Is Your Surgeon Focused on You or His Smartphone?

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Texting and surfing can distract from patient care

The increasing digitalization of health care data is quickly making the smartphone one of the more important medical devices found in hospitals and clinics today. But their growing ubiquity and utility come at a cost. The smartphone allows the outside world to encroach on doctors and other health care personnel, often at the most inopportune times.

Patient safety advocates are warning there is a growing problem with distractions from cellphones during surgery and other high-risk medical procedures, leading to medical errors, inefficiencies and patient harm.

“It’s a major problem,” said Dr. Peter Papadakos, an anesthesiologist with the University of Rochester Medical Center. “We need to educate doctors, we need to educate our nurses, we need to educate our therapists. We need to tell the general public that this is a major health issue.”

While smartphones undoubtedly offer significant benefits for health care providers in terms of improved communication and ready access to guidelines and data, they carry a number of risks for patients. Studies have shown that phones routinely carry bacteria and viruses that pose infection risk, particularly in the operating room. Last year, reports from Uganda linked the transmission of the Ebola virus to contaminated cellphones. And the sending and receiving of data can interfere with the operation of some medical equipment.

But it’s the potential to take a doctor’s focus away from the task at hand that might have the most direct adverse effect on patients. The ECRI Institute, a nonprofit medical technology evaluation group based outside of Philadelphia, listed distractions from smartphones among its Top 10 technology hazards in health care in 2013.

In a number of cases in recent years, medical errors have occurred while doctors or other members of the surgical team were looking at their cellphones, texting, surfing the Internet or posting to social media.

“If something untold happens in the operating room, we know the malpractice litigant’s lawyer is going to get records of everybody’s cellphones in the room,” Papadakos said. “I think the Dallas case made people aware.”

That case involved Mary Milne, 61, who died during surgery to correct her irregular heartbeat in a Dallas hospital in 2011. Her family sued for malpractice. According to depositions obtained by the Dallas Observer newspaper last year, the surgeon, Dr. Robert Rinkenberger, accused the anesthesiologist of looking at a cellphone or tablet and failing to notice the patient’s low blood-oxygen levels for 15 to 20 minutes.

The anesthesiologist, Dr. Christopher Spillers, initially testified that he did not surf the Internet or post to Facebook during surgery, and uses his cellphone only to check on patient care issues. But prosecutors found an entry on Spillers’ Facebook page in which he had posted a photo of the anesthesia monitor during another surgery.

“Just sitting here — sitting here watching the tube on Christmas morning. Ho, ho, ho,” he wrote.

Scope of the problem

Michelle Feil, a patient safety advocate with the Pennsylvania Patient Safety Authority, highlights that case in trying to explain the risks of smartphone distractions to hospital administrators.

“Their eyes light up when they see pieces from the depositions in these cases,” she said. “That’s when they realize, ‘Oh my goodness, it could happen in our facility.’”

It’s unclear just how often that happens. Even in Pennsylvania where hospitals are required to file a report with the Patient Safety Authority any time a problem occurs, hospitals often report only the minimum required information. When Feil tried to analyze those reports to see whether smartphones were causing medical errors or patient harm, she found almost no mention of cellphones. But when she looked for errors related to distraction, she found 169 cases between January 2010 and May 2013.

Many safety advocates believe hospitals and surgery centers should adopt the sterile cockpit approach used in aviation to limit distractions during critical periods such as taxi, takeoff and landing. The rule prohibits nonessential conversation, eating or reading materials not directly related to operating the plane until the tasks at hand are completed.

In the operating room, those rules might have to be modified to account for the critical periods for different members of the surgical team.

When Feil looked at the types of errors in Pennsylvania linked to distractions, most of them had to do with inaccurate counts. Surgical teams must count things like sponges and other medical implements used in the surgery to ensure that nothing is left inside the patient.

“Everyone else may feel the case is coming to a close,” she said. “They’re not literally cutting into the patient or dissecting a nerve or operating on your blood vessel. But the team may not realize that it is a very critical moment for the person or persons doing the count.”

Doctor denial

Hospitals are increasingly facing financial penalties from public and private insurers for medical errors, infections or readmissions, so many administrators and patient safety coordinators see the value in stricter controls over cellphones to limit distractions.

“When they go back to their hospital and try to talk to the surgeons and their staff, they do get a lot of pushback,” Feil said. “There are surgeons and anesthesiologists who are on board with this, but I would say the majority still need to be convinced that it’s a problem.”

A survey of 2011 perfusionists, who operate heart-lung bypass machines during heart surgery, found that more than half used cellphones during procedures, including for things such as texting, surfing the Internet and using social media. But while 93 percent said they’ve never been distracted from patient care while doing so, 33 percent said they’ve seen colleagues who have been.

“I think the biggest problem that all of us have with distractions — everywhere, not just in health care — is we think we are capable of multitasking,” Feil said. “And we are not.”

The Agency for Healthcare Research and Quality, a federal agency charged with improving health care quality, recently published a case study involving a resident in a Boston-area academic medical center who was instructed to discontinue a blood thinner for a patient. The hospital used a computerized physician order entry system that allowed doctors to enter orders using handheld devices and smartphones.

But as the resident began to enter the order to discontinue the blood thinner, she received a text from a friend about an upcoming party. She responded to the text, but never completed her order.

The patient continued to receive blood thinners for the next three days, until blood filled the sack around his heart, requiring emergency open heart surgery.

Three years ago, researchers at Oregon State University-Cascades and Oregon Health & Science University collaborated on an experiment to test the impact of distractions on residents during a simulated gall-bladder surgery. When the researchers interrupted surgeons with a cellphone ringing or someone asking about complications with a previous patient, eight out of the 18 surgical residents made serious errors. Only one of the 18 made an error when there were no distractions.

“This research clearly shows that at least with younger surgeons, distractions in the operating can hurt you,” Robin Feuerbacher, an assistant professor of engineering at OSU-Cascades and lead author said in a prepared statement on the study.

Papadakos was among the first to warn of the potential for distraction from smartphones in the operating room back in 2011. His essay in a medical journal spurred a New York Times article that coined the phrase “distracted doctoring,” and brought both industry and public scrutiny to the issue. “Initially, there was denial. ‘Nothing is going to happen, we’re dedicated,’” he said. “But then people started looking around, and they started seeing these young people, doctors, nurses, technicians, fixated on their phones.”

Over the past four years professional medical societies and health care institutions have begun to recognize the potential risks, he said, and have developed guidelines and education to address them.

The Association of Perioperative Registered Nurses has recommended that cellphones be banned from the emergency room, left outside with an employee monitoring them for emergency calls. The American College of Surgeons issued guidelines in 2008 discouraging but not banning cellphones from the OR. The group is now revising those guidelines and according to Papadakos, plans to recommend tougher standards.

“So I think there’s been a paradigm shift, from denial to self-correction,” he said.

Still, many doctors and nurses seem unable to tear their attentions away from their phones, leading to a number of high-profile, even salacious, incidents.

Federal officials investigating the death of comedian Joan Rivers found that the clinic director had taken a cellphone photo of the surgeon and Rivers while she was sedated. And just last year, officials in Washington state disciplined Dr. Arthur Zilberstein, 47, an anesthesiologist practicing at Swedish Medical Center in Seattle, for sending text messages, often of a sexual nature, during patient care. When authorities matched Zilberstein’s cellphone history with medical records, they found 23 cases in which he was texting during patient care, including during several cesarean deliveries and surgical procedures. Zilberstein lost his license over the texting and prescribing irregularities.

Papadakos believes the health care industry, much like society in general, has failed to realize the addictive nature of this new technology.

“We have to respond to these tweets and noises, and we do that above and beyond our normal duties. They take precedence over our normal duties,” he said. “Just like texting and driving, there’s no rationale to do it. We all learned that we should keep our eyes on the road and be careful, and suddenly, you’re not. You’re staring down at your phone, driving 70 miles an hour on the expressway. It completely overwhelms your survival pattern.”

Corrective action

While doctors aren’t exempt from these problems, Papadakos believes health professionals are more likely to understand the addictive process and intervene. Papadakos and colleagues at the University of Rochester recently repurposed a classic four-question survey for identifying alcoholism, substituting the term “personal electronic device” for “drink.”

When he gives talks about distracted doctoring, he asks the audience to take the test. Depending on the makeup of the group, positive responses for each question generally range from 20 to 50 percent. Younger doctors tend to score higher.

“You take these four question, and you say, ‘Oh my god, I’m addicted. These are the questions for alcoholism. Is my phone that important?’” he said.

Papadakos suggested that if surgeons and other health care professionals need smartphones for patient care purposes, they should have separate devices for their personal communications and to leave those outside the operating room.

The Oregon Outpatient Surgery Center in Tigard recently implemented a policy that limits cellphone use to non-patient care areas of the center.

“It kind of started with our staff, frankly, who were using their cellphones quite a bit in the OR for personal reasons, when their job, what we’re paying them for, was concentrating on patients and patient safety,” said Jesseye Arrambide, the center’s executive director. “We saw this as number one, a distracting, taking away from the focus on the patient, and number two, it’s well proven that cellphones, they are a source of bacteria, so you definitely don’t want it in surgery.

The center gave teeth to the rules, tying violations to the staff’s performance reviews.

“We’ve counseled people, it’s grounds for termination, using your cellphone during work hours,” she said. The clinic makes exceptions for parents who might be worried about a sick child or are facing some other type of unusual situation.

“We just feel the patient needs to be the focus and not the cellphone,” Arrambide said.

In Bend, the Cascade Surgicenter does not allow staff to use personal cellphones in the operating room but does allow physicians who may need to be reached for other patient emergencies to bring those in. The doctors usually leave the phones on a table so the circulating nurse can check to see whether the call or text needs an immediate response.

St. Charles Bend has a policy against caregivers using personal cellphones while performing work duties, and surgeons in their operating rooms usually leave cellphones with the circulating nurse and are not allowed to use them during surgery.

Oregon Health & Science University has made operating rooms quiet zones and does not allow any cellphone use that’s not related to patient care. But Dio Sumagaysay, division director for preoperative services, said it’s unrealistic in today’s cost-conscious health care environment to have a person dedicated solely to baby-sitting cellphones outside of the operating room.

“The OR is a noisy environment to begin with,” he said. By limiting non-essential cellphone use, he said, staff can avoid adding to the unpreventable noise.

Benefit analysis

The risks of cellphones and mobile devices must also be balanced against their potential to improve the efficiency and quality of care. One study found that when doctors had iPads they spent 39 fewer minutes per eight-hour shift at the hospital sitting at computer workstations, increasing the time they could spend with patients. Anesthesiologists use the devices during surgery to access dosing guidelines, medical calculators and resuscitation algorithms.

Dr. Scott Jacobson, an orthopedic surgeon with The Center: Orthopedic & Neurosurgical Care & Research in Bend said the most common use of smartphones in surgery is to play music.

“Nobody is talking on the phone, nobody is texting,” he said. “In 20 years, I’ve never seen that happen.”

Dr. Andrew Neeb, a urologist with Urology Specialists of Bend, said he has an application on his phone that allows him to quickly check American Urological Association guidelines for patient care. Having his phone in the operating room also allows him to take a picture when he encounters something unexpected during surgery. He can then show the patient or the family after the surgery, before deleting it.

“You can show way more with a picture than with a thousand words,” he said.

For most surgeons, the smartphone has now replaced the pager and holds the promise of improving communication between providers and potentially patient care.

“If a doctor just needs a quick answer, with a pager it’s hard,” he said. “You sit there and wait and wait, and hope the guy calls you back. And the patient is sitting there waiting.”

Physicians working at St. Charles Bend are now exploring options for adding text messaging that is compliant with patient privacy laws, so that doctors can communicate more easily about patients.

Standard text messaging is not secure, and so doctors often must text — “Remember that patient this morning with the kidney stone?” — in code to protect patient privacy. But that can open the door for misunderstandings and potentially medical errors.

“The hope is we can use these tools to make our jobs much easier,” Neeb said.

Although Papadakos sees progress among doctors in battling cellphone distraction, he recently identified a similar worrisome trend of distracted patients.

“Patients are looking at their phones while I’m trying to get their medical information. What medications do you take? What medical problems do you have?” he said. “Taking their selfies of themselves in the hospital gown is more important than participating in the interview.”

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