a bolus strategy intended to achieve rapid decongestion. In practice, however, the relentless demands of a busy emergency department make it difficult for clinicians to quickly review home medication lists and adjust diuretic therapy accordingly, and recommended dosing is frequently missed.

To address this gap, the University of Michigan team implemented an interruptive alert within the electronic health record that fired when a patient showed signs of fluid overload or kidney dysfunction, prompting the treating clinician to consider guideline-recommended diuretic dosing. The alert was triggered in 223 patient encounters at the U-M Health Emergency Department. In nearly three-quarters of those cases, clinicians followed the recommended diuretic dosing after the alert appeared. Critically, the tool accomplished this without creating the kind of delay that often undermines the adoption of decision support systems: the median time from arrival at the emergency department to diuretic administration was roughly two hours in both groups, meaning the alert influenced the content of the treatment decision rather than its timing.

The researchers were careful to note the limits of what the study demonstrated. The investigation did not assess whether following the digital alerts improved downstream patient outcomes such as the amount of fluid removed or the length of hospital stay. Even so, the results establish something foundational for the field: the tools are easily used in a real clinical setting and measurably affect treatment decisions. As Sarah Adie, Pharm.D., a clinical cardiology pharmacy specialist at U-M Health and an author on all three studies, explained, this is a critical first step toward broad clinical adoption in settings that treat critically ill cardiac patients. Demonstrating feasibility and behavioral impact in a live emergency department environment is a prerequisite for the larger outcome trials that would justify deployment across many institutions.

The second study shifted the setting to the intensive care unit and examined sedation practices in more than 1,600 patients receiving mechanical ventilation in the cardiac and medical intensive care units. Deep sedation is common in intensive care, but leading cardiac and critical care society guidelines favor limiting its use, because prolonged heavy sedation may contribute to worse outcomes, including prolonged ventilator dependence and longer recovery. Changing sedation practice, however, is notoriously difficult, since it requires coordinated action from both physicians and nurses at the bedside, often under time pressure. The research team introduced an electronic health record-based intervention that encouraged the care team to use lighter sedation, surfacing the recommendation at the moment sedative decisions were being made.

The results were striking. After implementation, the average amount of time patients spent deeply sedated during the first 48 hours after intubation dropped in the cardiac intensive care unit from 16.8 hours to 12.4 hours, a reduction of more than four hours per patient. Nurses also reduced the continuous dose of commonly used sedatives, including fentanyl, propofol, midazolam and dexmedetomidine, in 23 percent of cases when the electronic health record generated an alert. These figures suggest that a well-timed digital prompt can shift entrenched practice patterns in an environment where clinicians are managing multiple simultaneous demands. As Anna Barker, M.D., Ph.D., a pulmonologist at University of Michigan Health and senior author of the light sedation paper, emphasized, the alerts are not designed to replace clinical judgment; rather, they are a tool delivered at high-pressure moments to assist clinicians with evidence-based guidance.

The third study tackled one of the most treacherous diagnostic challenges in cardiology: normotensive cardiogenic shock. This condition occurs when the heart cannot pump enough blood to the organs even though the patient’s blood pressure remains normal. Because cardiogenic shock is classically associated with low blood pressure, clinicians may fail to recognize that a normotensive patient is already in shock, and delays in diagnosis can be life threatening. The researchers implemented an electronic health record alert that identified patients displaying additional physiological signs of normotensive cardiogenic shock, such as subtle markers of hypoperfusion that might otherwise be overlooked, and facilitated direct communication with the shock team in the cardiac intensive care unit.

Clinicians engaged with the alert in 14 percent of cases, and those engagements were linked with higher rates of cardiac intensive care unit consultation within 12 hours. While the engagement rate may appear modest, the study illustrates a different design philosophy from the diuretic and sedation alerts: rather than prompting a medication decision, this alert functioned as a recognition and escalation tool, bridging the gap between a bedside clinician who may not suspect shock and a specialized team equipped to deploy advanced therapies. In conditions where early specialist involvement changes the trajectory of illness, even a low-frequency, high-value alert can be clinically meaningful.

Taken together, the three studies map how targeted electronic health record alerts can assist clinicians across the continuum of critical cardiac care, from the first hours in the emergency department through intensive care management. The design of each intervention differed according to the clinical problem. In the emergency department, the tool offered patient-specific recommendations at the moment the diuretic order was placed, embedding the guideline directly into the ordering workflow. In the two intensive care unit studies, alerts prompted clinicians to limit deep sedation or to escalate suspected shock cases to specialized critical care teams. In each case, the intervention respected the existing workflow rather than adding parallel tasks, which the researchers identify as a key principle: these clinical decision support tools are most useful when they help clinicians make the right decision in the moment, rather than adding more noise to already busy workflows, as Scott Ketcham, M.D., a cardiologist at the University of Michigan Health Frankel Cardiovascular Center and an author on all three studies, observed.

The researchers describe the work as proof of concept, and they are explicit that more must be done to ensure electronic alerts are beneficial without disrupting clinical workflow. Alert fatigue remains one of the most persistent problems in health information technology, as clinicians bombarded with low-value notifications learn to dismiss them reflexively, undermining even genuinely useful tools. The Michigan studies suggest a path forward: alerts that are triggered by specific clinical signals, deliver a single actionable recommendation, and arrive at the exact moment a decision is being made. The next step, according to Ketcham, is to evaluate these interventions across multiple health systems to better understand their impact on patient outcomes and determine how they can help improve the care of critically ill cardiac patients nationwide. If those multi-center evaluations confirm what these early studies hint at, the electronic health record, long criticized as a source of friction, may earn a new role as an active partner in the care of the sickest patients with heart disease.

Subject of Research: Electronic health record clinical decision support alerts for critically ill cardiac patients

Article Title: Digital alerts support timely treatment decisions of critically ill cardiac patients

Article References: Digital alerts support timely treatment decisions of critically ill cardiac patients. (n.d.). Original publication

Image Credits: AI Generated

DOI: Not provided

Keywords: electronic health records, clinical decision support, acute decompensated heart failure, diuretics, cardiac intensive care, sedation, cardiogenic shock, emergency department, ventilators, alert fatigue, Michigan Medicine, patient outcomes