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Quality and patient safety

Incidence and impact of distracting events during induction of general anaesthesia for urgent surgical cases

Savoldelli, Georges L; Thieblemont, Juliette; Clergue, François; Waeber, Jean-Luc; Forster, Alain; Garnerin, Philippe

Author Information
European Journal of Anaesthesiology: August 2010 - Volume 27 - Issue 8 - p 683-689
doi: 10.1097/EJA.0b013e328333de09

Abstract

Introduction

Distractions and interruptions during daily clinical activities are numerous and diverse. Sometimes necessary and beneficial to perform and succeed in the task, they can, however, reduce performance and increase the risk of error.1–4 Their frequency and their negative effects on human performance have been well analysed and measured in aviation5–8 and other work environments.9,10

In medicine, sources of distraction also appear to be common and frequent in emergency departments11–14 and during surgery.15–17 Although sources of distractions have been analysed and quantified in the operating room during surgery, little is known about distracting events on anaesthesia providers. Few studies on ergonomics and human factors affecting the anaesthetist's vigilance and performance have been conducted in the operating room.18–20 Nor has any study examined the incidence and impact of distracting events on the anaesthetic team during the period of induction of general anaesthesia (IGA). This phase is critical because it requires the establishment of a climate of trust and calm, as well as constant vigilance by the anaesthetic team.

The purpose of this study was to quantify and analyse the frequency, source and impact of events that can potentially distract anaesthesia team members and hinder the workflow of the team. The observation period focused on the IGA for urgent surgical cases.

Participants and methods

Study design

The present prospective observational and descriptive study was part of a larger project on anaesthetic risk management and communication within the team in the emergency theatre. The project was conducted in cooperation with the laboratory ICAR (Interactions, Corpus, Apprentissages, Représentations) of the Centre Nationale de la Recherche Scientifique (CNRS) (National Centre for Scientific Research) of University of Lyon 2, and the Division of Anaesthesiology at our institution. The Chairman of the Ethics Committee and the Medical Director of the institution approved the research. The study focused on the anaesthetic team. Therefore, written informed consent and oral informed consent were obtained from the team members and the patients, respectively. Data were collected and analysed confidentially and anonymously.

Participants, setting and sampling

A total of 29 anaesthetic team members participated in the study: 16 physicians (11 senior residents and five consultants) and 13 nurse anaesthetists.

All IGAs were performed in one of the induction rooms of the emergency operating theatre of the Geneva University Hospitals. All types of urgent surgery are performed in this theatre day and night. Patient sampling was conducted during the day shift and on the basis of convenience depending on the availability of the investigators in charge of the study.

For safety reasons, it is a policy of our institution that two members of the anaesthetic team must be present during the IGA. One of them must be a physician. Accordingly, anaesthetic teams were composed of one nurse and one or two physicians, or of two physicians alone. Within the team, team members (physician and nurse) could play two different roles: ‘airway’ or ‘drugs’ manager. Occasionally, a third member was present as a supervisor (consulting anaesthetist).

Audio and video recording

Before the start of the IGA, two mobile cameras provided video and audio recording of a front view and a side view of the IGA being performed in the induction room, and the members of the anaesthetic team were equipped with lapel microphones. Recording began when the patient arrived and ended after the fixation of the endotracheal tube. The study investigators were not present in the induction room.

Videotape review and definitions

All videotapes were jointly reviewed by two investigators (G.L.S. and J.T.). The period between the beginning of the preoxygenation up to the fixation of the endotracheal tube was analysed. This period was defined as the IGA duration. We used an original scoring system designed to categorize and analyse distracting events. A distracting event was defined as an event that could potentially or actually distract or interrupt anaesthetic team activity and hinder the workflow of the team. According to this definition, the consequences of a distracting event on the team members could be a distraction (break in attention), an interruption of the task (suspending task, task switching), a modification of the task (multitasking, suboptimally performed task) or no observable consequence (see Table 1 for definitions). The consequences of a distracting event could have a positive, a negative, or no influence on the management of the patient.

Table 1
Table 1:
Variables used in the coding system to categorize and code the distracting events

Scoring system

The scoring system used to review the videos was developed with Access (Microsoft Access 2000). Its purpose was to categorize distracting events according to their origin, source, nature, duration, impact on patient and team and consequences on team activities for each team member (Table 1). Initially, we created the scoring system using an inductive a priori classification of categories. The choice of the categories was based on previous studies on workplace interruptions in healthcare15,21,22 and on local expert consensus (quality controller, sociolinguist and consultant anaesthetists). The initial version was used to score 13 videotapes. During this pilot study, it was further improved and refined.23

The originality of this system for categorizing distracting events is based on the distinction between distracting events directly related to activities tied to the care provided to the patient (internal distracting events) and those not directly related (external distracting events).

Data analysis

Traditional descriptive statistics were used to analyse the frequency and the duration of distracting events and their consequences. Total distracting event duration per case was defined as the total time during which at least one distracting event was present. Similarly, total duration of distracting event consequences on team member activity was defined as the total time during which at least one distracting event consequence was present. These total durations were used to compute the percentage of distracting event duration per case. Depending on their nature and distribution, data were reported as number, percentage, median (range) or mean (SD).

Results

Inductions of general anaesthesia

Thirty-eight IGAs were videotaped and audiotaped. Only 37 were included in the final analysis due to technical problems during one recording. The total observed time of all IGAs was 306 min and the median IGA duration was 8.3 min (4.3–16.3).

Organization of the team

Out of the 37 teams observed, 25 were composed of one physician and one nurse, eight of two physicians and one nurse and four of two physicians. Physicians played the role of ‘drugs manager’ or ‘airway manager’ in 81.1 and 30% of the cases, respectively.

Duration and origin of distracting events

Distracting events occurred frequently with a median occurrence of five (1–14) per IGA. At least one distracting event was present for 39.5% of the total IGA duration. The most frequent origin of distracting events observed was ‘internal’ and represented 61.7% of the total distracting event number. Table 2 details the frequency and the duration of observed distracting events from the 37 IGAs.

Table 2
Table 2:
Frequency and duration of observed distracting events from the 37 videos

Sources of distracting events

The origins (internal and external) of distracting events had different possible sources. The most frequent source was the intrusion of a nonmember of the anaesthetic team (external staff), which accounted for 28.7% of total distracting events. Two other sources were also very frequent: an appropriate intervention of one of the team members (23.9% of total distracting events; this category includes many inappropriate conversations between anaesthesia providers) and inappropriate intervention of patient (13.9%). Table 3 details the frequency and duration of distracting events according to their origins and sources. The most frequent distracting events were not necessarily the ones that lasted the longest. Whereas distracting events linked to workspace constraints were five times less frequent than distracting events linked to external staff, their accumulated total duration was almost identical.

Table 3
Table 3:
Frequency and duration of distracting events according to their origins and sources

Impact and consequences of distracting events on team members

One hundred and seventy-three distracting events (82.8%) had an observable impact: on all team members (43.4% of instances); only on the ‘airway manager’ (30.1% of instances); only on the ‘drugs manager’ (25.4% of instances); or only on the supervising physician (0.1% of instances).

The median number of consequences per distracting event was one (1–5). The median duration of one consequence was 4 s with a wide range (1–235). During 66.6 min (21.8% of total IGA duration), at least one consequence of a distracting event interfered with the activity of at least one team member.

Table 4 details the frequency and the duration of consequences according to the origin and source of the distracting events. Even though distracting events due to ‘external staff’ were the most frequent, their average duration in terms of disturbance of activity was the shortest. Conversely, problems with ‘equipment’ were relatively rare, but had a high impact on team members (100% of observed cases had at least one consequence) and a relatively high median duration of consequences.

Table 4
Table 4:
Frequency and duration of consequences for each source of distracting event

Classical examples included difficulties with pulse oximetry probes and ECG electrodes.

Distracting events due to phones and beepers were relatively infrequent but had a high level of disturbance in terms of consequences and duration. Finally, distracting events relating to team members were very frequent, with a high impact and duration in terms of disturbance of activity.

The most frequent types of consequences on activity were ‘task switching’ (43.9% of the total), ‘multitasking’ (29.3%) and ‘brief break in attention’ (25%). Less frequent types were ‘suboptimally performed task’ (8.6%) and ‘suspending task’ (3.2%; see Table 1 for definitions). Table 5 further details the types of consequences (number and duration) according to each source of distracting event.

Table 5
Table 5:
Frequency and duration of each type of consequence according to each source of distracting events

Consequences of distracting events according to the role of the team members

The activities of the airway and the drugs managers were affected by a similar number of consequences (138 and 134, respectively). However, Fig. 1 shows that the type of consequence for the task at hand was different for these two roles.

Fig. 1
Fig. 1

Impact on patient

The vast majority of distracting events (71.3% of the total distracting events) had no observable impact on patient management. A negative impact on patient management was observed in 21.5% of the cases and a positive impact was present in 7.2% of the cases.

Most external distracting events (93.9%) had no impact on patient management. A small number (3.7%) had either a positive impact (example: external staff interrupting the team to provide additional information pertaining to the patient) or a negative (2.4%) impact (example: a physician was interrupted by a beeper as he had just placed a tourniquet on the patient's arm, hence he left it in place for a longer period).

The majority (56.7%) of the internal distracting events had no impact on patient management. One-third (33.9%) had negative consequences (examples: suboptimally performed task resulting in inadequate preoxygenation; preoxygenation with unintended open isoflurane vaporizer, lack of light in the laryngoscope during use). Few (9.4%) had a positive impact (examples: phone call during preoxygenation to seek additional information on the patient; preoxygenation paused to examine airways and reposition patient's head; change of patient's drip, which had been causing pain).

Discussion

The present observational study proposes an original approach to categorizing and analysing the impact of distracting events on anaesthetic teams. This taxonomy is the first classification specifically developed for and applied to the anaesthesia setting.

Our results show that distracting events are frequent and diverse during IGA for urgent surgical cases. The median rate of distracting events observed per minute was relatively high. Distracting events were most frequently due to intrusion of external staff; carelessness or inappropriate intervention of the team members; and inappropriate behaviour or intervention of the patient. The distinction between internal and external distracting events is important because it allows us to better understand on which distracting events we may act.

The distracting events with the longest duration were linked to equipment, workspace constraints, phone and beeper. However, it was not necessarily those distracting events which were the most frequent or had the longest accumulated duration that had the greatest impact (consequences) on the team.

Our analysis of the consequences of distracting events enabled us to show that the most disturbing distracting events were phones/beepers, team members (inappropriate conversation was frequent) and equipment. These findings can be explained by the obligation to take these events into consideration in the context of an emergency theatre (i.e. an obligation to answer the beeper/telephone). Conversely, the distracting events with the shortest disturbance came under the ‘external staff’ category.

The high incidence of distracting events observed in our study is consistent with previous work carried out by Healey et al.15,22 on distractions and interruptions during surgery. In their study on 30 urological surgeries, theses authors observed a mean of 20.47 distractions or interruptions per case with a wide range.22 The average duration of interruption per operation was also relatively high with a mean of 0.45 event per min. Similarly to our results, they noted that the most disruptive categories (e.g. equipment) were not necessarily the most frequent.

The intervention of ‘external staff’ was frequently observed in our study but had a limited impact. This finding is in apparent contradiction with another study by Healey et al.15, which showed that ‘external staff’ were among the most distracting events in the operating room. The high frequency of distracting events due to external staff in our study can be traced to the fact that the induction room is also used as a transit route for patients leaving the operating theatre. In addition, this room is also a storage room for various pieces of equipment required in the operating room. Manifestly, this configuration results in an increased flow of operating staff in the induction room. This is a good illustration of how architectural and ergonomic factors can influence the incidence of distractions and work interruptions. This point should be taken into account in the pros and cons that feed the old debate surrounding the anaesthetic room.24

Regarding the consequences of the distracting events on activity, ‘task switching’ was the most frequent type for all sources of distracting events. The only exception was distracting events due to ‘external staff’, which mostly resulted in ‘multitasking’ and ‘brief break in attention’. We also noted that the ‘drugs’ and ‘airway’ were influenced differently. The high frequency of multitasking in team leaders is due to the nature of the tasks to be performed, which cannot be interrupted or suspended (ensuring an airtight seal for the mask during preoxygenation; monitoring the patient's reactions after the injection of drugs; laryngoscopy intubation; etc.). Likewise, the fact that drugs managers were physicians in the vast majority of cases can explain the high frequency of change of activity. Owing to their status, physicians are more often sought and disturbed by outside events than nurses.

Distraction and interruption are often seen as events that can decrease efficiency, increase the risk of error and, therefore, compromise patient safety. On the other hand, there is some evidence that appropriate interruptions can also have a positive impact. The question of the positive or negative effects of distracting events on the activities under way is a delicate one for the answer is contextual in nature. It depends on several factors, such as the nature of the interrupted activity or that of the stimulus (visual or auditory, degrees of urgency, etc.) or of the duration of the interruption or the individual characteristics of the persons interrupted.9,25–27 According to Walji et al.,25 certain interruptions in healthcare, such as warnings and alerts, reminders, suggestions and notifications, are interruptions that can increase efficiency and reduce errors. We have attempted to evaluate the benefits and drawbacks of distracting events for patient management. The findings showed that the vast majority of distracting events had no observable impact on patient management; one-fifth had a negative impact; and approximately 7% had a positive impact. The events deemed to have had a positive impact in our corpus are those with a clear benefit for the patient and increased patient safety (example: phone call during preoxygenation to obtain additional information on the patient; a physician who noticed a problem with the pressure sensor and solved it before induction; workflow interrupted by an alarm, which in turn induced an adjustment of the anaesthetic strategy). Moreover, even though they may seem intrusive and inappropriate at the time, the frequent discussions with external staff on how to care for patients and lay out the rooms can also have a beneficial impact on the team by reducing work-related stress in the emergency ward and fostering better organization and cohesion in the team. Additional work on beneficial interruptions for individuals in the performance of a task is warranted. Such research could facilitate the drafting of guidelines to ensure better management of interruptions.

The context of the study, including architectural constraints, organization of the work, constitution of the team, academic setting and the observation conducted only during daylight, may have influenced our results. Therefore, the generalizability of our findings to other operating rooms in our own institution or to other institutions is unknown. It is likely that the incidence of external distracting events has been increased by the study setting (emergency theatre and induction room); however, it is unlikely that the incidence of internal distracting events has been influenced to the same extent.

Our study features other potential limitations. First, observations were conducted only with voluntary participants, as a result of which a selection bias cannot be formally excluded. Second, although we have attempted to limit the impact of our observation on participants' behaviour by using video and audio recording instead of an observer, a ‘Hawthorne effect’ is always possible. Finally, we did not formally measure the interrater reliability of our scoring system. Nevertheless, eight videos picked at random were coded independently by the two scorers for the study. The reliability of coding was over 80% in this sample. However, the two scorers (a sociolinguistic researcher and an anaesthesia consultant) shared a complementary view, which is why all videos were jointly coded. Even though this reflected a deliberate choice in this initial study, it would be essential to evaluate the reliability of our tool by conducting interrater reliability tests in the future.

Recently, the application of a safety checklist to routine surgical cases was associated with a reduction in surgical morbidity and mortality.28 It is likely that the healthcare system in general and the practice of anaesthesia in particular would benefit from the transfer of other safety principles drawn from the aviation or from other high reliability organizations. As already mentioned, the problem of distractions and interruption is a well known issue among cockpit crew members. In order to limit the impact of theses events, psychologists and human factors specialists have designed several approaches, including, but not limited to, human factors and teamwork training (including simulation); avoidance of inappropriate conversation during high-risk situations; introduction of timely procedures and checklists with limited interruptions; designing operating procedures to minimize concurrent task demands and interruptions; and providing explicit guidance to crews on the importance of monitoring and situational awareness.7,8

In conclusion, this work represents the first ‘snapshot’ of the frequency and impact of distracting events on anaesthetic activity. The findings bear out the general impression of professionals: distracting events and interruptions are frequent during this phase of anaesthesia when calm and vigilance should prevail. Future research should be oriented towards the development and implementation of various approaches such as those used in the aviation industry, first to minimize the occurrence of unnecessary distracting events and second to promote coping strategies such as effective multitasking and prioritizing.

Acknowledgement

We would like to thank the Department of Anaesthesia for its financial support; the staff, residents, nurses and patients for their participation in the study; and the head of the audiovisual unit, Franck Schneider, for his logistical support. The present study was supported by departmental funding (Fonds de Services APSI).

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Keywords:

anaesthesia; distracting events; general; interruptions; medical errors; safety

© 2010 European Society of Anaesthesiology