Distraction-Free Induction Zone: A Quality Improvement Initiative at a Large Academic Children’s Hospital to Improve the Quality and Safety of Anesthetic Care for Our Patients

Abstract

BACKGROUND: 

Noise in the operating room may cause distractions during critical periods and impair reliable communication between staff. Even momentary inefficiency while administering anesthesia can lead to errors and serious consequences for the patient. Distractions to an anesthesia provider during critical periods such as induction and emergence are a patient safety issue. Because of concerns regarding unacceptable noise levels and distractions during induction of general anesthesia, our institution developed a quality improvement initiative, the “Distraction-Free Induction Zone.” The specific aim of this project was to decrease the percentage of cases with a distraction, described as music, unnecessary conversations, or loud noises, occurring during induction of general anesthesia in pediatric otolaryngology operating rooms from 61% to 15%.

METHODS: 

To complete this quality improvement initiative, a multidisciplinary team used improvement science methods, including The Model for Improvement with interventions tested via Plan-Do-Study-Act cycles. We used tools such as the Key Driver Diagram, Pareto Charts, Process Flow Chart, and Plan-Do-Study-Act worksheets. Data were manually collected and entered weekly in an Excel spreadsheet. Statistical process control methods, including a run chart and a P-control chart, were used for data analysis. Our measure was a composite measure in which observation of 1 of the 3 distractions during induction of general anesthesia categorized the case as a case with a distraction.

RESULTS: 

We tested and implemented several interventions via Plan-Do-Study-Act cycles in which 3 main interventions collectively were associated with an observed decrease in distractions during induction of general anesthesia. These included educating the perioperative staff present in the operating room to help them understand that distractions to anesthesia providers represent a patient safety issue, the operating room circulating nurse taking responsibility to pause any music on arrival to the operating room, and the anesthesiologist reminding the staff in the operating room of induction time and/or asking for quiet during induction if a distraction occurs. The percentage of cases with a distraction during induction of general anesthesia in our pediatric otolaryngology operating rooms decreased from 61% to 15% by April 15, 2017 and to 10% by June 5, 2017.

CONCLUSIONS: 

Using improvement science methods, we observed a decrease in distractions during induction of general anesthesia, improved a process, and encouraged change in culture at a large academic children’s hospital to enhance the quality and safety of the anesthetic care we provide our patients.

KEY POINTS

• Question: Can improvement science methods be used to help decrease the percentage of cases in which an auditory distraction occurs during induction of general anesthesia?
• Findings: By using improvement science methods in a quality improvement initiative, we observed a decrease in the percentage of cases in which an auditory distraction occurs during induction of general anesthesia in our pediatric otolaryngology operating rooms from 61% to 10%.
• Meaning: We were able to complete a quality improvement initiative, using improvement science methods to influence change in culture, improve a process, and help decrease distractions during induction of general anesthesia in our pediatric operating rooms to improve the quality and safety of the anesthetic care we provide our patients.

It is known among anesthesiologists that induction of general anesthesia (GA) is a critical period. Literature indicates that operating room (OR) noise can cause distractions during critical periods,^1,2 may impair reliable communication between staff,^1,3 adversely affects anesthesia resident short-term memory and mental efficiency² and their ability to detect changes in the pitch of the pulse oximeter,⁴ detrimentally affects complex tasks that require high levels of information or perception processing,^2,5 can have physiological effects,^3,6 and can cause phenomenon of masking.^3,7 Even momentary inefficiency while administering anesthesia can lead to serious consequences for the patient.^1,2 The majority of anesthesia accidents begin with small errors that cascade into serious events.⁴ Inattention and lack of monitor vigilance are 2 of the most commonly cited factors; efforts to decrease distractors and background noise should be considered during induction when anesthesiologists must attend to several tasks and are susceptible to error.⁴ The American Society of Anesthesiologists Committee on Quality Management and Departmental Administration issued a “Statement on Distractions” including that anesthesiologists have the responsibility to minimize distractions that decrease appropriate attention to the patient.⁸

Because of concerns regarding unacceptable noise levels and distractions during induction of GA, our institution (Monroe Carell Jr. Children’s Hospital at Vanderbilt) developed a quality improvement (QI) initiative titled “Distraction-Free Induction Zone.” Patient requests for a quiet OR and survey data from our anesthesia providers indicated the severity of the problem. The purpose of this report is to describe how we completed a QI initiative using improvement science methods, including The Model for Improvement, and tested interventions via Plan-Do-Study-Act (PDSA) cycles⁹ to help decrease distractions during induction of GA to improve safety and quality of anesthesia care (our global aim). Our SMART (specific, measurable, actionable, reliable, time bound) aim was to decrease the percentage of cases with a distraction (defined as music playing, unnecessary conversations unrelated to the patient, or loud noises) occurring during induction of GA in the pediatric otolaryngology (ears, nose, throat/otolaryngology [ENT]) ORs from 61% to 15% by April 15, 2017.

METHODS

The Institutional Review Board determined this QI project does not meet “criteria for research,” Institutional Review Board approval was not required, and requirement for written informed consent was waived. This manuscript adheres to the applicable Standards for Quality Improvement Reporting Excellence 2.0 guidelines.¹⁰ We used improvement science methods, including The Model for Improvement⁹ and tools from Cincinnati Children’s Hospital Medical Center Intermediate Improvement Science Series (CCHMC I2S2)¹¹ to complete this QI initiative. Course materials from the I2S2 are used with written permission from The James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center.

This QI initiative consisted of a survey phase and a data gathering phase. A survey was completed by anesthesia providers to measure the perception of the problem of distractions in the OR during induction of GA at Monroe Carell Jr. Children’s Hospital at Vanderbilt (Children’s Hospital). For the remainder of this manuscript, “induction” implies induction of GA. In the data gathering phase, data were gathered regarding the incidence and nature of distractions on a continuous basis and evaluated for trend. A multidisciplinary team was created, with representation from each group working in the OR. The team was led by a staff anesthesiologist and included 2 certified registered nurse anesthetists (CRNAs), an otolaryngology surgeon, an OR circulating nurse, and an OR surgical technologist (ST). The team was coached by a QI instructor from the CCHMC I2S2.

Survey Phase

In the survey phase, 53 of 77 of our anesthesia providers, including CRNAs, anesthesiologists, student registered nurse anesthetists (SRNAs), and anesthesiology residents/fellows, completed a survey via Research Electronic Data Capture (REDCap)¹² using a method similar to that of Hawksworth et al.¹³ The study data were collected and managed with REDCap electronic data capture tools hosted at Vanderbilt University Medical Center.¹² The purpose of the survey was to measure the perception and relevance of auditory distractions on anesthesia providers during induction at Children’s Hospital. Parent/patient requests for a quiet OR at a Family Advisory Council meeting supported the relevance of the survey.

Figure 1.: Survey results of responses from Monroe Carell Jr. Children’s Hospital at Vanderbilt anesthesia providers, including certified registered nurse anesthetists, student registered nurse anesthetists, anesthesiology residents, anesthesiology fellows, and pediatric anesthesiology attending physicians, regarding their perceptions of auditory distractions occurring during induction of general anesthesia in the Children’s Hospital ORs. Fifty-three of 77 providers responded (68.8% response rate). The survey was conducted, and the study data were collected and managed using the REDCap electronic data capture tools hosted at Vanderbilt University Medical Center.¹² A–C, The results of responses to questions as asked on the survey are shown. ENT indicates ears, nose, throat/otolaryngology; OR, operating room; REDCap, Research Electronic Data Capture.

Results of this survey are provided in Figure 1. Over 86% of respondents noticed unnecessary conversations, music, or loud noises ≥50% of the time during induction in the pediatric ORs and specifically in the pediatric ENT ORs at Children’s Hospital (Figure 1A). More than 66% felt they were distracted ≥50% of the time by one of these sounds during induction (Figure 1B). When one of these distractions occurs during induction, 49.1% felt it reduces their vigilance while providing care, 58.5% felt it distracts them from noticing alarms, 52.8% felt it distracts their attention from patient care during an emergency, and 79.2% felt it impairs communication with other staff (Figure 1C).

Data Gathering Phase

In the data gathering phase, we defined our measures using an operational definition worksheet¹¹ and collected baseline data via a data collection form (Figure 2). We defined our measure of a distraction as music playing, unnecessary conversations unrelated to the patient, or loud noises. We believed that these things covered the majority of the auditory distractions occurring during induction. At his or her discretion, the anesthesia provider completing the form determined whether noises such as nonanesthesia alarms, phones ringing, or instruments dropping were “loud noises.” The measure was an all-or-none measure. Observation of any 1 of the 3 distractions during induction identified the case as a case with a distraction. The data collection form was placed in the ENT ORs near the anesthesia cart. It included checkboxes to document presence or absence of music, unnecessary conversations unrelated to the patient, or loud noises during induction (until airway secured or “anesthesia ready”) for the first 2 cases of the day. The hands-on anesthesia provider or anesthesiologist completed this form daily.

Figure 2.: Shown here is the quality improvement project data collection form. This form was placed in the OR for the anesthesia provider to complete each day. # indicates number; OR, operating room; RNs, registered nurses; techs, surgical technologists.

We chose the ENT ORs to start this project because the current QI approach is to test interventions on a small scale, and if successful, implement the interventions and apply to other applicable areas.⁹ The ENT ORs afforded us high-volume cases, ensuring sufficient volume to obtain data weekly. We chose the first 2 cases of the day because of anesthesia provider workload and to foster provider consistency (data gathered before breaks).

Data were manually gathered, recorded in an Excel spreadsheet, and analyzed by use of a run chart weekly. We required ≥10 cases per week to be included in the analysis. Using this restriction, only 4 weeks were excluded (see Results). Baseline data from 9 weeks indicated that a median of 61% (mean, 62%) of pediatric ENT cases had ≥1 of the 3 distractions during induction. With these baseline data, we clarified our SMART aim statement with our starting incidence of distractions.

We created a process flow chart¹¹ to document our process from the time the anesthesia provider and OR staff are preparing the OR through anesthesia ready. The process flow chart identified areas of failure and where interventions could be tested to improve our process. We created a Pareto chart¹¹ of the baseline data, which illustrated out of the 3 distractions, approximately 48.8% were music, 44.6% were unnecessary conversations, and 6.6% were loud noises. This helped us focus our interventions.

We subsequently created our Key Driver Diagram,¹¹ which includes our SMART aim, global aim, key drivers needed to help decrease distractions during induction, and intervention ideas to obtain our key drivers (Figure 3). It became obvious that a major intervention to be tested to obtain the majority of these key drivers would be education/awareness training of OR staff.

Figure 3.: The KDD for the distraction-free induction zone quality improvement project illustrating the specific and global aims, key drivers, and intervention ideas along with the associated LOR for each intervention. (Template used with permission from The James M. Anderson Center for Health Systems Excellence. Cincinnati Children’s Hospital Medical Center.¹¹) # indicates number; ENT, ears, nose, throat/otolaryngology; GA, general anesthesia; KDD, Key Driver Diagram; LOR, level of reliability; OR, operating room; periop, perioperative; RN, registered nurse; SMART, specific, measurable, actionable, reliable, time bound; STs, surgical technologists.

The SMART aim to decrease incidence of distractions from 61% to 15% was an a priori goal. This goal was based on our ideas of planned interventions having a level of reliability (LOR) of 1 or 2.¹⁴ An intervention with LOR 1 can have 1 or 2 failures out of 10 opportunities (80%–90% reliability of the process/intervention to perform its intended function; 10%–20% failures).¹⁴ An intervention with LOR 2 can have <5 failures out of 100 opportunities (95% reliability; 5% failures).¹⁴ Our planned interventions had LOR 1 or 2, suggesting that we could reliably observe a decrease in the incidence of distractions to 5%–20%.¹⁴ We estimated that we would continue to have 10%–20% failures; therefore, the goal selected was the mean of this interval, 15%.

After creating the process flow chart and Key Driver Diagram,¹¹ we tested interventions via PDSA cycles⁹ while continuing to collect and analyze data weekly via run chart and P-control chart analyses to determine whether our interventions were leading to change and improvement. Our tested interventions included the following (each intervention contained multiple PDSA cycles):

Intervention 1: OR Circulating Nurse Takes Responsibility to Pause Any Music in the OR Before Leaving to Get the Patient in Preoperative Area With the Anesthesia Provider and/or on Arrival to OR With the Patient.

This intervention has a LOR 2, a standardization of essential tasks, which could lead to <5 failures out of 100 opportunities.¹⁴ This PDSA cycle began with 1 OR nurse in 1 ENT OR. We subsequently tested the intervention with other circulating nurses with different ENT surgeons on different days. At the end of each tested intervention, we received verbal feedback from the circulating nurse. Nurses replied that this new process was not a hindrance to their workflow and was easy to perform. They agreed to continue this role. The first PDSA cycle of this intervention was on November 8, 2016 and was implemented as a new expected standardized process to all OR circulating nurses in all of our pediatric ORs on January 23, 2017. This was discussed at a perioperative staff meeting and was followed up with an email reminder with nursing leadership support. It was not implemented in all ORs until January 23, 2017 because we needed to provide education/awareness to all OR staff before implementing a tested intervention/change in process.

Intervention 2: Educational Awareness for Perioperative Staff.

PDSA Cycle 1.

Team leader created and presented an educational lecture to the perioperative staff, including CRNAs, SRNAs, OR nurses, and STs, at a perioperative educational staff meeting on December 7, 2016. The goals of this presentation were to provide awareness and understanding that distractions around an anesthesia provider during critical periods represent a patient safety issue, illustrate the significant impact of distractions during induction on our anesthesia providers, identify potential changes in the ORs, and use the information presented to decrease distractions during induction.

This intervention has a LOR 1 (providing awareness and training) that could lead to 1 or 2 failures out of 10 opportunities.¹⁴ This intervention impacted all of our key drivers. After the presentation, a REDCap¹² survey was completed by participants, with results indicating the presentation met the teaching objectives and was an effective way to present the material. However, several staff were unable to attend the meeting, leading to PDSA cycle 2.

PDSA 2.

Team leader edited the presentation into a training module for perioperative staff unable to attend the meeting. The goals of the electronic material were similar to those of the lecture presented at the educational meeting previously noted. It was emailed to the perioperative staff from their respective educational leaders. The staff confirmed their review of the material. We reached the majority of the perioperative staff after emailing the educational presentation. Subsequently, REDCap¹² survey results from staff who reviewed it electronically indicated the electronic educational material met teaching objectives and was an effective way to present the material. We implemented this intervention (January 3, 2017) by including this educational material in the orientation material for all perioperative staff (OR nurses, STs, CRNAs, SRNAs, anesthesiology residents). This electronic orientation material is updated as indicated quarterly to sustain the project.

Intervention 3: Educational Awareness for Pediatric Otolaryngology Surgeons.

The team leader presented a PowerPoint presentation to the pediatric otolaryngology surgeons at an educational conference on January 4, 2017. The goal of this presentation was to cultivate awareness among the pediatric otolaryngology surgeons that distractions during critical periods of anesthesia are a patient safety issue, we have had families request a quiet OR on arrival, and our anesthesia providers recognize that distractions are occurring during induction. We requested their assistance by pausing their music, rounding with residents outside of the OR, not dictating during induction, and being cooperative when asked to pause unnecessary conversations or music during induction. This intervention has a LOR 1 (awareness/training).¹⁴

Intervention 4: Educational Awareness for Pediatric Anesthesiologists.

The team leader presented a PowerPoint presentation to the pediatric anesthesiologists at a Pediatric Anesthesiology Division faculty meeting on January 11, 2017. The goal of this presentation was to remind the pediatric anesthesiologists of the importance of minimizing distractions during induction, inform them of our QI project, and develop awareness that families have requested a quiet OR and our anesthesia providers recognize the severity of the distractions and potential impact on patient safety occurring. We asked them to help change the culture in our institution by minimizing unnecessary conversations and asking for music to be paused during induction. This intervention has a LOR 1 (awareness/training).¹⁴

Intervention 5: Anesthesia Provider in the OR Places a Sign on the OR Front Door Before Induction and Removes It After Anesthesia Ready as a Visual Cue to Those Entering to Be Quiet During Induction.

It was aborted after we received feedback from the CRNAs tested that this task was too difficult to remember to perform and increased their workload while providing patient care.

Intervention 6: The Pediatric Anesthesiologist Attending Provides a Verbal Cue of Induction Time and/or Asks for Quiet During Induction of GA if Distractions Occur.

We received verbal feedback from each attending tested. By obtaining staff buy-in and empowering staff to ask for quiet, this intervention may have increased the culture of safety in the OR. We started with 1 attending and then tested different attendings on different days over several weeks to obtain their feedback on feasibility of this intervention. This intervention was first tested February 6, 2017 and implemented on April 12, 2017 when we asked all pediatric anesthesiologist attendings to continue this role in all pediatric ORs at a Pediatric Anesthesiology Division meeting. An email was sent May 15, 2017 reminding all attendings to continue this role in all ORs. This intervention has a LOR 2 (a real-time identification of failures).¹⁴

In addition to the tested and implemented interventions, we emailed quarterly project updates to perioperative staff and physicians and posted updated data on the ENT OR doors to continue to encourage perioperative staff involvement. We provided project updates at other meetings to raise awareness of the project and encourage continued involvement, including the “All Pediatric Surgeon Meeting” on March 7, 2017 and the perioperative staff meeting on April 26, 2017.

After the QI project was completed in the ENT ORs, we expanded the project and collected the same baseline data in all 14 of our noncardiac pediatric ORs (excluding special procedure ORs off site) using the same data collection form. These data were followed monthly for 4 months and then quarterly for a year to measure spread and sustainability of the project.

Statistical Analysis

Statistical process control methods⁹ were used to analyze data. A run chart and P-control chart (templates provided by CCHMC I2S2¹¹) allowed for illustration and analysis of variation in the time-series data and were used to assess the results associated with the tested interventions as a whole over time. The 4 rules for special causes using run charts were used to determine if tested interventions led to improvement and a change in the system.^9,11 Project milestones and special causes were annotated on the run chart. When a special cause had data that followed a special cause rule, there was evidence of a significant change in the system and a new median baseline was formed.

RESULTS

The percentage of cases with a distraction during induction of GA in our pediatric ENT ORs decreased from 61% to 15% by April 15, 2017 and to 10% by June 5, 2017 (Figure 4).

Figure 4.: Run chart for the percentage of Peds ENT operating room cases with a distraction (including music playing, nonessential conversation, or loud noises) occurring during induction of GA. Data were entered weekly, with n that data were collected for each week in the Peds ENT operating rooms. The dates of interventions tested/initiated and subsequently implemented are annotated on the chart. Each intervention is described in detail in the text. The green dotted line was the goal. The red solid line is the median percentage of Peds ENT cases in which ≥1 of the 3 distractions occurred during induction of GA. The green arrow indicates the direction of the goal from the baseline median. Special causes with significant change in the system are illustrated by a shift of the median below the center line. (Run chart template used with permission from The James M. Anderson Center for Health Systems Excellence. Cincinnati Children’s Hospital Medical Center.¹¹) ENT indicates ears, nose, throat/otolaryngology; Mtg, meeting; n, number of cases; Peds, pediatric; STs, surgical technologists.

Using the run chart¹¹ for data analysis (Figure 4), the first change in our system was indicated by a shift in our median from 61% to 39%, as seen after 8 consecutive points below the baseline median, which occurred week ending January 13, 2017 after start of interventions/special causes. The interventions that influenced this change included initiation of intervention 1 and interventions 2–4 listed above.

The second change in our system and shift in our median from 39% to 15% occurred week ending March 24, 2017 after ≥8 points below the median occurred again with special cause. The interventions associated with this change (in combination with the ones associated with the first shift) were the implementation of intervention 1 on January 23, 2017 and initiation of intervention 6. During this shift, we held a meeting with the pediatric surgeons on March 7, 2017 to provide awareness of our QI project and inform them of plan for spread to all of the ORs. At this point, we had reached our goal and continued to collect data.

The third and last change in our system was indicated by a shift in our median from 15% to 10% on week ending June 2, 2017 with special cause (implementation of intervention 6 on April 12, 2017 in combination with the previous interventions associated with the first and second shifts).

A P-control chart was also used to analyze the data (Figure 5). It showed the same information as our run chart and illustrates the control limits. There was no special cause identified to explain the data point from the 1 week that was outside of the control limits (week ending April 7, 2017).

Figure 5.: Control chart (P-Chart) illustrating the percentage of pediatric ENT operating room cases with a distraction (including music playing, nonessential conversation, or loud noises) occurring during induction of GA. Data were entered weekly, with n that data were collected for each week in the pediatric ENT operating rooms. The green dotted line was the goal. The red solid line is the mean percentage of pediatric ENT cases in which ≥1 of the 3 distractions occurred during induction of GA. The green arrow indicates the direction of the goal from the baseline mean. The upper and lower control limits are noted by the red dotted lines. (Control chart [P-Chart] template used with permission from The James M. Anderson Center for Health Systems Excellence. Cincinnati Children’s Hospital Medical Center.¹¹) ENT indicates ears, nose, throat/otolaryngology; GA, general anesthesia; n, number of cases.

Figure 6.: Run chart for the percentage of the main Monroe Carell Jr. Children’s Hospital at Vanderbilt pediatric operating room cases from 14 operating rooms (excluding cardiac and procedural suites) with the occurrence of ≥1 distraction (including music playing, nonessential conversation, or loud noises) during induction of general anesthesia since May 2017. These data include the pediatric otolaryngology operating rooms. The green dotted line was the goal. The red solid line is the median percentage of pediatric operating room cases in which ≥1 of the 3 distractions occurred during induction of general anesthesia. Data were collected monthly for 4 mo, then quarterly, to illustrate spread and sustainability of the quality improvement project. (Run chart template used with permission from The James M. Anderson Center for Health Systems Excellence at Cincinnati Children’s Hospital Medical Center.¹¹) n indicates number of cases.

Subsequently, we expanded the project and collected the same baseline data in all noncardiac pediatric ORs (excluding special procedure ORs off site) using the same data collection form. We found that <15% of cases with a distraction occurred in all 14 ORs combined (Figure 6). This was followed monthly for 4 months and then quarterly for a year, illustrating an association of the project with a low rate of cases with a distraction during induction of <15% still observed at 12 months.

Missing Data

Only 4 weeks were excluded in our data analysis because of small case volume (<10 cases) during the project data collection period, from week ending August 19, 2016 to June 30, 2017. Those excluded were weeks ending November 25, 2016, December 23, 2016, January 27, 2017, and June 23, 2017. The weeks ending November 25, 2016 and December 23, 2016 represented low OR volume due to holidays. During the weeks ending January 27, 2017 and June 23, 2017, the team leader was unavailable. Our team leader was actively involved on a daily basis to ensure completion of the data collection forms.

DISCUSSION

Using improvement science methods, including The Model for Improvement⁹ and QI tools learned from CCHMC I2S2,¹¹ we launched this QI initiative, reached our goal, spread it to other pediatric ORs, and observed sustained difference from baseline. We observed a decrease in distractions during induction in our pediatric ENT ORs (and other pediatric ORs) in a large academic children’s hospital. A decreased rate of cases with a distraction during induction of <15% in all 14 of our pediatric ORs combined was still observed 12 months after completion of the initial project.

This QI project follows the established QI approach⁹ in which the point of the project is to improve a process based on a set of achievable interventions. This study is not designed to test the effect of each individual intervention on the outcome but to adopt a sequential set of changes and monitor the results across time.

We tested and implemented interventions via PDSA cycles in which 3 main interventions as a collection were associated with decreased distractions during induction. These 3 interventions included education/awareness of all perioperative staff and physicians that distractions to anesthesia providers represent a patient safety issue, the OR nurse taking responsibility to pause any music on arrival to the OR, and the anesthesiologist reminding staff in OR of induction time and/or asking for quiet if distractions occur.

The relevance of this project is that decreasing distractions on anesthesia providers during induction (and other critical parts of anesthesia) may lead to important secondary improvements such as decreased errors, improved vigilance, improved communication in the OR, better quality and safer patient care, higher collegiality in the OR, and improved provider well-being/stress that would be a benefit at hospitals with both pediatric and adult populations. This project could also be expanded to the entire procedure when using sedation with an awake patient and other phases of care. These secondary improvements were not monitored in this study. We recognize the need for further studies to address these highly relevant outcomes.

Although several studies have advocated for the use of audiovisual or music distractions for pediatric patients to decrease preoperative and induction levels of anxiety,^15–17 distractions for the patient are materially different from distractions for the provider. The music used for distraction of children is typically of a different character and stopped immediately after the child becomes unconscious. It is not the same distraction as a computer playing a different kind of music, usually much louder, continuously, and intended for the purpose of entertaining the operating team.

The associated increased costs or opportunity costs of this project were minimal. Indirect costs associated with this project include personal time of team members for planning and implementation of the project and collecting and analyzing data.

Over 100 hours were consumed in this effort. Efforts that focus on better professionalism and attention to detail make sense to undertake given the existing literature on the relationship between distractions and potential errors, considering the ongoing need to maintain quality during periods of production pressure and resource limitation.

Few personnel resisted the idea of our project because of personal reasons. Reasoning individually with people and adopting a nonpunitive approach encouraged staff buy-in.

Limitations

This study is subject to the inherent limitations of all QI initiatives, most importantly the possibility of confounding by unknown independent variables, Hawthorne effect, and/or the natural improvement of processes over time. Because there was no concurrent control group, it is impossible to fully rule out the possibility of such biases. However, while such biases may be present to some degree, the observation of a sustained period of improved outcome at the end of the study argues that the benefits of the interventions were probably stronger than these biases. This project was performed at an academic children’s hospital, which frequently includes a learner as the hands-on anesthesia provider (ie, residents, fellows, SRNAs); data and outcomes may not necessarily be generalizable to other settings.

We also collected data from only the first 2 cases of the day. It seemed the findings could be generalizable throughout the rest of the day, but potentially there could be differences in frequency and nature of auditory distractions as the day goes on. Our method does not account for potential impact of late-day fatigue, shift changes, or late night issues. Data samples from an entire day of cases or randomly selected cases by an outside observer could help eliminate potential sample bias. Data were collected without an independent assistant solely functioning as an observer. The case forms were mostly completed on the same day, but we did not track the time to completion, which might affect recall. Bias in data collection may hence have been introduced owing to the hands-on anesthesia provider completing the data collection form. For example, 1 provider may not have considered a phone ringing or instrument counting as a “loud noise” distraction, whereas another may have. Independent observers, use of remote monitoring, or objective visual indicators of noise level could all contribute to improving the validity of the study. The resources currently do not exist for this type of data gathering but may be available in the future.

This being a pilot study, we focused on feasible interventions in a limited OR setting. As this project expands, later cases, stronger interventions, and more objective monitoring (such as visual noise indicators) may be included. There is also potential to spread this project to other contexts, such as distractions during emergence, time out process, critical parts of the operation, and to other environments, such as private practice and adult hospitals. We intend to report updates of this QI program as we advance into other areas of patient care.

ACKNOWLEDGMENTS

The authors thank the following Quality Improvement (QI) Project team members for their assistance in designing the project, collecting data, and testing and implementing interventions: Heather Frankenfield, CRNA; Matthew Lucas, RN, BSN; Anne Upton, ST; all from Vanderbilt University Medical Center, Nashville, TN; and Edward Penn Jr, MD, from Greenville ENT Associates at Greenville Health System in Greenville, SC. The authors thank the following people from the James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, for their guidance through QI methods and data interpretation and analysis: Christopher Jordan, MA, Senior Director of Improvement Science Education and Course Director of the Intermediate Improvement Science Series; and Brenda Lee, BSIE, Sr QI Consultant, QI Education and Training. The authors thank Martha Tanner, BA, from the Department of Anesthesiology at Vanderbilt University Medical Center, Nashville, TN, for assistance with manuscript editing/revision and submission.

DISCLOSURES

Name: Christy J. Crockett, MD.

Contribution: This author was the creator and leader of this Quality Improvement Initiative. This author helped create and design the project, including the measures; design and execute the interventions; collect, enter, review, and analyze the data; and draft the initial manuscript and subsequent revisions.

Name: Brian S. Donahue, MD, PhD.

Contribution: This author helped interpret the data for the work and critically review and edit the initial draft of the manuscript and subsequent revisions.

Name: Deana C. Vandivier, CRNA.

Contribution: This author helped design the project, collect the data, test and implement the interventions, and revise the manuscript.

This manuscript was handled by: James A. DiNardo, MD, FAAP.