In the past several decades, the convenience of personal electronic devices (PEDs) has revolutionized our existence. With an increasing number of digital natives in the workforce, the utilization of PEDs has transformed our educational and work environments. Health care providers (HCPs) make up a high percentage of daily PEDs users, especially with the advent of electronic medical records (EMRs) (J Anesthe Clinic 2013;4:e112). Although utilization of PEDs, particularly in high-acuity areas like the intensive care unit (ICU) and OR, has been instrumental, the unintended side effects of PEDs, like distraction and dependency, call for a review of personal behavior (J Clin Anesth 2021;68:110110).
The devil is in the details
Anesthesia care professionals (ACPs) practice in a complex work environment that is rich in external (unavoidable) and self-initiated distractions (intraoperative activities unrelated to patient care like small talk, reading, and using PEDs for personal use) (J Clin Anesth 2021;68:110110; Anesthesiology 2013;118:376-81; Anesthesiology 2009;110:275-83). Expectedly, when we are required to demonstrate situational awareness, vigilance, and critical decision-making in such an environment, serious patient safety issues may occur. Intraoperative distractions like high attentional load and environmental noise are additive in nature and are known to negatively impact patient care (J Clin Anesth 2021;68:110110). In recent years, widespread implementation of EMRs has increased the use of PEDs in ORs and somewhat justified their use, but PEDs, particularly cell phone use, have been identified as one of the most common self-initiated distractors in the OR (J Clin Anesth 2021;68:110110).
According to Pinar et al., 93.7% of ACPs reported using smartphones during anesthetized patient care, though 96.7% reported not using them during critical phases of anesthesia care like induction and emergence. While 87.3% of the providers reported never being distracted by smartphone use, interestingly, 41.5% reported having witnessed a colleague being distracted by the use of a smartphone at least once (Figure) (BMC Anesthesiol 2016;16:88). This particular finding indicates that ACPs may underestimate the ability of PEDs to cause distractions in the OR. A similar study was performed by Smith et al. among perfusionists, showing that 55.6% of perfusionists used their cell phones during cardiopulmonary bypass. Alarmingly, 78.3% of those still used their cell phones during cardiopulmonary bypass despite their concern that cell phone use can introduce a potential safety risk to patients’ care (Perfusion 2011;26:375-80).
Several studies have reported that self-initiated distractors like reading, listening to music, and small nonpatient-related talks may represent an intentional strategy to decrease boredom during periods of information underload, like during maintenance of anesthesia (Anesthesiology 1990;73:995-1021). Boredom has been identified as one of the contributing factors to human error in the aviation industry (J Hum Ergol 1975;4:65-76; Proceedings of the IATA Human Factors Seminar 1998;1-7). Therefore, utilization of these distractors may help maintain cognitive vigilance and prevent mind wandering. Slagle et al. observed 172 general anesthesia cases in an academic medical center to evaluate the effects of intraoperative reading on vigilance and workload. They found that ACPs read during 35% of the cases, but mostly during periods of low workload, like maintenance. Also, no significant difference was found in vigilance among readers and nonreaders (Anesthesiology 2009;110:275-83). Similarly, Cohen et al. observed PEDs usage during cardiac surgeries. A total of 558 PEDs usage events were observed, of which 48.8% were by ACPs. Most of that usage, i.e., 42.8%, was during the low workload period of cardiopulmonary bypass. No adverse outcomes were observed (Perioper Care Oper Room Manag 2018;10:10-3).
Use of PEDs during low-workload periods is mostly self-controlled, but distractions created by pagers and phone calls on “service-line devices” like phones carried by the team leader, chiefs, and on-call personnel are mostly unpredictable and can occur irrespective of workload. Schulte et al. looked at cellular company data for a 10-month period for a single “service-line cell phone” carried by the on-call anesthesiologist and clinical director at an academic institution. A median of 82 calls per day were received in addition to a similar number of text messages, indicating an enormous amount of time spent that may result in significant distraction while providing anesthesia care (J Clin Anesth 2016;34:658-60).
Compared to other widely studied OR distractors, such as intraoperative noise, there is a lack of direct evidence that PEDs usage in the OR results in compromised patient care. But it does not exclude the fact that the use of PEDs like cell phones has been identified as one of the most common factors in car crashes (BMJ 2005;331:428). In fact, cell phone use increases the risk of a crash by a factor of four (BMJ 2005;331:428). Strayer et al. did a very interesting study comparing intoxicated drivers and drivers conversing on cell phones using a high-fidelity driving simulator. Although the impairments were different, they were comparable in both groups. Also, handheld or hands-free cell phones made no difference in the development of impairments (Hum Factors 2006;48:381-91). Similarly, Klauer et al. looked at the risk of crashes and near-crashes among novice and experienced drivers while engaged in secondary tasks like dialing or texting on a cell phone, eating, reaching out for objects, etc. Although the risk of crashes and near-crashes was higher in novice drivers with many of the secondary tasks, the one common distractor resulting in crashes and near-crashes between the two groups was cell phone usage (N Engl J Med 2014;370:54-9).
Considering the above, one may suggest that anesthesia trainees may be at a higher risk of getting distracted, as they have not yet developed the ability to multitask while maintaining cognitive vigilance when compared to an experienced ACP. But research is currently limited to direct comparisons among different levels of ACPs. Nevertheless, one can also argue that the time spent on EMR documentation intraoperatively may pose a similar risk of distraction by paying attention to the “iPatient” and not the actual patient.
According to the ASA Closed Claims database report, the number of claims related to distractions in the OR is relatively small, but distraction-related claims were judged to be substandard care in most of the claims (APSF Newsletter 2017;31:59-62).
What makes PEDs usage in the OR interesting is that usage data is discoverable (APSF Newsletter 2017;31:59-62). The ability to “e-discover” provides a time stamp on all electronic activities and can be served as an “expert witness” that indicates a lack of ACP vigilance in cases of litigation. Additionally, utilization of PEDs for nonpatient use may also give other team members the wrong perception regarding the lack of attention and quality of anesthetic care administered. This can also lead to unwanted investigations by institutional and licensing boards, potential suspension of practice privileges, disciplinary actions, and loss of employment.
Knowing that PEDs use in the OR may result in a potential adverse outcome, why do ACPs have this irresistible temptation to use PEDs as a self-initiated distractor? This brings up a very important yet critically understudied topic: PEDs addiction, particularly cell phone addiction (J Anesthe Clinic 2013;4:e112). As mentioned above, Smith et al. showed that even though cardiac perfusionists felt that using cell phones during cardiopulmonary bypass was distracting, 50% still used their cell phones for texting. A similar survey study conducted by Hitti et al. among emergency department personnel showed no exception despite the acute nature of clinical care and periods of heavy clinical loads. This highlights the classic addictive tendencies among HCPs, indicating the dire need for research and regulatory policies. With almost 80% of HCPs using PEDs in workspaces, it has become the new occupational reality and potential hazard. In an effort to introduce some self-regulatory and behavioral aptitudes, the University of Rochester has modified the CAGE questionnaire by using the term “PEDs” in place of “drinks” (Table 1) (J Anesthe Clinic 2013;4:e112).
Utilization of this questionnaire was an eye-opener for participants, providing them with a self-assessment tool for digital addictive behavior. Guidelines and position statements have also been issued by several professional societies and organizations regarding appropriate PEDs use in the OR (Bull Am Coll Surg 2008;93:33-4; asamonitor.pub/3NxSf3u; asamonitor.pub/46j6MaG; OR Manager 2013;29:20-2). However, more education and research are needed for behavioral modification toward electronic addiction.
A cell phone is 10 times dirtier than a toilet seat! (asamonitor.pub/42Imau3). Health care-associated infection (HAI) is one of the leading causes of significant morbidity and mortality. According to the CDC, the cost related to all HAI in the United States is between $28 billion and $45 billion annually, putting a huge financial burden on patients, families, and the health care system (JAMA Intern Med 2013;173:2039-46). Transmission of infectious organisms through contamination plays a crucial role in contracting HAI. Ubiquitous use of PEDs by HCPs in work environments, especially cell phones, has been linked to the contamination of clinical surfaces that could serve as bacterial reservoirs. While direct transmission is unlikely, indirect transmission via the hands of HCPs and medical equipment could easily occur (Texto Contexto Enferm 2018;27:e5140016; World J Orthop 2020;11:252-64). According to Ulger et al., 94.5% of cell phones in their study were contaminated, of which some contained bacterial isolates that are known to cause HAI. Similar flora was also found on the hands of HCPs. Interestingly, roughly half of the strains isolated from cell phones and one-third of the strains isolated from hands were drug resistant (Table 2) (Ann Clin Microbiol Antimicrob 2009;8:7).
How many times have we observed an HCP not paying attention to the patient because they are working on the EMR? Or busy socializing on PEDs? Or trying to respond to an array of pagers? Electronic gadgets have proliferated in all professions and have changed the landscape of medicine. PED use has certainly become an indispensable part of our daily lives. It has made learning, data gathering, resource accessibility, real-time clinical decision-making, and communication timely and easier, but at what cost? (J Clin Anesth 2021;68:110110; J Hosp Med 2013;8:589-97). The enormous wealth of knowledge accessible with EMRs and PEDs is unparalleled, but it comes with unintended side effects – growing pressure to use devices, temptation to use PEDs for self-initiated distraction, long periods of isolation, and electronic addiction (J Anesthe Clinic 2013;4:e112). This makes an urgent case for the evaluation of the optimal use of PEDs by HCPs. Is using PEDs for case-related activities acceptable? What is acceptable? What is the definition of optimal use? The question remains!
Some of us are probably reading this article in the OR right now on PEDs. We have all adapted to this mantra of making our lives easier or faster. Mere clicks away from shopping, socializing, eating, and gathering information; the convenience of PEDs is indisputable, but the concern is its improper use, which may impact the safety of our patients. Evidence-based research on the appropriate use of PEDs in the OR is urgently needed, specifically on perceptual and multisensory processing, human-machine interface, behavioral modifications, self-control, and policy regulations. A skilled ACP should be able to multitask and maintain cognitive vigilance despite distractions. We should. The question is whether we could.