Unnecessary distractions frequent during surgery

NEW YORK - Surgical teams face an intraoperative distraction every 10 minutes, on average, according to a new study in which investigators observed 90 surgical cases in real time.

Distractions occurred in 88 cases (98%), with an average of nearly 11 distractions per case, Ana Wheelock, of Imperial College London, and her colleagues found.

"Although some distractions may be inevitable in the OR, they can also be detrimental to patients and surgical teams," Wheelock told Reuters Health by E-mail.

Multitasking can worsen performance, especially in high-pressure situations - for example, among airline pilots, Wheelock and her colleagues note in their report, published online January 23 in the Annals of Surgery.

However, they add, little is known about the consequences of distractions in the OR. Concerns have been raised that distractions can increase the risk of adverse events, the researchers add, and the Agency for Healthcare Research and Quality has made the reduction of distractions in the OR a "high-level priority" to improve patient safety.

To better understand the impacts of distractions in the OR on surgical team performance and stress levels, the researchers used four validated tools to assess distractions while observing 90 randomly sampled general surgery cases. A behavioral scientist and a surgeon were present in the OR during each case, for a total of 69 hours 40 minutes of real-time observation.

The most common type of distractions were when external staff entered the OR, which occurred an average of more than seven times per hour of surgery, or five times per case. Eighty-one percent of these visits were unnecessary.

"Case-irrelevant conversations" initiated by surgical team members were the second most frequent source of distraction, occurring more than four times per case, and nearly eight times an hour.

Distractions related to unavailable or faulty equipment were rated as the most intense type, followed by procedural distractions that were inherent to surgical work. Both types of distractions occurred less than two times per case, and roughly twice per hour.

Distractions were linked to worse teamwork, and the more irrelevant conversations a surgeon initiated, the worse his or her communications and leadership skills, while these conversations also affected coordination and leadership among anesthesiologists and OR nurses. However, these conversations were more likely to occur when OR team members reported lower workloads.

Distractions occurred less often during complex cases.

"Most external distractions were unnecessary," Dr. Wheelock said. "The main motivation of external visitors was to socialize with the members of the team or to fetch equipment and material to take to their own ORs."

"Importantly," she added, "excessive external visits not only distract team-members from their main task but can also facilitate the transmission of hospital-acquired infections."

"I was surprised by the sheer number of distractions, which at times were challenging to record, as some would happen simultaneously," Wheelock said. "The lack of association between external distractions and stress, workload, or teamwork was also baffling. Studies with larger samples may show different results."

Use of pagers and smart phones was also common during the surgeries observed, the researcher added. "Although some messages and calls were important, many weren't. There were at least two pagers, two mobile phones, and one OR landline active during each procedure. In my opinion, the number of devices allowed in the OR was excessive. Would you be comfortable flying on a plane with a cockpit subjected to such a number of distractions?"

While chatting about holidays or lunch can help relieve some of the stress that surgical teams face, Dr. Wheelock added, "Our findings show that ORs were constantly distracted and that surgical teams and hospital management were largely unaware of how perilous this could be. We propose that distractions should be the exception rather than the rule."

To limit such distractions, Dr. Wheelock suggested a "zero tolerance approach" to unnecessary distractions, "enforced by the attending surgeon with buy-in from the rest of the team."

"In the article, we proposed implementing the concept of a 'sterile OR' (the 'sterile cockpit' is already well established in aviation), where no unnecessary conversations occur at safety-critical points of a procedure," she said. "Better preoperative planning and communication, including a preoperative briefing, to minimize equipment-related distractions (e.g. missing or wrong equipment) are also necessary."

This research was funded by the UK National Institute for Health Research. The authors report no disclosures.

SOURCE: http://bit.ly/1zsX8tr

Ann Surg 2015.

References: Reuters Health
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