Grand Central Station

Maybe my patience is getting shorter as I get older but I have felt that the number of distractions in the operating room has increased dramatically.  I know this is a well researched topic and as I was contemplating what I would write about I had a chance to review PUBMED as well as several other sites including several well written statements from the American College of Surgeons.  However, in my review of these sources, I found that the real world implications of this distracting environment were lacking.  Sure, we all know that every time someone enters or exits the room the positive pressure can be overcome allowing the “dirty environment” from the hall to enter the room increasing the risk of infection for the patient we are trying to help.  We also know that our smart phones provide distractions to those in the operating room in multiple ways.  However, I would like to argue that the problem is much greater than this and as a surgeon who cares both about the patient and the entire surgical team, it is time that we all speak up in the interest of better outcomes and patient care.

I’d like to break this topic into three segments.  First, I will try to describe the elements of the distracting environment from the ground level.  Second, I will review the problems with distractions.  Third, I will discuss what we can all do about this.

Distractions in the OR can be broken down into two categories.  The first is related to the movement of people.  The second is the encroachment of the external environment into the OR environment.  When I walked into the OR for my first case earlier this week, I found a total of 14 people in the room including me and the patient.  Of course, many of these people are necessary to help with the surgery but I think we can all agree that 14 is too many.  In addition to me, the patient, the anesthesiologist, and my resident, the other people in the room were the nurse anesthetist (needed when the anesthesiologist goes to another room), an EMT student there to practice intubation, the circulating nurse, the scrub technician and her scrub student, our surgical PA, the robotic technician, and a monitor who comes in randomly to see if we are performing the pre-induction and pre-incision checklist correctly.  Finally, there were two medical students in the room- one rotating on Urology and the other on anesthesiology.

While this was a larger operating room, many of our operating room spaces are small and this many people make a crowd.  I am very supportive of our need to teach but as the surgeon who the patient came to with their cancer, it is my duty to balance this teaching obligation with my number one priority of patient care.  Even in the best of circumstances where we have a large number of people working together on a regular basis, this large a group requires leadership and management to direct activities.  In normal circumstances, I have not routinely worked with everyone in the room and worrying about who is doing what and whether they are capable of doing what they are supposed to be doing is a huge distraction from my primary job which is to perform a safe and effective operation.

The other challenge with this many people is that as a surgeon who cherishes my role as a teacher, there is only so much bandwidth I can contribute to teaching on any single operation.  If I am performing a robotic surgery and have a relatively new PA assisting at the bedside as well as a resident or fellow who is sitting on the other console wanting to learn and a medical student who is asking questions to learn about the surgery, disease process, and natural history of the cancer, how do I divide that time?  I have enough experience and expertise to be able to confidently teach while I am operating but even the best teachers struggle between transitioning to different learners with different needs at the same time.  Its akin to trying to teach at an old one room schoolhouse with multiple grade levels while performing a skilled trade all at the same time.  To manage this, I compartmentalize my efforts so that I try to give everyone the attention they need but not at the same time.  Sometimes, one group must be ignored out of necessity if teaching one particular person is necessary to help progress the surgery.

Of course, this complexity is only the tip of the iceberg.  The second big component of distraction related to people is the constant intrusions into the room from various people for various reasons.  This is perhaps the best studied aspect of distraction in the operation room with the metric of door openings as the key outcome measure for any study.  What these studies don’t often get into is the reason for why a person is opening the door and what the implications are for the surgery.  On first pass, the most logical reason to leave or enter the room is to obtain additional supplies or equipment needed for the surgery.  In my informal review over the last several weeks, tmost common reason is actually one staff member giving a break for another staff member.  There are many people in the OR space that get routine breaks to have lunch, get a drink of water, etc… as mandated by law and/or institutional policy.  This includes the circulating nurse, the scrub tech, and the anesthesia team.  I don’t begrudge people breaks but there is often no apparent pattern to me as to when breaks are given.  It did not seem to matter how long the case was as to whether someone got a break.  It did not really matter when during the case someone was given a break (although scrubs that I regularly work with will pass on a break at critical parts of the surgery).  It feels like breaks seem to escalate as the day progresses and it is not unusual for me to have a different anesthesia team, scrub, and circulator for every case after 3 PM which is when shift change occurs at our institution.

The door openings are only a minor distraction compared to not knowing who the circulator or scrub is in your room at any given time.  A key component of the surgical checklist is that everyone introduces themselves by name at the beginning of the surgery.  This is supposed to create familiarity and a sense of team because it is easier to communicate with a person who’s name you know rather than calling them circulator or anesthesia.  The current process makes this a moot point because I have to look up, ask the person’s name, and then ask for what I need when someone is being subbed out every 15 to 30 minutes.  Those few seconds can disrupt the cadence of the case.  And forget about me but this churn distracts everyone in the room from the work that needs to be done.  The perfect consequence of this occurs on a very long case when the people who I started the surgery with are long gone and the replacements had variable sign out resulting in incorrect needle, sponge, or instrument counts resulting in the need for unnecessary x-rays and added time under anesthesia.

I don’t want to belabor the point but the number of reasons people come in and out of an operating room are mindboggling.  Good reasons include bringing in supplies or medication or picking up surgical specimens.  In addition, I often will check on my colleagues in other rooms before or after a surgery to see if they need any help or if I can do anything like check on their inpatients to help reduce their distraction in the OR.  But often we have charge nurses walking in to see how long a surgery may last, other people coming in to discuss non-patient related issues with a colleague.  In this environment, the patient and what we are here to accomplish becomes an afterthought to some team members.

The second culprit of distraction is the external environment encroaching into the OR.  Again, this is a topic that has been well studied and characterized.  There are so many ways that things in the OR encroach on our attention.  Pagers, electronic white boards, smart phones, other monitors and instruments with alerts, the electronic medical record, internet access, music, and probably 10 other things I have not described that bring in external pressures on the attention of the surgeon and surgical team.  Some of these are of course necessary.  Our integrated electronic medical record allows real-time access to the patient’s medical record as well as being able to instantly call-up and display imaging studies.  This is a huge improvement to when I first started and everything was still paper charts and imaging studies that had to be displayed on light boxes.  But just like Times Square, almost everywhere you look in the operating room is occupied by visual and auditory distractions.  The decision to play music in the operating room has been studied with inconclusive results but I find that it helps because it provides a “white noise” that helps dampen other noises and the beat can often help with the cadence of a case (I will ask the circulator to change the music if it is particularly slow).

Many have transitioned to smart phones for medical communication but it is often difficult to discern whether an alert on the phone is a page, text communication, or an alert from an app that I or any of the other myriad people in the room forgot to turn off.  We can’t shut our phones off because even though we must be focused on the patient we are taking care of, on call responsibilities, calls from clinic, or other urgent matters sometimes do require temporary distraction to assist with the care of another patient.  The bigger issue is how much technology can pull our attention away from the patient and task at hand.  The amount of effort by any one member of the team ebbs and flows during a case.  Circulators and anesthesia members who are not scrubbed in may fill the boredom with searching the internet, social media, etc… As a robotic surgeon, the more common phenomenon that I see is the resident or fellow on the computer or their phone when I am preparing to transition a portion of the surgery to them.  They often are doing other work (checking labs or directing patient care) but these distractions disrupt the flow and teaching in the OR.

I could go on with many other examples but I believe that I’ve captured the major causes of distraction in the OR.  Some of you who work in environments where a surgeon runs several rooms might think that this is just something a skilled surgeon must learn to balance to be successful but I can’t imagine that all these sensory and mental distractions don’t impact care especially in the setting of sicker patients or complex operative procedures.  I find that after a long day in the OR I am not as much physically tired as emotionally drained from having to manage these distraction for 10-12 hours.

The problem with distractions is far greater than infection control.  In fact, I am surprised at how few infections I do have given the churn of people coming in and out of the OR.  If you have read my other blogs, you might expect me to say that the bigger problem is efficiency.  While I believe that distractions create a great deal of inefficiency, I believe that it is an uphill battle to improve this.  Some of our inefficiency is baked into the academic model where teaching is a critical part of our mission- a mission that I strongly believe in.  Inefficiency also comes from the complexity of the patients.  However, efficiency could be improved with less distraction from the churn of people and decreasing sensory distractions that might add up to a 5-10% improvement each case.  It would be an interesting cost-effective analysis to perform and I would suspect that a health system that was willing to embrace this analysis could see large returns on investment.

The greatest problem with distractions is that it fundamentally dehumanizes the patient we are caring for and in the process, dehumanizes everyone involved in the operating room.  Like a three ring circus, the environment of distraction in the operating room creates multiple foci of attention of which the surgery and patient are only one of the centers of attraction.  In fact, the operative field becomes another sensory overload in the overall tapestry of the OR.  Everyone hopefully knows what we are technically there to do, but the distractions of smartphones, EHRs, instrument/sponge counts, time outs, hand offs become the immediate goals taking away from the meaningful work of caring for the patient who is someone’s neighbor, friend, parent, child, and/or family member.

Each one of us becomes dehumanized in the process because our attention is drawn to these small and sometimes unimportant tasks over understanding how our presence and action benefits the patient we are trying to heal.  This is accelerated by the constant churn in the room.  When we are treated like cogs in the machine where one person replaces another on what is supposed to be a team (think back to the surgical introduction at the time out), we begin to feel that our work is replaceable.  From personal experience and getting back to the issue of efficiency, that is not the case.  As I alluded to in my post on “Close to Perfect”, a good team makes for a great day not only because we get to take great care of patients but also because it acknowledges the importance and value of each member of the team.

What can we do about distractions and the dehumanizing effect it has on every person in the OR?  While I appreciated the reports from the American College of Surgeons, I believe it fails to acknowledge the realities of the day.  Our mobile devices have truly become life lines and silencing them or signing them out to the room would not prevent the other mechanisms (texts, emails, etc…) that people use to access us in the OR.  However, we should all make an effort to reduce the noise coming from our phones.  First, disable all the push notifications sent from some apps.  It seems like every app that is installed vies for our attention aside from pager or text function, nothing else truly needs to intrude in the OR.  In addition, a parking lot for our mobile devices should be created in the OR and rules should be set for what the circulator needs to respond to.  The circulator has a critical job to do in the OR and it is not to respond to text messages from a significant other asking about dinner plans.

Dealing with the churn of people in the OR is somewhat more difficult but it starts with acknowledging the problem.  Those in charge of patient flow need to understand the impact of the number and timing of breaks, of the number of learners that can be meaningfully served in any particular operating room, and not forget that we are here to care for patients.  I plan to try a couple of experiments in this scenario.  First, I will ensure that the patient is aware of every learner in the operating room.  As surgeons, we explain the presence of residents and fellows as part of the consent process.  Does the anesthesia team and circulating/scrub team make the patient aware of other learners in the OR?  While we need to promote the teaching mission of academic medicine, there should be a reasonable limit on the number of people in the operating room.  That number may vary but there is an upper limit.  Finally, and perhaps most important we need to restore both the patient’s and our humanity to the operation.  This starts with the surgical checklist.  Team introductions should mean something.  It should not mean that I am here for 15 minutes until my shift ends or that I can take a break during the critical portion of the surgery.  It means that we all take accountability for the patient and each other.  At one point, a colleague of mine suggested telling something meaningful about the patient during the surgical checklist.  This could be simple like Mr. X is a retired high school math teacher with three children and 5 grandchildren or more applicable to the case such as Mrs. Y was diagnosed with invasive bladder cancer, was able to get through but struggled with her chemotherapy and hopes to be able to get back to her volunteer work once she has recovered from surgery.

I’m not trying to preach but I would suspect that if we re-inserted the human element into the OR instead of treating it like Grand Central Station it would pay dividends for efficiency, health care costs, improved outcomes and most importantly the very meaning of why we are here- to alleviate suffering.  Thanks for reading and have a great week.

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