Rothman, Brian S. MD; Ehrenfeld, Jesse M. MD, MPH
Emergencies requiring the immediate presence of a supervising anesthesiologist are relatively uncommon during planned elective surgery.1 However, situations do arise in which an immediate intervention is required. Warner et al.2 in this month’s issue highlight that these urgent events, defined as those generating a STAT page to a supervising anesthesiologist, are driven by patient issues occurring primarily outside the operating room (OR) (i.e., in the preoperative holding area or postanesthesia care unit). This finding suggests that to optimize care, anesthesiologists must (1) consider these pre- and postprocedural areas when making staffing decisions and (2) develop mechanisms to maintain situational awareness outside the OR.2
Situational awareness is the perception of environmental elements, comprehension of their meaning, and the prediction of a future state based on those elements and their meaning.3 When anesthesia providers lack awareness and understanding of what is happening around them, communication may suffer. Traditionally, situational awareness among anesthesia care providers has focused on intraoperative care for both the in-room provider and the medically directing or supervising attending anesthesiologist participating in care team model care. Loss of situational awareness can lead to communication lapses, increased latency, and even failures, which are a significant source of OR errors.3,4
Given the findings demonstrated by Warner et al.2, it is clear that situational awareness is required throughout the entire perioperative period because emergency events occur with a sufficient frequency during preoperative and postoperative care. Communication with anesthesia providers during these periods of care to facilitate a rapid response, evaluation, and treatment could mitigate or avoid significant, evolving events and possibly improve outcomes. Some may argue intraoperative safety improvements have only now allowed us to shine a light on emergency situations in our other perioperative areas. Conversely, it may be that our focus should be on a patient’s entire perioperative experience. With at least 45% of pages originating outside the OR,5 anesthesia providers facilitating rapid responses, evaluation preoperatively, intraoperatively, and postoperatively to support continuous care would best support a culture of safety and our role as true perioperative care providers. Either way, enhanced participation in the care of our patients is clearly aligned with the promulgation of the perioperative surgical home model of care.6
After a procedure has concluded and the patient has left the OR, events that are treatable, and often preventable, continue to occur. Complications including hemodynamic changes, pain, and airway obstruction, to name a few, require vigilance and proactive management. Some have explored how we might use technology to facilitate better communication throughout the perioperative period. Here the goal would be to provide information faster with fewer false positives (alarm fatigue and unnecessary work interruptions) and fewer false negatives (communication failures and lost opportunities to treat).3 In addition, more rapid alert communication than what currently exists in the OR is required. Messaging latency to attending anesthesiologists often results in episode resolution before they can arrive to contribute.7 Delivering data to mobile providers with the advanced development concepts of transparency, augmented vigilance, integration, decision support, and automated process control and automated process monitoring through mobile computing tools or ubiquitous signaling with an “at-a-glance” design leveraging focus heuristics8 are 2 possible solutions.
The present manuscript in this issue of the journal extends our knowledge about perioperative emergencies and emergency pages. As an alternative to traditional paging approaches, the Mayo Clinic uses an intraoperative computer-based anesthesiology paging system to provide visual alerts throughout the perioperative suites to facilitate communication with attending anesthesiologists in an emergency.2 Intraoperative incidents in children were previously found to be preventable 82% of the time.9 Weingarten et al.9 identified that emergency pages were most common in infants, followed by children under the age of 2 years, and the nature of the emergency was most commonly (60%) related to respiratory and airway events. In contrast, emergency pages for adult patients were most common during anesthetic maintenance for hemodynamic reasons. The commonality of these pages was that the attending anesthesiologist was least likely to be at the bedside, requiring them to be called upon to travel to the patient to deliver personal, focused care.9
While situational awareness in the OR has not been shown to improve outcomes, analyses assessing and improving situational awareness of care teams are complex.3 A single center, stepped-wedge study has shown decreased length of stay, reduced adjusted odds of mortality, and improved best practice adherence after a Tele-ICU implementation delivering situational awareness to intensive care unit providers across medical, surgical, and cardiovascular units.
Timely and reliable communication can be essential for patient safety.10 However, alert latency for resolved episodic events7 can lead to unnecessary workflow interruptions, which can increase miscommunication11 and compromise safety.12 Information transfer and communication (ITC) has been an area of study in the surgical literature. Communication failures are recognized as the main cause for surgical errors and adverse events with an incident rate reported as high as 75% with ITC failures as a root cause. Interestingly, some of the highest surgical failure rates have been demonstrated to occur during the perioperative period with 61.7% occurring preprocedurally and 52.4% during postoperative handovers.13 The overall observed risk of communication delays causing errors or injury is estimated at 15%.10
Information communication technology (ITC) has been used in various forms to try to improve communication and improve safety. While these tools can reduce and even prevent errors, a persistent question has been whether it would in and of itself improve performance.3
Familiar to most are radio pagers that are still widely used across medicine.14,4,10 While inexpensive and relatively reliable to deliver short messages, delivery lag time may be minutes or may be completely lost14 at an unacceptable rate when external networks are relied upon.15 Furthermore, communication is only one way, and there is no receipt confirmation, so the sender cannot know when and if the message was received.14 This prevents the recipient from easily acknowledging receipt, resulting in a workflow interruption to find a phone and call, assuming the entered number is correct.4,14 Pager delays have been associated with a 19% risk of causing medical error or injury.10 Conversely, pagers have been used on general care floors to notify providers of low patient oxygen saturation levels, resulting in faster identification of patient declines and enabling faster decision making.16
An alternative communication technology is voice over Internet protocol (VOIP). Small receivers are used permitting 2-way and one-to-many communication using voice recognition to activate the application through the Internet. Message receipt, communication lag times, and message loss are immediately apparent to the users. VOIP’s limitation is that it is dependent on electrical power and Internet connectivity.14 Network reliability, wireless dead spots, and device recognition of the user’s voice, defeating its hands-free advantage, may be limitations of the technology, but VOIP has been shown to allow communication between providers 4 times faster than conventional pagers.17
Another method of voice communication is cellular communication. Wireless phone use in clinical areas was discouraged when the technology was young. The Emergency Care Research Institute (ECRI) warned against their use in 1993 due to the phones’ analog signals, high wattage output, and unshielded medical devices that were still in use.10,14 By 2001, mobile phones were digital devices, with lower power output, and medical devices were shielded, so ECRI relaxed their restrictions. Mobile phones can now be used in proximity of medical devices, but it is still recommended that they should be kept at least 3 feet away.4,10,14 The incidence of device interference was 2.9% against communication delays and medical errors (14.9%) in 1 study, and ECRI now recommends the use of mobile phones for rapid clinical communication.4,10 Despite this recommendation, bottlenecks do occur in the cellular systems during regional and national events that can lead to disruption of mobile device voice communications and unacceptable Short Message Services (SMS) text message latencies for high criticality areas.15
The computer-based anesthesiology paging system described above recognizes the mobility of OR providers through ubiquitous message delivery, transparently signaling that attention to an evolving condition is required.9 However, the evolution of mobile phones to mobile computing devices that can make phone calls presents health care with an opportunity to fulfill some of the goals set forth by the Anesthesia Patient Safety Foundation. Specifically, mobile computing could help mobile providers with easy data retrieval and improve communication to improve patient safety. The application of health information technology to decrease medical errors and medical costs is a high priority.14
While phones have been seen as work interrupters,3,18 smartphones may improve the speed and quality of communication, improve physician response times, and be more effective overall.18–20
While data retrieval and voice communication are excellent features, providers must actively use them. Mobile computing can also allow passive provider zone tracking. Benefits could include saved steps and a decrease in cognitive workload increasing situational awareness.21
Beyond voice and SMS communication, notification delivery services such as Apple Inc.’s push notification service (Cupertino, CA) are more reliable with shorter latencies. In addition, mobile computing has allowed for integrated data, including notifications, to be presented in mobile applications and Web applications to deliver situational awareness. Applications such as VigiVUTM (Vanderbilt University Medical Center, Nashville, TN) and Airstrip from Airstrip Technologies (San Antonio, TX) and others deliver situational awareness to providers who are away from the bedside at other care locations. Features including communication, real-time video, waveforms, vital signs, and system notifications of patient data from the electronic health record facilitate providers’ awareness of patient states and changing states and the opportunity to proactively prioritize their care of multiple patients in multiple care areas.22
Obstacles to implementing the next generation communication technology include infrastructure costs that can be significant.16 In addition, current technology can limit system functionality and usefulness. False positives generated from the system can result in alarm fatigue, work interruptions and limit or prevent adequate system adoption.16 Measuring latencies and identifying their root cause (delayed documentation,23 communication infrastructure,23 or both) are yet another obstacle in ensuring timely communication. It is also possible that undesirable downstream effects from more “efficient” communication and mobile computing could be realized, reinforcing the belief that our current health care informatics systems do not meet our expectations.14
In summary, as the practice of anesthesiology evolves, our workflows and communications needs will evolve as well. The article by Warner et al.2 is significant in that it points out a growing need for enhanced engagement and situational awareness by anesthesia providers outside the OR for patients still within the perioperative realm. As our practices change, it is crucial for whatever communication tools we use in the future to minimize workflow interruptions and false alerts.
Name: Brian S. Rothman, MD.
Contribution: This author helped analyze the data and write the manuscript.
Attestation: Brian S. Rothman approved the final manuscript.
Name: Jesse M. Ehrenfeld, MD, MPH.
Contribution: This author helped analyze the data and write the manuscript.
Attestation: Jesse M. Ehrenfeld approved the final manuscript.
This manuscript was handled by: Franklin Dexter, MD, PhD.
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