With the development of the electronic record to the COVID-era growth of telehealth, health care is adapting and expanding to newer electronic formats. The use of cell phones, smartphones, tablets, and other personal electronic devices (PEDs) within health care systems naturally extends from this pattern. With ever-smaller yet more powerful microprocessors and ever-improving memory and resolution, PEDs offer instant communication, portable internet connectivity, and full-strength computing power. Furthermore, open-access programming for applications renders PEDs near-infinitely customizable to the user and task at hand.
“The ‘sterile cockpit’ rule augmented the existing policy requiring pilots to refrain from nonessential activities during critical phases of flight. Just as many concepts like preflight checklists and closed-loop communication have been adapted from the aviation industry to anesthesia care, the idea of a ‘sterile cockpit’ has been lauded by some anesthesia professionals. But is it possible to use PEDs within perioperative care to the benefit of the patient?”
PEDs have the potential to assist communication between health care professionals and enhance clinical decision-making. Professional applications (apps) exist for task management, electronic record keeping, secure communication, medical consultation, and medical education, including many devoted specifically to anesthesia care (Anesthesiol Res Pract 22018;2018:8694357). App-based clinical tools developed for both inpatient and outpatient settings have already demonstrated direct patient benefits like improved adherence to clinical guidelines and evidence-based care, such as improved antibiotic decision accuracy and reduction of unsafe prescribing of NSAIDs (J Am Coll Surg 2006;202:459-67; J Am Med Inform Assoc 2006;13:171-9). But is a PED a safe and effective tool for care optimization within the OR, or is it a glitzy distraction from patient-centered anesthesia care?
Although pervasive in the daily life of nearly 80% of Americans, data on PED use among anesthesia professionals and its downstream effects on patient care is still in its infancy (asamonitor.pub/3NAdTUQ). Within other fields like aviation and nuclear material processing, data has consistently demonstrated that distractions like PEDs have detrimental consequences on performance (Qual Saf Health Care 2007;16:135-9). In high-risk environments, these performance gaps generate risk to public safety. In the high-risk environment of the OR, PED use may have significant implications for patient safety.
PED use in high-risk environments
Cell phone and PED use has been studied in several other fields. Smartphone use during high cognitive load tasks leads to longer reaction times, reduced focus, and lower behavioral performance (Traffic Inj Prev 2012;13:566-74). According to 2020 data from the U.S. National Highway Traffic Safety Administration, 13% of crashes resulting in injuries involved distracted driving, and cell phones were implicated in 13% of distracted driving deaths (asamonitor.pub/469TyN6). The cell phone or other electronic device competes for driver attention and lessens accurate knowledge of driving circumstances (Accid Anal Prev 2004;36:471-80). When used as a personal accessory or nonessential detractor of attention, perioperative PEDs likewise may contribute to a loss of situational awareness, equating highly with the idea of distracted driving.
Addressing these risks of distraction by electronic devices, the Federal Aviation Administration restricted the personal use of laptops, cell phones, and other PEDs by pilots while operating an aircraft (Fed Regist 2014;79:8257-63). This mandate, commonly called the “sterile cockpit” rule, augmented the existing policy requiring pilots to refrain from nonessential activities during critical phases of flight. Just as many concepts like preflight checklists and closed-loop communication have been adapted from the aviation industry to anesthesia care, the idea of a “sterile cockpit” has been lauded by some anesthesia professionals. But is it possible to use PEDs within perioperative care to the benefit of the patient?
PED use among OR staff
Given the ubiquity of cell phone use, it is not surprising to find PED use in the perioperative setting. In a survey of OR nurses in the Netherlands, respondents reported using devices to check the internet to read more about specific procedures or instruments, to record specific configurations of equipment, to communicate problems with technicians through photos, and to document something medically important for the surgeon during the procedure (Health Informatics J 2016;1101-10). Almost all of the nurses reported the devices save time, help better prepare for surgeries, improve learning, support knowledge transfer, and aid them in their interactions with surgeons and other colleagues.
However, just as in the aviation industry, there is a large concern for distraction by PEDs among perioperative providers. In a 2016 survey of anesthesia professionals in Turkey, nearly all respondents acknowledged using smartphones during anesthesia care, most commonly for phone calls and messaging, followed by surfing the internet and social media (BMC Anesthesiol 2016;16:88). While the vast majority of these respondents stated they had never experienced any negative medical consequences of smartphone use, nearly half had witnessed a negative consequence as a result of smartphone use by a colleague. Likewise, a large majority of surveyed perfusionists reported using a cell phone during cardiopulmonary bypass, and this usage never contributed to an error during the procedure (Perfusion 2011;26:375-80). However, one-third of respondents noted having seen another perfusionist distracted by cell phone use in a manner that negatively impacted patient care. Just as in distracted driving, there seems to be a lack of self-awareness or minimization of distracted behavior.
Lastly, in an environment that relies on meticulous maintenance of sterility, the mere presence of a device handled so frequently raises concerns of contamination. Of 53 cell phones used by orthopedic surgeons swabbed in the OR, 83% grew out pathogenic bacteria in cultures, including coagulase negative staphylococcus, viridans streptococci, staphylococcus aureus, and enterococcus faecalis (J Microsc Ultrastruct 2016;4:143-6). Given that surgical site infections are the most common health care-associated infection, PEDs may not only be a distraction but could also be a potential source of bacterial contamination in ORs (J Bone Joint Surg Am 2015;97:225-31).
PED use among the anesthesia care team
A survey of anesthesiologists conducted during the 2003 ASA annual meeting found that anesthesiologists who used pagers as the primary form of communication in the OR reported more significant delays in communication than those who used cell phones (Eur J Anaesthesiol 2017;34:239-47). Furthermore, more than a third of those who witnessed communication delays reported observing a medical error or injury as a result of that delay. By simply streamlining communication, cell phones in the OR may decrease the incidence of medical errors or injury.
“In addition to communication, a variety of mobile applications tailored to the anesthesia professional are available for preoperative care, intraoperative and postoperative monitoring, systems-based improvement, medication safety, adverse event reporting, guideline compliance, and medical education.”
In addition to communication, a variety of mobile applications tailored to the anesthesia professional are available for preoperative care, intraoperative and postoperative monitoring, systems-based improvement, medication safety, adverse event reporting, guideline compliance, and medical education (J Med Internet Res 2021;23:e25115). The most common and most useful mobile applications among anesthesia professionals include the ability to calculate drug dosage, determine risk scores, and check medication interactions (Anesthesiol Res Pract 22018;2018:8694357). The probability of administering accurate medication dosages in emergency situations is higher with a dosage calculator app versus without it (94% vs. 77.7%) (J Clin Monit Comput 2019;33:531-9). Cell phone applications can also be used in an individualized therapeutic capacity. Games or videos from these devices can provide an opportunity to alleviate preoperative anxiety in the pediatric population better than preoperative intravenous midazolam alone (Korean J Anesthesiol 2013;65:508-18).
To better characterize the use of PEDs among anesthesia personnel within the perioperative environment, a survey of anesthesiologists and nurse anesthetists was conducted by our team at a large academic health care system (Anesth Analg 2022;134:269-75). Of the 249 respondents to an anonymous survey, more than 25% reported using PEDs within the OR, and they were most often used for texting, phone calls, and browsing the internet. It was noted that across all domains, personnel reported and observed less frequent PED use in the OR as compared to baseline use outside the OR. And when used in the OR, they were more often utilized for job-related tasks as opposed to personal ones. However, the observation of smartphone use by others in the OR was noted to be two to three times that of self-reported use. Furthermore, despite awareness among most professionals of the potential for negative impacts of PED use on patient safety, respondents continued to use PEDs.
As PEDs now integrate with the electronic medical record, the anesthesiologist must develop an enhanced awareness of multiple sites of patient care through direct-to-provider, real-time data delivery and secure communication. The availability of a personal device in a high-risk professional environment brings the question of risk of harm to the patient when the device is not used for the patient’s benefit. Perhaps that risk is still present despite the perceived patient benefit. A recent editorial by Rothman et al. appropriately draws attention to the potential medicolegal consequence of distractions in the OR, especially by the use of PEDs (Anesth Analg 2022;134:266-8). This group highlights the legally discoverable nature of your personal electronic data and calls for judicious HIPAA-compliant use in a way that does not distract from patient care. Finally, these authors call upon anesthesiologists to become good stewards of such technology and make a personal, professional choice to operationalize perioperative PED use in a manner that benefits patient care while avoiding distractions.
It is important for anesthesiologists to reap the benefits of real-time patient-centered data such as vital signs and laboratory values pushed directly to them via a PED. However, departmental policies must take into account that all PED use can be scrutinized in our legal system. Thus, policies related to PED use may benefit from adherence to a model similar to the “sterile cockpit.”