AAOS Now

Published 3/1/2016

Face-Off: Smart Phones in the OR

Recently, patient deaths and other adverse events in the operating room have been attributed to distraction among physicians and operating room staff when they use their own smart phones for non–patient-care-related activities in the operating room. Should they be banned? Dwight W. Burney III, MD, and Bopha Crea, MD, face off with their views on the issue.

Point: Recognize the Risks
Dwight W. Burney III, MD
Smart phones and tablets are well on the way to replacing computers as the method of choice for Internet access. This "disruptive innovation" has obviated an expensive wired infrastructure in much of the world, and instantaneous access to information via search engines and apps is a universal expectation. It is abundantly clear that smart phones are not going anywhere.

Recent media focus on the role of smart phones in surgical mishaps is clearly sensationalized. However, it has called attention to the human factors at work and the safety hazards of distraction in a complex adaptive system such as surgery.

Humans have limits to short-term memory, and the ability to "multitask" is in large part urban legend. "Multitasking" is really performing multiple single tasks in rapid sequence, and any task-irrelevant information is a distraction that takes up our limited short-term memory and thus detracts from task performance.

It is also clear that peak cognitive load occurs at different stages of a surgical procedure, depending on the surgical team member's role. Case-irrelevant communications are significant causes of stress and distraction in the operating room (OR)—and two thirds of these are directed at surgeons. Even though surgeons generally handle stress and distraction well, the performance of other team members (and thus the team's efficacy) can be adversely affected.

Smart phones offer access to case-relevant information, but the powerful attraction of case-irrelevant information sources such as text messaging and social media cannot be denied. The current model of "BYOD" (bring your own device) inevitably leads to mingling of clinical and personal information.

Use of text messaging to convey clinical information lacks the richness of verbal communication and leads to oversimplification due to the lack of context. The impact can be seen in the information loss that haunts current methods of transition of care (hand-offs) and in the potential for many preventable serious adverse events. Although text messaging is clearly more time-effective than use of pagers, the temptation to rely exclusively on text messages carries risks.

Medical educators have pointed to dependence on smart devices and the subsequent potential for superficial learning and the failure to internalize fundamental information. Use of global positioning devices has been shown to diminish cognitive function in navigation. Sociologists have noted a tendency toward diminished face-to-face communication and some features of addictive behavior in people who are compulsive users of smart phones and other devices.

Finally, the issue of potential bacterial contamination arises with hand-held devices. A recent article in the Journal of Bone & Joint Surgery on bacterial contamination of smart phones used by orthopaedic surgeons found that more than 80 percent of phones were colonized with pathogenic bacteria. Although low-level decontamination effectively reduced colonization, significant bacterial recontamination typically occurred within 7 days.

Although the Association of periOperative Registered Nurses recommends low-level decontamination of hand-held devices before entering and after exiting the OR, how many members of the surgical team actually do this? Does failure to decontaminate these smart devices sabotage hand hygiene?

Earl Wiener, one of the pioneers in Crew Resource Management, once facetiously noted that (in automated flight systems) "for every function there is an equal and opposite malfunction." Clearly, although significant benefits may accrue from surgeons' use of smart phones, the downside may be less apparent; situation awareness (the most common "nontechnical" contributor to technical error in surgery) is degraded and communication is deficient when team members are distracted.

The principles of prudent, nondistracted use of smart phones in surgery must be internalized by all surgical team members as part of a culture of safety and high reliability. As humans, we make complex adaptive systems work by maintaining safe margins in performing our tasks. This includes recognizing and managing threats to safety.

As surgeons, we have an ethical and professional duty to serve the best interest of the patient. Recognizing and acknowledging the risks of smart phone use in surgery are the first steps in effectively managing them.

Counterpoint: Realize the Potential
Bopha Chrea, MD
Novelty and error: Like shiny objects to a crow, these concepts capture our collective attention more than almost anything else. Recent high-profile deaths resulting from smart phone-related distraction in the OR tick both boxes. The response has been incendiary—and for good reason.

All disruptive technologies deserve careful scrutiny before being introduced into an environment as fundamentally touch-and-go as the OR. In fact, my gut reaction upon hearing about these events was to support an outright ban—and I know I'm not alone. When a surgeon is wrist-deep in a patient, Facebook isn't going to be helpful. Right?

But before we, as surgeons, do anything overly reactionary, we need to weigh the pros and cons of mobile devices. Orthopaedics is a discipline that is symbiotic with technology; before we shut the door on both the current benefits and the potential for future innovations, let's slow down and consider what smart phone technology enables in the OR setting.

At a broad level, smart phones make available the booming realm of digital information. Search engines cleanly index the entire stock of medical knowledge for residents, medical students, and nursing staff, enabling them to amplify their learning from the sidelines.

Beyond being great educational tools, mobile devices provide instant access to the electronic health record (EHR), to surgical guides, and to other reference materials that can help a surgeon make informed decisions on the fly. They also enable more rigorous case documentation by providing convenient ways to upload photos and notes to EHR through apps like Haiku.

Smartphones, not surprisingly, amplify our communication abilities. In 10 keystrokes or less, we can instantaneously collaborate with experts and peers during difficult cases. This expands our ability to collaborate with other healthcare providers. Smart phones also enable on-the-fly coordination between ancillary staff, between ORs, and between residents and staff by cutting out the extraneous step associated with pagers. And, because any form of technology—including pagers—can fail or run out of batteries, having a smart phone as a reliable backup just makes sense.

On top of the clear benefits smart phones provide today, this technology is still in its youth. The potential for advancements that open up powerful new methods of patient care is huge. What innovations in telehealth, sensor technology, unified communications, and e-learning will be stifled by an out-and-out ban that signals to the market we aren't interested?

It's easy to argue that the OR is already equipped with computers, phones, pagers, cameras, and health records that achieve the same ends. The hard question is, why aren't people using them? My guess is that we have begun to hold technology to a much higher standard of convenience.

The first computers weighed thousands of pounds and filled rooms larger than our ORs. Today, I have enough computing power in my pocket to run the Apollo program. With a simple thumb scan and voice command, I can interface with an entire collection of medical information.

Older computing and communication tools also lose out to today's mobile devices on both ergonomic and economic levels. They aren't as convenient, as familiar, or as cheap as smart phones. Until hospitals have the resources to provide a better solution, BYOD fills a sizeable technological gap.

When we get down to it, distraction is a problem with people and not the tools that people use. Subtract the anesthesiologist's mobile device and he may still scamper off into his own imagination. Forbidding cell phones in the OR treats the symptom and not the disease. Rather than talk about a blanket ban that deprives surgeons of a powerful tool and forecloses the potential for revolutionary innovations, let's shift the conversation to thinking about how we can foster an OR culture with more centripetal force maintaining attention on the task at hand.

If actual health risks are associated with the introduction of cell signals to the surgical field, or if privacy ramifications or liability issues arise, the arguments against cell phones in the OR might be stronger. But until these risks are identified, legislating against a common-sense use of smart technology seems intrusive, reactionary, and overly bureaucratic.   

Dr. Burney heads the AAOS Patient Safety Committee's section on safety education. Dr. Chrea is an orthopaedic surgery resident at the University of Mississippi Medical Center.

Reference
Shakir IA, Patel NH, Chamberland RR, Kaar SG: Investigation of cell phones as a potential source of bacterial contamination in the operating room. J Bone Joint Surg Am 2015;97(3):225–231.