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It’s been a year since our last soapbox rant about cellphones in the OR (see our January 28, 2020 Patient Safety Tip of the Week “Dang Those Cell Phones!”). A recent “Viewpoint” in JAMA Surgery has rekindled the debate about cellphones in the OR. Cohen et al. (Cohen 2020) reviewed the benefits and harms of personal communication devices (PCD’s) or smartphones in the OR. They summarized the benefits and harms of PCD’s:
We’ll be quick to point out that most of the benefits listed by Cohen et al. do not necessitate cellphones being in the OR. Also, the important access to medical imaging and access to tools such as medication dosing apps are already available on the computers currently in the OR, so we don’t need cellphones for access to those in the OR.
But the potential harms listed by Cohen et al. are real, particularly the unwanted disruptions and distractions and cognitive disengagement from other tasks. A previous study by Cohen et al. (Cohen 2018) had looked at the impact of PCD’s during cardiovascular surgeries. They identified a total of 545 PCD-related events during 25 cases. While most individuals spent less than a few minutes attending to their PCD’s, a handful of these disruptions lasted an abnormally long time. On average, each of the 545 events took 1 min, 26 s (SD = 1 min, 40 s) of attention. Most PCD use events took place during bypass (n = 233) followed by pre-bypass (n = 197) and post-bypass (n = 115). Of the 545 events, nearly half (48.81%) involved the anesthesia team, followed by the perfusion team (30.28%), circulating nurse (16.70%) and surgeon (4.22%).
While the authors could not determine exactly how the devices were being used in some of the cases, they were able to document behaviors such texting, emailing, phone calls, and non-hospital related use. Thus, the device itself resulted in multiple types of distractions distributed across the different phases surgery.
The authors also point out that their data do not support the commonly used argument that PCD use is restricted to non-critical phases of surgery. Their data showed team members were engaged with their PCD’s for approximately a minute and a half regardless of the stage of the operation. Additionally, the greatest number of PCD-use events occurred during the most critical phase of surgery, bypass.
One example provided was that the surgeon was opening patient chest when his personal cell phone started ringing. He stopped opening so that the circulating nurse could get his cell phone out of his pocket and hold up the phone to his ear so he could answer. In our August 20, 2019 Patient Safety Tip of the Week “Yet Another (Not So) Unusual RSI” we described a case that resulted in a retained surgical item (RSI). In that case, one of the likely contributing factors was that the surgeon’s phone rang several times during the third count, before being answered by the anesthesiologist.
Cohen et al. discuss several factors that may explain such behavior in the operating room. These include comfort with the procedure and equipment, complacency, boredom in what are typically hours-long procedures, and feeling the societal pressure to answer texts, calls, and emails as soon as possible.
A 2016 APSF (Anesthesia Patient Safety Foundation) conference “Distractions in the Anesthesia Work Environment: Impact on Patient Safety” (van Pelt 2017) noted several issues related to personal electronic devices (PED’s) in the OR:
In addition to our example above of a surgeon’s phone ringing several times during a surgical count as one of several factors likely contributing to a retained surgical item, our Patient Safety Tips of the Week May 21, 2013 “Perioperative Distractions”, March 17, 2015 “Distractions in the OR”, and July 21, 2015 “Avoiding Distractions in the OR” had detailed discussion about use of cell phones and other wireless devices in and around the OR with multiple examples of distractions related to such in the OR. There are a multitude of issues related to cell phones in the OR including not only interruptions and distractions but also infection control issues, security and confidentiality issues, and detrimental effects on communication in the OR. We have yet to see a cogent argument as to why cellphones are actually needed in the OR. Our own recommendation is for all the OR team to leave their cellphones at the main OR desk where someone can triage incoming phone calls and messages.
Our January 28, 2020 Patient Safety Tip of the Week “Dang Those Cell Phones!” noted an AORN (Association of periOperative Registered Nurses) proposal having several recommendations to reduce distractions and interruptions in the OR (AORN 2019). Some focused on reducing overall sources of noise pollution in the OR. But others focused specifically on cell phones. One recommendation is to “Emphasize the importance of limiting non-essential conversations, muting cell phones or limiting their use, and limiting the number of people in the OR.” Another recommendation was to reiterate safe cell phone use, recognizing that some facilities allow surgical team members to carry their personal cell phone with them, Regular reminders about safe cell phone use can be helpful, such as “Personal devices may add to the overall noise pollution in the OR, which can distract personnel from clear communication and safe patient care.” It goes on to emphasize minimization of distractions during critical phases of the procedure, such as the time out, anesthesia induction and emergence, surgical counts, and specimen management. Especially during those critical times, “personal devices should be left outside the OR, turned off, placed on vibrate or silent mode, and handled only when needed.”
A number of questions about cell phones in the OR were addressed in a another AORN Journal article (Ogg 2019). The AORN "Guideline for a safe environment of care" recommends that personal electronic devices should be limited to use directly required for job performance. It states that health care organizations should have policies and procedures in place that specify when a cell phone may be brought into the OR. Furthermore, it states that perioperative personnel also should consider interventions to mitigate the known risks associated with bringing personal electronic devices into the OR.
They note the risks involved with bringing a personal electronic device into the OR include:
They cite statistics on microbial contamination of cell phones and note interventions that may reduce the risk of a surgical site infection (SSI) originating from contaminated personal electronic devices include cleaning the device regularly, handling the device sparingly, and performing hand hygiene after each use.
Overall, they recommend that, whenever possible, personal devices should be:
And the other issue related to cell phones is the issue of texting. Orders should never be texted (see our multiple columns on the subject below). But even for messages used for communication other than orders, care must be taken so that commonly used text abbreviations and shortcuts are not mistaken by these receiving the texts.
Every facility and organization needs to have a PED policy. A report from the ECRI Institute (Rose 2019) had some very good suggestions for facilities to develop policies for use of personal electronic devices. Such policies should balance the needs of staff members, residents, visitors, and the institution as a whole while clearly defining when, where, and for what purposes PED’s may be used. The policy should also include a clear definition of data ownership—that is, which data are considered owned by the facility and which are considered owned by the PED user—and clearly identify what constitutes sensitive information. It also discusses 3 approaches to allowing PED’s in the facility: (1) facility-provided devices, (2) “Bring your own device” (BYOD), and (3) a hybrid approach. The facility/organization should have a committee that decides where PED’s may be used. It may decide to ban PED’s from certain areas or to restrict them to certain areas, such as common areas or staff lounges. It also has practical recommendations on what information may be accessed or stored on PED’s, how PED’s will be managed, what to do if a PED is lost or stolen, and how restrictions on PED use or misuse will be enforced.
Prior Patient Safety Tips of the Week dealing with cell phones:
· January 28, 2020 “Dang Those Cell Phones!”
See our other Patient Safety Tip of the Week columns dealing with texting:
· January 28, 2020 “Dang Those Cell Phones!”
Prior Patient Safety Tips of the Week dealing with interruptions and distractions:
· January 28, 2020 “Dang Those Cell Phones!”
· September 2020 “AORN on Distractions and Interruptions”
Cohen TN, Jain M, Gewertz BL. Personal Communication Devices Among Surgeons—Exploring the Empowerment/Enslavement Paradox. JAMA Surg 2020; Published online December 23, 2020
Cohen TN, Shappell SA, Reeves ST, Boquet AJ. Distracted doctoring: the role of personal electronic devices in the operating room. Perioper Care Oper Room Manag 2018; 10: 10-13
van Pelt M, Weinger MB. Distractions in the anesthesia work environment: impact on patient safety? Report of a meeting sponsored by the Anesthesia Patient Safety Foundation. Anesth Analg. 2017; 125(1): 347-350
AORN (Association of periOperative Registered Nurses). Can You Hear Me? 3 Reminders to Reduce OR Distractions. Periop Today 2019; December 11, 2019
Ogg MJ, Anderson MA. Clinical Issues—August 2019. AORN Journal 2019; 110(2): 199-202 First published: 29 July 2019
Rose VL Foundations of a Personal Electronic Device Policy. Ann Longterm Care 2019; 27(6): e5-e7
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