The use of personal electronic devices (PEDs) in the operative setting is a constant area of controversy. In this edition of the ASA Monitor, issues regarding the use or misuse of these devices will be discussed. But how did we get here? Prior to the onset of personal devices, concerns regarding distraction and vigilance were prevalent but involved other items such as journals, papers, and books. These items were found in and around the anesthesia workspace and were felt to be an infection control risk as well as a major distractor to the delivery of anesthesia care. Many can recall, though unrealistic, images or jokes about anesthesia providers reading the stock reports or other news items while the surgeon diligently takes care of the patient. These images did nothing to further the perception of anesthesiologists and the critical role they play within the perioperative space. And though bans regarding extraneous items were issued (especially within training programs), enforcement was found to be difficult.
As technology has changed over the past 30 years, the way information is obtained, processed, and implemented has significantly changed as well. The development of cellular technology has truly been a game changer. Initially, though, cell phones were strictly that – phones. Viewed as a way to communicate without the presence of bulky landlines, cellular technology was quickly adapted. The technology had limited utilization, especially in OR or remote hospital locations, notably due to poor cellular signals and shielding inherent to radiological spaces.
The introduction of the easy-to-use Apple iPad tablet in 2010 was an additional change to the way anesthesiologists obtain information. These devices allowed for easier access to materials such as electronic books (used as reference sources) and, when connected to the internet via WiFi or a cellular system, allowed for the use of the devices as minicomputer workstations. The workstation concept had the tendency to distract health care professionals since individuals could easily become engrossed in research, reading, or task completion and ignore the subtle signs of changes (monitor tones, suction, etc.). At the same time, we also saw an increase in monitor sophistication and the de-emphasis of simpler devices that would physically link the anesthesiologist to the patient during specific procedures (e.g., esophageal stethoscopes).
Technology continued to evolve, especially in the area of cellular systems and with the launch of the smartphone (a cellular device that could connect to the internet or use internet-based applications). Smartphones have proven to be useful in daily life, allowing for easier access to valuable information concerning patient care. However, the downside is that these devices also allow for distraction, since nonmedical usage occurs with their use.
Over the years, the introduction of technology to generations of earlier ages changed the way many obtain information used on a daily basis. In addition, the creation and implementation of the electronic medical record as well as application-based paging systems have made cell phone usage that much more important.
The controversy regarding PED use has been discussed in several articles in both anesthesia and surgery. In 2012, the problem with distraction in the OR was investigated by the team of Campbell et al (Br J Anaesth 2012;109:707-15). Though not strictly focused on PEDs, the team judged that 22% of events of interruption were noted to have a negative effect during 30 anesthetics. In 2016, the American College of Surgeons developed a position statement that addressed some of these distraction issues (asamonitor.pub/440tsdv). A few key takeaways were that smartphone use may compromise care due to distraction, affect sterility of the OR environment, and may inadvertently expose sensitive patient information to awake patients.
In 2017, the Anesthesia Patient Safety Foundation dedicated safety meetings to address the growing issue. Both van Pelt and Weinger summarized the results, underscoring the fact that not only were there concerns about distraction from patient care, but PEDs use was creating medicolegal concerns a well (Anesth Analg 2017;125:347-50). They noted HIPAA-related issues and that PED data is discoverable and could lead to more findings against a defendant. Per their conclusions, “consequences of PED-related plaintiff verdicts went beyond compensatory damages, including licensing sanctions, National Practitioner Data Bank reporting, and unfavorable media coverage.”
Cohen, Jain, and Gewertz have also presented scholarly work regarding the use of PEDs, specifically with surgeons. In their 2020 JAMA article, the team elucidated some of the benefits and harms associated with the use of these devices (JAMA Surg 2021;156:302-4). Benefits included the ability to transfer clinical images efficiently, access applications that could be used as educational resources, and easy collaboration among team members. The potential for harm included disengagement from tasks, an increase in impolite or disruptive behavior, and the creation of expectation of increased availability and immediate response.
A recent single institute survey conducted by Porter and Renew in 2022 noted that PED use was prevalent in the anesthesiology environment, with self-reported activity inside the OR consisting of 24% texting, 5% talking on the phone, and 11% browsing the internet (Anesth Analg 2022;134:269-75). Observed activity was even higher, with over 52% observed texting and 34% browsing. The accompanying editorial by Rothman et al. reinforced the necessity of organizations to have secure means of communication that is distinct from personal email and texting formats (Anesth Analg 2022;134:266-8). In addition, it was again reiterated that there is a strong need to understand the difference between privacy laws and discoverable information – never text about a patient (in a non-HIPAA secure platform) and that “text messages, social media posts, emails, health record audit trails, badge swipe information, and other types of electronic data are generally discoverable in a lawsuit.”
The reality of our hyperconnected world is that PEDs are here to stay, for better or for worse. These heavily marketed devices are introduced to a younger and younger generation and have as a result become part of the fabric of society worldwide. The expectation that these items will be banned from the perioperative environment is unrealistic. PEDs do serve a purpose, especially as a mode for quick communication between teams (especially since landlines continue to decline) and a source for data and educational information. The question is how and when we use these devices, and that will require thought and consideration. For example, the use of a PED during periods of high intensity and stress should not even be considered, since the focus should be on the environment and other team members. However, can a PED play a role if the device has an application dedicated to crisis management? What if it allows for rapid distribution of personnel and appropriate resources to support clinical care? There are no quick and easy answers as this technology continues to grow and be refined.
In the following articles, the authors review various aspects of a complicated subject, with focus on the legal implications of PEDs, the overall incidence and pattern of usage, “addictive” behaviors, PED use in lower- and middle-income countries, and parallels to the aviation industry. One thing is certain: the use of personal electronic devices will continue. How we address the use of and manage these devices will be the key to enhancing patient safety and supporting those undergoing anesthesia care.