April Journal Club

[katevaughn]

This month's journal club is presented by Belinda. Technology has provided a tremendous pathway to improving medical/surgical outcomes. Unfortunately, it has also led to more distractions in the operating room. Belinda has chosen a great article looking into this issue further and the impact it has had on our practice. Please see the link to the article below.  

Here is a link to the article. 

Personal Electronic Devices (PEDs) are an integral fixture in our daily lives.



1. What are you thoughts related to reading anesthesia related articles/literature (not specific to your patient) or checking work email in the OR or web surfing/shopping while providing patient care. Do you think the anesthesia provider described in this article was at fault for the patient outcome? Why/why not?



2. How do you manage your PED use in the OR/patient care areas (strictly for patient care purposes or for personal purposes) and do you think this should/will change? Do you think this article will change your practice? Should we be held to different standards than everyone else in the operating room?

[mscotth2]

The world we live in is changing!

1. I will look up syndromes or procedures I am not familiar with on my computer or phone. Occasionally I re-access those during a case to refer back to pertinent points. We have a wealth of knowledge at our finger tips! I don't think shopping is appropriate though In the article presented, I can see where the lay person was looking to place blame and how it looked that the anesthesia provider was looking at the internet. However, with the information provided, it sounds as though short of asking that the procedure be aborted, the anesthesia provider followed the standard of care.

2. I use my cell to text and call attendings; I don't use a pager as I found it unreliable. Tis article raises awareness of potential issues that could arise. What kind of standards are we referring to? We are the most vigilant providers so we are already held to high standards..............

[AugustineEmmanuel]

Great article and very relevant in the our current healthcare environment. 
1. I think that due to the legal consequences of using PEDs in the OR it is best to avoid using it unless it's directly related to the patient you're taking care of. As anesthesia professional I'm sure we do often look up patient pertinent information online however other staff may perceive this as us entertaining ourselves by reading random things online. I do not think that the anesthesia provider was at fault in this particular scenario. We have often been in situations where we communicate our concerns with various proceduralists and it's dismissed or acknowledged without any intervention. From what I read it appears that the anesthesia provider managed the situation as best as he/she could. 
2. I usually default to using my pager to communicate with the attendings and surgery staff, however I do occasionally use my PED for those purposes as well. I think that it's hard to set a no PED policy in the OR since there are various extraneous circumstances not in our control: our paging system isn't always reliable,  lack of access to phones, urgency of situations, etc.

[Ben Waldbaum]

1.) From the description in the article, it does not seem like the anesthesia provider is at fault. It seems like they met the standard of care and communicated problems as they arose. The cardiologist is the one who chose to not act. It's a moot point, though, because of the PR problem of the "appearance" of distraction. I do not believe reading of patient related articles has the same "appearance" problem as it is obvious it is part of the care provided. As such, I am defining distraction as something not part of the care of the patient. To me, those activities should be avoided.

2.) Personally I do not use a PED in the OR because of the appearance of distraction. One cannot control when emails or texts arrive, and the urge to read them can be hard to resist. At the same time, clearly pagers are outdated and many hospitals have adopted widespread use of an ASCOM system among the anesthesia team. In our litigious world, your electronic data is constantly being monitored. As providers we must be cognizant of this "appearance" problem.

[Wai-Ling Lo]

Thank you for sharing the article. Here are my 2 cents:

1. It's obvious that surfing on the web for personal entertainment or shopping online while providing patient care is inappropriate. But whether everyone will strictly adhere to it is a different story. About the article, I think the anesthesia provider may still be at fault for the adverse patient outcome but I don't agree that was from the distraction of PED use. In my opinion, the problems were more about the provider's experience with EP procedures, the lack of ability to identify the differential diagnoses for persistent hypotension in EP procedures and the tell-tail sign of tamponade. Another TEE or TTE should have been done very early on when the pt first dropped his BP... at least that's what we will do on the 5th floor.

2. I mainly use PED to check work email or look up diagnosis/pathophysiology/medications/procedures that I'm not familiar with. In my opinion, technology may be new but distraction is not new. Even if there are no computer/PED/music/magazines... one can still be day dreaming or dozing off... The bottom line is being professional and accountable at all time. When our patient's life is at stake, the whole OR team should be vigilant and not just anesthesia providers. Hospital and departmental guidelines and policies can be used to guide the PED use. But these are good only if we adhere to them. The question is how to reinforce the policies to ensure patient safety. Should there be constant surveillance and monitoring from employers to ensure everyone adhere to the policy? Meanwhile before that's in place , I will continue to use PED responsibly and sensibly.

[Kels]

1. The standard of care seems to have been followed by the anesthesia provider in this case especially since the communication lines were kept wide open between anesthesia and cardiology. To protect oneself it just seems like you are better off just keeping everything you read/ reference/ look up (while in the or) related to the pt on the table at that time.

2. The only PED that I bring to work is my cell phone. However, the cell phone stays in my locker. The only time I have ever accessed my cell while at work has been during breaks and after work. Usually when coworkers find out that I do not carry my cell on me while working they ask why ? I strongly believe my personal cell phone should not be mixed with work in anyway. At the moment I will not change my practice of keeping my cell in my locker because the pressure to respond to my latest text is too great . In the past I have seen circulator nurses shop online. I believe all OR staff should be held to the same standard. All or staff should be focused on pt care and if on the computer it should be related to the pt in some way . If I have a pt on the table that is about to code I want to see my circulator by my side vs on the computer surfing the web .

[faresha]

Great article!

1. I do not think there should be a restriction on anesthesia providers relating to non-patient related activites as long as the provider provides safe high-quality care. Each provider is accountable and should be responsible for behavior that negatively affects patient care. The world is evolving and constantly changing. It may seem inappropriate to some that music may be played in the operating rooms during a surgery but I doubt any surgeon would be accused of malpractice because (s)he was distracted by the radio. I think it is appropriate to check work emails while in the OR but we don't need a policy to tell us not to do this during induction, emergence, or massive transfusion administration.

2. I don't think this article will change my practice because nothing on my PED is more important to me than a patient under my care but this article is relevant and important. No, we should not be held to different standards any more than we already are!

[emedina1]

My biggest problem is when I try to relieve someone for a break I see surfing on the web not related to the pt. on the table. I am not there to
lecture to someone however I think that our moral obligation to that pt. is to confirm their trust that they are our only object of our attention
at that moment.
Beth Medina CRNA

[nanci]

1. I agree that as long as the provider is paying attention to the patient, the monitors, their environment and being safe that there should not be any restriction to non-patient activities. That is the way of current communication-using your PED (phone, pager, computer, etc... to communicate with those not in the operating room). I don't think that the provider was at fault because he communicated with the cardiologist multiple times. As practitioners we multi-task all of the time. It does become a problem when the provider does not notice and when that becomes habitual should be amended.

2) I don't think that this article will change my current practice. I would hope that if PED are banned that organizations would find other means of providing communication. We should not be held to different standards as others (RN's answering pages for the surgeons, surgeons requesting music, other surgeons coming into the OR to discuss things not pertaining to that specific patient on the table, RN on computer playing games or reading their email, etc...).

[Vania]

1. My phone is my primary communication (via text) with attendings and other CRNA's during my work day. We also receive many emails throughout the day regarding schedule changes, requests for "call offs", etc. This makes my phone (and iWatch) critical to my day. I think this type of use is totally appropriate, and while I don't think that surfing or shopping is ok, I think glancing at emails or texts or even responding to them is fine, just not during critical portions of procedures or during complicated cases. As others have mentioned, everyone in the OR has multiple distractions and we all need to learn how to manage this while providing vigilant patient care. I do not think the anesthesia provider is at fault in this scenario. He made multiple attempts to communicate with the surgeon and made all of his concerns known without appropriate response from the team. It's unfortunate that they were able to use his PUD use to settle the case, when there were far more factors involved.

2. I don't think this will affect my current use. I feel that the large majority of us use our devices responsibly and for the purpose of patient care. Everyone in the OR should be held to the same standards because the patient is relying on everyone present to perform their job reliably and diligently.

[kty67]

1. The phone became a part of everybody's life. As mentioned by most of responses, we keep all important info in our phone: schedule, addresses, notes. I use my phone mainly in OR just to check texts that come through since I transferred all my pages to my phone. I can check my emails from work and answer if I am in a middle of the case and it is smooth ride. I don't even look or hold my phone in any critical situation or even when I can hear any changes of sound from the monitor. I believe it is a distraction, but you just have to be vigilant. I think some conversations and music (loud) is more distractive in OR, that actually comes from surgeons and nurses.
2. I don't think this article will affect my future use of my phone in OR because I am very conscious about it use. I keep my sound off or very low, I don't answer it during the case, I can send a text message to let people know I will call back when I can.

[krechti1]

1) I agree that the anesthesia provider is not at fault in the case presented. It seems they did the right thing by informing the surgeon about every change in patient status, and what happened was beyond their control. I do think it brings up a very good point regarding perception of what the anesthesia provider is doing by everybody else in the room. Some of us are very good at multitasking, and can check emails, etc. without it causing any disruption to our vigilance to the patient or surgeon. Others get sidetracked and are not able to do this while caring for a patient. I think we all know which one of these we are, but we also have to be mindful of what people in the OR perceive us to do. Even if we are completely in tune with the sounds of the monitors, voices of the surgeons, and if we are doing monitor and patient checks frequently..... if something happens to the patient and somebody in the room says you were surfing the web, or texting, this could have a negative impact on us.

2) I also use my phone as my pager. Often, when I am texting a page, I verbalize that I am paging so-and-so for extubation, etc.. This way, people in the room will know I am not just texting but rather paging my attending regarding the case. This article will not change my practice but I have become ever more aware of the perception of what I am doing in the OR, and this article does reinforce my belief that we have to continue to be cautious of the perception of us by others in the room.

[jhadley]

Great article, it really made me stop and think about my current practices.
1. I do not think we should be reading non-work related articles or surfing the internet while providing anesthesia to patients. In regards to work email, important information is often disseminated via email and I feel if I don't check it frequently things get buried in my inbox and can be missed. I feel I can do this without it impacting my patient care. The provider in this case seemed like he took appropriate actions and was not at fault. It does highlight the lengths that lawyers are willing to go to win a case, which I find unsettling.

2. In regards to PED, I carry my cell on me in case there is an emergency with my baby; but I do not respond to texts, calls, or check my personal email while I am physically in the OR taking care of patients. I prefer not to use my phone to text attendings and use ping instead.

[Andy Benson]

This is a great article. Thanks Belinda for sharing it with the group.

1. I actually think about this topic frequently. One day I walked around Weinberg and noticed that in 90% of the rooms the anesthesia provider was surfing on the internet (and it wasn't EPIC). I didn't go into the rooms, I just walked by and saw from a distance. I didn't pay attention of who the providers were; it wasn't my objective. This topic is very concerning and yet I don't think anyone has a good answer on what to do. I think it is beneficial to have access and look up anesthesia literature related to your cases. I don't think we do a complete lit review in the OR but if you need to look something up it is extremely helpful. I use my phone to communicate with my attending as I handed in my pager. One has to be able to balance the OR distractions. In the article, I don't believe the provider is at fault. However, it is the perception of others that he/she was not paying attention. It's unfair but it happens. The scary thing is that lawyers now will look into PED use and probably use it in every case. Forget the lawyers, I want to avoid the surgeon looking over the drape seeing me with my phone in hand.

2. I believe in the future there will be an official policy about the use of PED in the OR at Hopkins. It will be a reaction from something that horribly happened. I have heard a few lectures on this topic so I really try to limit my PED use. It is extremely hard for me. I can feel the emails building up in my inbox when I am in clinical and the last thing that I want to do at the end of the day is to read 100 emails but it must be done. When we are in the OR, it is our only job to focus and take care of the patient. We need to minimize the use of our PEDs.

[BrittneyKeating]

1.) I do not think that reading anesthesia related articles or literature should be prohibited while in the OR providing patient care. Scientific knowledge and evidence-based practices in our field are changing rapidly, making it a challenge for health care providers to be up to date on all of the medical conditions and anesthesia related practices that we face on a daily basis. When presented with a unfamiliar medical diagnosis or unique anesthesia considerations for a given patient, I think that the anesthesia provider should be able to utilize the large database of research available to us on the internet to become better informed and provide optimal anesthetic care, even while providing patient care. The article mentioned that there has been research suggesting that vigilance is improved under some circumstances by keeping the anesthesia provider intellectually occupied and clinically stimulated during low workload portions of the maintenance phase of anesthesia. I agree with this suggestion, as reading and re-familiarizing oneself with patient related or case related considerations can stimulate increased awareness and consciousness of certain patient/case/anesthesia related factors that otherwise might have “gone under the radar.”

2.) I utilize my cell phone for getting in touch with other anesthesia providers that I work with during the day, as I find PING messaging to be slow and inconsistent in delivering messages. Given the fast pace, and urgency often associated with our day to day work, I find that utilizing my cell phone for communicating with my anesthesia attending to be often the safer and more reliable option. Unfortunately, this then presents temptations to check emails or text messages unrelated to patient care. I think that use of the Ascom phone for anesthesia providers is a great option, as it offer the same ease of communication and speed as a personal cell phone, without the distraction of personal text messages, emails or work related emails while providing patient care.



This article has increased my consciousness in regards to utilizing PEDs in the OR and procedural areas. I think the article does a great job at highlighting the fact that the jury and other examiners in a medical-legal case are usually unfamiliar with our day to day work environment, and that even the slightest activity on the computer or PED will be seen as a distraction from patient care, and lack of vigilance.