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Patient Safety Tip
of the Week
February 23, 2021
Cellphones and the OR
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:
Benefits
- Ease of collaboration between physicians
of different specialties and training levels
- Ability to obtain expert advice from
off-site senior colleagues/ specialists
- Ability to transfer and remotely
evaluate clinical images
- Allow medically underserved areas to
obtain specialist guidance
- Allow synchronous communication
- Offer applications that can be used to
guide medical care (eg. medication dosing,
clinical guidelines, and surgical equipment/technique guides)
- Can be used to access social
media platforms, which have been used to disseminate and discuss medical information
Harms
- Introduce unwanted disruptions and distractions
- Associated with cognitive disengagement
from other tasks
- Associated with reclusive behaviors (eg. being more invasive, impolite, and disruptive)
- Create the expectation of increased
availability and immediate responsivity
- Make it difficult to maintain the
boundaries between work and personal life
- Introduce negative work-related
consequences (eg. increased work hours,
absenteeism, elevated stress levels, and lower productivity)
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.
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.
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:
- Infection
risk that PED’s pose when handled in proximity to sterile areas
- HIPAA-related
confidentiality concerns when accessing and sharing sensitive information
- PED
contribution to noise and distraction, particularly when used for
nonemergent and nonpatient care activities
- Medicolegal
issues
- Defense-favorable
verdicts were unlikely when PED use was introduced as evidence for lack
of vigilance, irrespective of purpose
- PED
usage data were discoverable
- Consequences
of PED-related plaintiff verdicts went beyond compensatory damages, including
licensing sanctions, National Practitioner Data Bank reporting, and
unfavorable media coverage
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:
- infection
- noise pollution
- distraction
- increased potential for
violations of patient privacy related to protected health information
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:
- left outside the OR
- turned off
- placed on vibrate or silent mode to
limit noise and distractions
- handled only when needed
- cleaned according to the manufacturer's
instructions for use
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:
- November 27, 2012 “Dealing with Distractions”
- April 16, 2013 “Distracted While Texting”
- May 21, 2013 “Perioperative Distractions”
- March 17, 2015 “Distractions in the OR”
- July 21, 2015 “Avoiding Distractions in the OR”
- February 9, 2016 “It was just a matter of
time…”
- August
20, 2019 “Yet
Another (Not So) Unusual RSI”
·
January 28, 2020 “Dang Those Cell Phones!”
See
our other Patient Safety Tip of the Week columns dealing with texting:
- February 9, 2016 “It
was just a matter of time…”
- May 24, 2016 “Texting
Orders – Is It Really Safe?”
- January 2017 “Joint
Commission Thinks Twice About Texting Orders”
- June 27, 2017 “Texting
– We Told You So!”
- January 30, 2018 “Texting
Errors Revealed”
·
January 28, 2020 “Dang Those Cell Phones!”
Prior
Patient Safety Tips of the Week dealing with interruptions and distractions:
- August
25, 2009 “Interruptions,
Distractions, Inattention…Oops!”
- November
3, 2009 “Medication
Safety: Frontline to the Rescue Again!”
- December
15, 2009 “The
Weekend Effect”
- May
4, 2010 “More
on the Impact of Interruptions”
- October 12, 2010 “Slowing Down in the OR”
- March
8, 2011 “Yes,
Physicians Get Interrupted Too!”
- July 31, 2012 “Surgical Case Duration and
Miscommunications”
- August 28, 2012 “New Care Model Copes with Interruptions
Better”
- November 27, 2012 “Dealing with Distractions”
- April 16, 2013 “Distracted While Texting”
- May 21, 2013 “Perioperative Distractions”
- July 1, 2014 “Interruptions and Radiologists”
- November 2014 “More Radiologist Interruptions”
- March 17, 2015 “Distractions in the OR”
- July 21, 2015 “Avoiding Distractions in the OR”
- August 30, 2016 “Can
You Really Limit Interruptions?”
- November 8, 2016 “Managing
Distractions and Interruptions”
- March 7, 2017 “Nested
Interruptions”
- April 11, 2017 “Interruptions:
The Ones We Forget About”
- February 13, 2018 “Interruptions
in the ED”
- May 2018 “Cost
of Interrupting a Radiologist”
- December 2019 “Hospitalist
Shifts Matter, Too”
·
January 28, 2020 “Dang Those Cell Phones!”
·
September 2020 “AORN on Distractions and
Interruptions”
References:
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
https://www.sciencedirect.com/science/article/abs/pii/S2405603017300365?via%3Dihub
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
https://aornjournal.onlinelibrary.wiley.com/doi/full/10.1002/aorn.12767
Rose VL Foundations of a Personal Electronic
Device Policy. Ann Longterm Care 2019; 27(6): e5-e7
https://www.managedhealthcareconnect.com/articles/foundations-personal-electronic-device-policy
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