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Distraction in the OR

Bells and Whistles on Silent Mode

Neves, Sara MD*; Soto, Roy G. MD

International Anesthesiology Clinics: Summer 2019 - Volume 57 - Issue 3 - p 62–67
doi: 10.1097/AIA.0000000000000236
Review Articles

*Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts

Department of Anesthesiology, Beaumont Health, Royal Oak, Michigan

The authors declare that they have nothing to disclose.

Address Correspondence to: Sara Neves, MD, Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215. E-mail:

Distraction can impact patient and public safety. The human brain is increasingly being bombarded with data. To some extent, we crave this input as evidenced by the fast-paced action sequences of modern movies, our insatiable appetite for immediately accessible information, and the technological advancements in health care that provide more data, faster. What is not clear is the brain’s ability to keep up with the processing of these data. Inability to do so can result in distraction and poor performance, which can have serious consequences on the lives of those around us. In health care, our ability to focus on the data relevant to our patients is threatened by many factors, from the seemingly mundane to the glaringly obvious. Although prevalent in all aspects of health care, distraction in the operating room (OR) has more immediate and severe consequences.

Anesthesiologists are responsible for the physiological well-being of the patient during a time of extreme vulnerability. Physiological systems that are maintained in homeostasis automatically in an awake patient now must be managed actively by the anesthesiologist in a highly variable environment. The anesthesia workstation provides many sources of information in many different forms. An anesthesiologist must monitor vital signs, manage fluid and medication administration, physically examine the patient at periodic intervals, anticipate and prepare for upcoming intraoperative events, and communicate with the rest of the surgical team. These functions are frequently performed in cramped, noisy rooms with personality differences, production pressure, and nonmedical distractions added into the mix. In this article, we will discuss how the complex perioperative environment can lead to distraction and potential patient harm, compare the health care field to other industries facing similar problems, and suggest improvements to enhance patient safety.

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The OR as a High-reliability Organization (HRO)

The OR is not the only high-stakes environment where distraction is problematic. Commercial aviation, military aircraft carriers, and nuclear power plants are just a few examples of other HRO. A HRO is any organization where accidents, which would normally be expected because of workload complexity, are avoided through specific safety improvement processes. HROs are characterized by the extreme complexity of their systems and components, with many interlocking parts that are dependent on each other, large numbers of critical players, and a high frequency of rapid decision-making. To avoid accidents and reduce their impact, HROs develop a culture of safety that includes vigilance, flexibility, and situational awareness (SA).

All of these points are relevant and in place in the modern surgical theater. Undergoing surgery in the United States in the 21st century is inherently safe, and anesthetic complications are infrequent. Nevertheless, distraction because of noise, alarm fatigue, and personal electronic devices (PEDs) still impacts SA and patient safety.

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Situational Awareness

Most anesthesiologists have an innate sense of SA, but what it is, and more importantly, how to teach it, remains elusive. SA is defined by 3 core elements: perception, comprehension, and projection. Perception refers to the ability to gather data and recognize a change in the environment. Comprehension is the ability to use the data gathered to recognize what that change means. Projection refers to the ability to use that understanding of the current environment and data to predict what will happen, and therefore be prepared to intervene appropriately.1 A typical OR example would be a perceived increase in heart rate and blood pressure as an incision is made, the understanding that the patient is inadequately sedated, and the projection that the patient may move or develop cardiovascular complications if more anesthetic is not administered.

Recently, Schulz et al2 analyzed the Anesthesia Closed Claims database to assess the impact of SA on adverse events attributed to anesthesia. They found that errors in SA contributed to death or severe neurological injury in up to 74% of cases, and 56% of those cases with SA errors had respiratory failure events. Breaking down the SA into stages, errors of perception were most common (42%) compared with comprehension (29%) and projection errors (29%). Understanding the components of SA and the root causes of its loss provides a concrete concept of vigilance that can be taught.

Traditionally, SA has been taught through role modeling and gradually increased independence as training progresses. More recently, simulation and an emphasis on quality assurance and reflection on errors have been used.3 Probably more importantly, there has been recent stress on the importance of team SA in the OR. It is clear that ORs function best when personnel work as a team. The ability of team members to develop a common understanding of the changing environment and adapt appropriately is vital. O’Neill et al4 created a rating system that assessed team SA; simulations were run before and after a team training intervention and the rating system was used to assess team SA without interrupting the simulation. Another system, the Anesthesiologist Non-Technical Skills (ANTS) scoring system, has been used to assess nontechnical skills including SA, communication, teamwork, and decision-making.5 Cole and colleagues utilized an OR Management and Leadership rotation to create a curriculum for residents on SA and other nontechnical skills. They found that a formal structure for nontechnical skills training results in significantly improved ANTS scores on 12 of 14 parameters.6 Although it seems that training may improve SA, the numbers of distractors continue to increase in the busy OR environment.

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Noise Levels in the OR and Alarm Fatigue

High levels of noise can have deleterious effects on health; noise pollution can lead to stress, anxiety, high blood pressure, tinnitus, hearing loss, and chronic fatigue. Anesthesiologists under 55 perform worse on hearing tests compared with the general population, and up to 84% of anesthesia providers report negative consequences related to the levels of noise at work. The National Institute for Occupational Safety and Health indicates a safe level of noise at 85 dB, averaged over an 8-hour period.7 As an example, a blender makes about 88 dB noise, a car wash is 89 dB, and a garbage disposal is 80 dB. A forced air warmer adds about 84 dB to the environment. The high level of noise in the OR is well described, with neurological and orthopedic surgeries having peak noise levels of >100 dB for over 40% of the procedure. Music in the OR is an additional source of noise pollution that can add an additional 87 dB to the background noise level. We already know that surgeons’ performance is affected with increasing levels of ambient sound.8 While surgical tools and electrical equipment are significant sources of OR noise, Ginsburg and colleagues assessed the noise levels at various points during cardiac surgery and found induction of anesthesia, emergence, and transport to be the times of highest noise. This not only indicates that the noisiest times of the OR may be modifiable but also that anesthesiologists are expected to perform under suboptimal conditions during some of the most critical times of surgery.9

Ambient noise and visual distraction also contribute to poor attention to alarms. Stevenson et al10 found that physicians took longer to detect changes in pulse oximetry when distracted by visual and or other ambient noise-simulating OR conditions. Alarms contribute to noise levels and alarm fatigue. In one study, during cardiac surgery, there were 359±158 alarms per case, or 1.2 per minute, the vast majority of which had no therapeutic significance.11 This problem leads to the widespread practice of disabling alarms, which places the patient at increased risk.7

Mitigating the effects of high noise levels in the OR is difficult. Specific surgical tools and equipment are required for a procedure, and anesthesia providers need to be able to communicate with other members of the team and still be able to hear the alarms from physiological monitors and other equipment. The Joint Commission has offered some practical ways to address noise levels in the OR. First, the most egregious sources of noise can be identified by formal measurements of noise levels and sources in the OR. Creating a “sterile cockpit” and prohibiting all nonessential conversation and activities can minimize noise levels during critical phases of the procedure or key periods of anesthetic management. Education on the hazards provided by noise can empower all members of the surgical team to take steps to minimize the risk.7

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Personal Electronic Devices

Mobile phones are prevalent, and it is clear that the telephonic component of these “smart devices” is only a minor part of what they offer. While children (and admittedly adults) may use the devices for game play or viewing of cat videos, adults increasingly utilize PEDs to make the complexities of life simpler. The PED becomes the map, the recipe book, the bank, the gift catalog, the newspaper, and the textbook. The phenomenon has even created new pathology; the fear of being without a mobile phone has been dubbed “nomophobia.” With the widespread use of PEDs, there has been concern over the distractions that they cause. Distraction during driving is well described.12 Distraction while working in health care has also been studied.13 It has been shown that perfusionists frequently use cell phones while on cardiopulmonary bypass, internal medicine residents use PED while on rounds, but studies are hardly necessary to prove that PED reach all areas of health care.14,15

Aguilera-Manrique et al16 assessed the level of nomophobia among nursing students and correlated it directly with smartphone use during clinical rotations. Soto et al17 surveyed anesthesia providers using a modified CAGE questionnaire to assess perioperative PED usage and found that not only was use prevalent in the OR, but that a significant number of respondents showed addictive behavior with respect to their PEDs.

Despite these risks, it is clear that PEDs can offer significant benefits and are here to stay. Rapid access to medical information can save lives, and having the world’s medical texts at one’s fingertips has revolutionized training and patient care.18 Given the prevalence of these devices, their utility, and their addictive nature, education and policy must address the appropriate balance of the good and the bad of PEDs in the perioperative environment. Both health care and non–health care organizations are doing more to address the omnipresence of smartphones, ranging from laws restricting cell phone use while driving to the complete banning of PEDs in the cockpit of commercial airplanes (the so-called “sterile cockpit”). The advantages of prohibiting smartphone use from ORs altogether include removing a source of significant distraction, protecting hospitals and personnel from PED-related medicolegal concerns when adverse events occur, and sending a clear message that the absolute priority is patient care at all times. Disadvantages include a decrease in the rapid availability of medical knowledge and a slowing of communication at a time when near-instantaneous availability is the expectation and the norm.

Restrictive “sterile cockpit” policies are unlikely to be put into place in hospitals for the aforementioned reasons. This leaves more conditional policies as options (for instance no use during high-risk periods such as induction of and emergence from anesthesia), but these are difficult to enforce and can be confusing in practice.

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As with any good multistep solution, the first step is to accept that there is a problem. Providers need to understand that PEDs, alarms, and the complexity of the OR environment can distract from good, safe patient care. We all view ourselves as master multitaskers, but we also recognize that our tasks (and distractions) continue to increase over time. However, recent studies may provide some hope. Slagle et al19 assessed nonclinical activities performed during surgical cases by residents and nurse anesthetists and found that self-initiated activities not associated with patient care that were performed during surgical cases were not associated with any adverse events. This suggests that anesthesia providers can learn how to mitigate risk to the patient in the setting of potentially distracting factors. With appropriate understanding of the problem of distractions, the challenges in maintaining SA, and appropriate training and focus on the patient, our ORs can remain a safe haven for surgical patient care.

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