Do cell phones and tablets affect communication and concentration?

A resident observing the surgery takes a call on his cell phone. The scrub nurse flips through images of wedding dresses on her smartphone. The operating surgeon’s assistant steps in to ask a question about another patient. The anesthesiologist taps his foot in time to the beat of the music in his earbud. It’s just another day in the operating room (OR).

Recently, AAOS Now editorial board member Michael F. Schafer, MD, assembled a group of surgeons with a particular interest in patient safety to discuss distractions in the OR, their potential impact on patient safety, and steps that can be taken to address the issue. Joining Dr. Schafer were Dwight W. Burney III, MD; William J. Robb III, MD, chair of the AAOS Patient Safety Committee; and Col Daniel W. White, MD, U.S. Army.

Dr. Schafer: Let’s start by defining the issue. Dr. Burney, what do you see as the problem in the OR with distractions?

Dr. Burney: Well, this came to our attention from a number of sources. A commentary by Peter J. Papadakos, MD, that appeared in Anesthesiology News (November 2011) focused on his concerns that the nonmedical use of wireless devices, such as smartphones and tablet computers, would be distracting. He also related his anecdotal experience of seeing OR staff surfing the Internet during a surgery.

The New York Times later picked up and expanded upon this issue, referencing an article in Perfusion that reported the results of a survey of cardiopulmonary bypass technicians, almost half of whom admitted that they had texted or taken cell phone calls while they were managing patients on cardiopulmonary bypass. But most of those surveyed also thought that was not a safe thing to do, so there was a disconnect between their ideas about safety and their actual practices.

Dr. White: I believe it is reaching epidemic levels. Nurses texting and playing “Words with Friends”, anesthesiologists surfing the Net, and alarms and notices throughout the case. All of it can be quite a distraction. The patient monitors and the necessary noises are enough. Add to that the deafening sound of some of our power tools, and the noise level is quite high. The louder it gets, the harder it is to communicate effectively.

Dr. Robb: One article measured and categorized distractions as being unpreventable or preventable and controllable. Unpreventable distractions might be noises created by monitoring equipment in the OR. The most frequent distraction was doors opening and closing, people just entering the room whether by necessity or not. The noise level was also much higher than would be allowable in most work environments. Although phones and pagers were mentioned, they were last on the list of measured distractions.

Dr. Schafer: How does the term ‘sterile cockpit’ apply to the OR?

Dr. Burney: Several articles in the anesthesia literature talk about the critical phases of anesthesia—induction and emergence—that are analogous to critical phases in aviation—take off and landing. Studies on distracting events during the critical phases have found few distractions during induction but a large number of distractions during emergence.

This corresponded with the findings that led to the Federal Aviation Administration’s passage of the ‘Sterile Cockpit Rules’ in aviation to reduce the number of accidents created by extraneous conversation or non–flying-related tasks that were being performed by pilots during taxi, takeoff, or approach to landing. The sterile cockpit means that no tasks are to be undertaken by the flight crew during the critical phases of taxi, takeoff, and landing in any operation below 10,000 feet above ground level other than level flight and cruising.

We can make the analogy between emergence and landing or induction and takeoff, and it’s been suggested that we adopt the sterile cockpit idea for the critical phases of surgical procedures.

Dr. Robb: The specific definition of the regulation—U.S. FAR Part 121,542—comes from the Aviation Safety Agency: “No command pilot and no flight crew may allow any other activity during a critical phase or flight which may confuse any flight crew member from the performance of his or her duties or interfere in any way in the performance of their duties.”

Dr. Schafer: Anesthesiologists shouldn’t be on the telephone or the Internet while they’re waking patients up or putting them to sleep and probably not on at all during the surgery. I can understand the circulator nurse not talking on the cell phone during the procedure. But what about distractions with the scrub nurse and the surgeon during procedures?

Dr. Robb: Within the OR environment, you have critical phases. Because everyone must work as an effective team, anything that interferes with team performance has a significant impact. Distraction has been shown to do that; it degrades the performance of the entire team and introduces errors that wouldn’t otherwise occur.

That’s why the sterile cockpit rules apply to the entire crew, not just the pilot. We’re talking about team performance and degradation of team performance, introducing errors, basically as observed in flight aviation, and similarly as a concern in ORs.

Dr. White: Personally, I’ve begun to wonder whether we’ve created an environment that leads to distracted teamwork with the implementation of all-electronic documents. Our facility has converted all OR documentation to an electronic format. The time-sensitive nature of date/time stamping documentation of the time out, antibiotics delivery, incision time, tourniquet times, and other required documentation is an issue for the OR staff. At times, the OR nurses are so occupied or preoccupied with entering the documentation that the focus on the case and patient care can be lost.

Dr. Burney: Only about 2 percent to 3 percent of people can actually multitask; most of us have a measurable decrease in performance if we try to do too many things. The widespread adoption of wireless devices such as tablets, computers, and smartphones is problematic. It’s really a question of being aware of the possible adverse effects of these activities on performance. If we’re not very careful about how we use these devices, we can introduce more chances for error and patient harm.

Dr. Schafer: Okay. What if I give my circulator nurse my smartphone and the phone goes off during surgery and she says to me, “This seems to be an important call, would you like to take it?” Number one, should she do that, and number two, if it is important, should I take it?

Dr. Robb: The American College of Surgeons has actually already published a position paper on this, with several recommendations. It says that such devices should be left outside the OR. If they are brought into the OR, they should be on silent function so that they’re not disruptive or distracting. If a critical call has to be taken, there’s a way of communicating that. When the team is distracted or interrupted, you have to go back and actually ask, “Where did we stop? Where are we starting?” They do this in cockpits.

I’m not sure surgeons do that. The processes to manage distraction or interruption aren’t commonly practiced in the OR. Changing the way we deal with these various communication devices is going to be important to maintain the integrity and focus of the OR team.

Dr. Burney: We know that disruption of the surgical flow is a major cause of potential errors. For example, with automated medication dispensers, nurses had to create a sterile zone around the dispenser so that the nurse who is trying to dispense medications or stock won’t be distracted by extraneous conversations or questions. One of the strategies for dealing with this is to put these machines away from high traffic areas or enforce a ‘no-interruption zone’ when the nurse is actually dispensing medication.

Dr. White: It is frustrating to be distracted during a multistep procedure and lose the flow of the operation. When excessive extraneous activity occurs in the OR—personnel changes, breaks, non–case-oriented discussions, phone calls—the surgeon can feel as though he or she is the only one in the room focused on the case. This feeling of being alone is exactly what the “sterile cockpit” is intended to avoid.

Dr. Schafer: I see the problem, but how do we prevent it? Dr. Robb, will you expound on those ACS recommendations?

Dr. Robb: Number one: Leave pagers and cell phones outside the OR or turn them to silent mode.

No web surfing, text messaging, or cell phone conversations in the OR. No loud or distracting music. And then finally, only pertinent conversation from the anesthesia team related to the case. The banter between the anesthesia, surgery, and/or nursing teams needs to be related to the surgical care. Limiting all nonessential conversation maintains the central focus of the surgical team. That’s particularly true for critical periods of the surgery. Nonessential conversation degrades the environment and is distracting.

Dr. Burney: A lot of the surgical literature deals with the two types of required skills—the technical skills, which are the actual performance skills, and the nontechnical skills, which have more to do with communication, coordination, and teamwork. Lab studies in which distractions were introduced into a simulated procedure have found that the technical skills hold up fairly well but the nontechnical skills suffer.

If you’re trying to maintain a smooth flow of the surgical process and your ability to communicate well and to coordinate is being affected, it can introduce the potential for error and harm.

Dr. White: I agree that distractions from the portable electronic realm should be minimized if not eliminated. A “sterile cockpit” environment should be established during critical phases of the operation such as critical dissections and when opening implants.

Dr. Schafer: That’s a good point. What about observers? Are they okay?

Dr. Burney: Some evidence suggests that interrupting the surgical flow to make teaching points may degrade your performance a little bit, but that’s part of the mission in the teaching institution. I think it’s incumbent on the surgeon to be aware and ensure that the process flow does not suffer. The patient’s safety is the overriding interest, and teaching has to be done within the context of a safe procedure.

Dr. White: Teaching has a distracting component, but patient safety must trump all distractions, including teaching and other “intended distractions.”

Dr. Schafer: What about computer-assisted surgery? Is that okay?

Dr. Robb: I do computer-assisted surgery, and it’s part of the workflow. If anything, it increases focus; it’s not a distraction.

Dr. Burney: At least one surgical simulation study showed that when you introduce a controlled level of distraction into the simulation, the performance really decreases the most for laparoscopy, less for robotic surgery, and least for standard open surgery.

Dr. Schafer: Do you think we should mandate that none of these distractions is allowed in the OR?

Dr. Burney: I don’t believe so, in part because wireless tablet computers are becoming a very big part of medical education. So the same device that gives access to text messaging, movies, and music also has medical school textbooks and lecture notes. That makes these multifunctioning devices potentially very valuable for enhancing patient care.

I think it’s going to be a question of individuals being very self-aware and understanding that their ability to monitor situations can be significantly degraded by using these devices for non–patient-care purposes.

Dr. Robb: As we accumulate information regarding the effects of different types of communication and distraction in the OR, regulations may evolve from various agencies, such as the Joint Commission. I think we will have regulation, but, until then, it’s the responsibility of the individual surgeon and surgical team to ensure that the patients have the best outcomes.

Dr. White: In our OR, we do the TeamSTEPPS brief in the morning and before each case. During these briefs we strive to point out the critical surgical portions of the case and request that staff turnover, breaks, and movement in and out of the OR be minimized during this time.

Dr. Burney: I think this really plays into the role of structured team communication, and I think that the more structured and the more formalized the communication techniques are, the more likely we will have a safe environment. That’s what we’re pursuing with TeamSTEPPS, but eliminating distractions in the OR will have the same effect. I think that communicating very carefully and in a very precise way will have a great deal to do with that.

I think it’s very interesting that the initial concern with smartphones and tablets was that people were taking work home to the detriment of their personal relationships. Now the concern is that people are bringing home to work to the detriment of patient safety.

Disclosures: Dr. Schafer— DePuy, A Johnson & Johnson Company; Medtronic; Journal of Bone and Joint Surgery–American; Spine; Dr. Burney—no conflicts; Dr. Robb—Innomed; Blue Cross Blue Sheild Association; Abbott; Baxter; emmi Solutions; Johnson & Johnson; Stryker; Dr. White—no conflicts. The opinions presented by Dr. White are his own and not the official positions of the U.S. Army, Department of Defense, or U.S. government.

Online resources:

1. Papadakos PJ: Electronic Distraction: An Unmeasured Variable in Modern Medicine. Anesthesiology News 2011;37:11. Accessed online 3/30/2012 (Login required)
2. Richtel M: As Doctors Use More Devices, Potential for Distraction Grows. The New York Times, Dec. 14, 2011; accessed online 3/30/2012
3. Smith T, Darling E, Searles B: 2010 Survey on cell phone use while performing cardiopulmonary bypass. Perfusion. 2011;26(5):375-380. Epub 2011 May 18. Accessed online 3/30/2012
4. Pereira BM, Pereira AM, Correia Cdos S, Marttos AC Jr, Fiorelli RK, Fraga GP: Interruptions and distractions in the trauma operating room: Understanding the threat of human error. Rev Col Bras Cir 2011;38(5):292-298. Accessed online 3/30/2012