Smartphones in the OR: Regulatory and Legal Aspects

Smartphones make it easy to communicate, access reference materials and medical records, and schedule procedures, appointments, and meetings from virtually any practice environment, thanks in part to widely available Wi-Fi at work (Saudi J Anaesth 2016;10:87-94). Beyond the administrative applications, anesthesiologists can utilize smartphone technology in the perioperative area in several beneficial ways. Recent adaptations include miniaturized ultrasound probes that enable point-of-care ultrasound imaging that once required a bulky machine. Preoperatively, research is being done to evaluate whether and how effectively smartphones can alleviate anxiety in children. The efficacy of parental presence, premedication, and behavioral preparation programs on preoperative anxiety in children has been well described (Pediatr Med Chir 2014;36:98; Paediatr Anaesth 2006;16:1019-27). Currently, the effectiveness of video games and video distractions (i.e., watching movies or television shows) in easing separation anxiety and mitigating observed postoperative maladaptive behaviors is being evaluated (Anesth Analg 2015;121:778-84). Allowing children to immerse themselves in an enjoyable activity like a video game, which can be easily downloaded to any smartphone, might reduce perioperative anxiety and maladaptive postoperative behaviors. During an inhalational induction, video distraction has demonstrated efficacy in facilitating the child’s acceptance of a mask and cooperation (Anesth Analg 2015;121:778-84). With a readily available tool to help potentially reduce the incidence of emergence delirium and perioperative anxiety, why would anesthesiologists not use a smartphone?

There is always more than one side to a story, and smartphones are certainly no exception. The Table describes the advantages and disadvantages of using smartphones in the perioperative area. An internet search yields multiple hits for lawsuits about “distracted doctoring,” a phenomenon describing the habitual nonessential use of smartphones during patient care that results in patient compromise. For example, in 2011, a Dallas-area anesthesiologist was sued for malpractice because a patient died while he allegedly used his smart device to access social media, read eBooks, and use the internet (Explore 2014;10:267-71). During the trial, the anesthesiologist’s social media posts were presented as evidence for the jury, and the prosecution called medical personnel involved in the case as witnesses to corroborate that the doctor-defendant was indeed distracted while the patient deteriorated.

In a medical malpractice lawsuit, records of any smartphone use during patient care (including texts, phone calls, emails, social media posting, and internet browsing) may be subpoenaed. While the Fourth Amendment does protect against unreasonable search and seizure, evidence of smartphone usage during patient care is admissible in court when a patient is harmed. Anesthesiologists should be mindful of this fact, since cell phone records are commonly subpoenaed and thus subject to review by both defense and personal injury attorneys during discovery. It is therefore important to remember that: 1) Any smartphone use (including the content) during a case with an adverse outcome may be subpoenaed and therefore made public and 2) any colleague in the room can be called upon to testify regarding whether the anesthesia care team was distracted. The consequences of distracted doctoring can include suspension of hospital/facility privileges, state medical board investigation and sanctions, negative media coverage, public relations challenges for the anesthesiologist and/or the practice group, loss of employment, and reporting to the National Practitioner Data Bank (APSF Newsletter 2017;31:59-61). These consequences may lead to severe mental distress for the anesthesiologist who experiences them.

Legal issues aside, smartphone use is thought to present other patient care risks. From a nosocomial infection standpoint, smartphones are typically kept close to the body. There are no universal guidelines for cleaning clinicians’ smartphones between patient encounters. In one study, 40 anesthesiologists working in the OR were asked to wash their hands and then make a personal call. Bacterial contamination was found almost universally (Anaesthesia 2007;62:904-6). Smartphones may potentially interfere with OR equipment, such as pacemakers and cardiac monitors, due to the electromagnetic radiation produced. Further, alerts and ringtones can amplify OR noise and distract the anesthesiologist. And using a smartphone camera to create photos or videos might reveal patient or personal health identifiers, thereby breaching medical confidentiality and posing ethical risks.

Given the risk of distraction, infection, and ethical infractions, why would any anesthesiologist bring a smartphone to work?

Smartphones are here to stay, and every anesthesiologist who uses one should do so safely and prudently. This can be accomplished by reviewing guidelines issued by employers and professional societies like ASA and the Anesthesia Patient Safety Foundation (APSF) regarding PED/smartphone use at work. The ASA Committee on Quality Management and Departmental Administration published a Statement on Distractions recommending that all workplace PED use should be kept to a minimum and limited to professional activities (asamonitor.pub/3Na4LEX). Further recommendations include establishing a workplace stratified risk policy for PED use, limiting noise/music in critical areas, creating no-interruption zones (sterile cockpits), enforcing PED-less safety time-outs, and evaluating all new technologies brought into the perioperative environment for their distraction potential (asamonitor.pub/3Na4LEX).

Distraction-free zones (sterile cockpits) are the product of quality safety initiatives designed to reduce errors and improve vigilance and communication in the OR via eliminating background noise and nonessential conversations during induction and extubation (Anesth Analg 2019;129:794-803). Like other medical safety initiatives (e.g., crisis resource management), the “sterile cockpit” was derived from an aviation industry safety initiative. Analysis performed after aviation accidents in the 1980s found distracted flight crews as the root cause. The Federal Aviation Administration called for ceasing nonessential conversations and activity during take-off and landing (Anaesthesia 2011;66:175-9). As a corollary, smartphone capabilities like texting, calling, social media, and playing music should be prohibited in distraction-free zones (e.g., during induction and extubation) to reduce auditory and physical distraction. Such prohibitions will increase patient safety by providing anesthesiologists with an environment where mental efficiency and cognitive load are not overburdened during critical phases.

The APSF reviewed relevant literature and polled key stakeholders to develop their own recommendations on PED use. The APSF advocates for designating distraction-free zones to eliminate unnecessary clinical distractions (Anesth Analg 2017;125:347-50). This includes eliminating environmental noise that PEDs produce via music or auditory alarms. The APSF also calls for practice groups to establish criteria for accepted and unaccepted PED use within work environments.

Employer policies regarding smartphones/PED use within the patient care environment will vary. These policies should be reviewed carefully prior to using any smartphone application during anesthesia. Anesthesiologists should take note if their employer has a policy on distraction-free zones and be sure to comply with the PED regulations. Other workplace policies may include required device cleaning between patient encounters (if PED use is permitted in patient care areas), stating whether employees may access email while at work, and what cybersecurity measures doctors must use when accessing electronic medical records on PEDs. It is equally important for employers to review, decide upon, and share any penalties for noncompliance.

As technology evolves, smartphone use in the perioperative area continues to streamline medicine and enhance convenience. Health care employers should regularly assess these new technologies not only to determine whether and how they improve efficiency and patient safety, but for potential sources of distraction and other risks that could lead to patient injury or litigation. Anesthesiologists may use smartphones to access medically relevant content and as an alternative to sedation to ease pediatric-patient anxiety, but only when in full compliance with employer and governing body policies and procedures.