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February 23, 2021
Cellphones and the OR
It’s been a year since our last soapbox rant about cellphones in the OR (see our January 28, 2020 Patient Safety Tip of the Week “Dang Those Cell Phones!”). A recent “Viewpoint” in JAMA Surgery has rekindled the debate about cellphones in the OR. Cohen et al. (Cohen 2020) reviewed the benefits and harms of personal communication devices (PCD’s) or smartphones in the OR. They summarized the benefits and harms of PCD’s:
Benefits
Harms
We’ll be quick to point out that most of the benefits listed by Cohen et al. do not necessitate cellphones being in the OR. Also, the important access to medical imaging and access to tools such as medication dosing apps are already available on the computers currently in the OR, so we don’t need cellphones for access to those in the OR.
But the potential harms listed by Cohen et al. are real, particularly the unwanted disruptions and distractions and cognitive disengagement from other tasks. A previous study by Cohen et al. (Cohen 2018) had looked at the impact of PCD’s during cardiovascular surgeries. They identified a total of 545 PCD-related events during 25 cases. While most individuals spent less than a few minutes attending to their PCD’s, a handful of these disruptions lasted an abnormally long time. On average, each of the 545 events took 1 min, 26 s (SD = 1 min, 40 s) of attention. Most PCD use events took place during bypass (n = 233) followed by pre-bypass (n = 197) and post-bypass (n = 115). Of the 545 events, nearly half (48.81%) involved the anesthesia team, followed by the perfusion team (30.28%), circulating nurse (16.70%) and surgeon (4.22%).
While the authors could not determine exactly how the devices were being used in some of the cases, they were able to document behaviors such texting, emailing, phone calls, and non-hospital related use. Thus, the device itself resulted in multiple types of distractions distributed across the different phases surgery.
The authors also point out that their data do not support the commonly used argument that PCD use is restricted to non-critical phases of surgery. Their data showed team members were engaged with their PCD’s for approximately a minute and a half regardless of the stage of the operation. Additionally, the greatest number of PCD-use events occurred during the most critical phase of surgery, bypass.
One example provided was that the surgeon was opening patient chest when his personal cell phone started ringing. He stopped opening so that the circulating nurse could get his cell phone out of his pocket and hold up the phone to his ear so he could answer. In our August 20, 2019 Patient Safety Tip of the Week “Yet Another (Not So) Unusual RSI” we described a case that resulted in a retained surgical item (RSI). In that case, one of the likely contributing factors was that the surgeon’s phone rang several times during the third count, before being answered by the anesthesiologist.
Cohen et al. discuss several factors that may explain such behavior in the operating room. These include comfort with the procedure and equipment, complacency, boredom in what are typically hours-long procedures, and feeling the societal pressure to answer texts, calls, and emails as soon as possible.
A 2016 APSF (Anesthesia Patient Safety Foundation) conference “Distractions in the Anesthesia Work Environment: Impact on Patient Safety” (van Pelt 2017) noted several issues related to personal electronic devices (PED’s) in the OR:
In addition to our example above of a surgeon’s phone ringing several times during a surgical count as one of several factors likely contributing to a retained surgical item, our Patient Safety Tips of the Week May 21, 2013 “Perioperative Distractions”, March 17, 2015 “Distractions in the OR”, and July 21, 2015 “Avoiding Distractions in the OR” had detailed discussion about use of cell phones and other wireless devices in and around the OR with multiple examples of distractions related to such in the OR. There are a multitude of issues related to cell phones in the OR including not only interruptions and distractions but also infection control issues, security and confidentiality issues, and detrimental effects on communication in the OR. We have yet to see a cogent argument as to why cellphones are actually needed in the OR. Our own recommendation is for all the OR team to leave their cellphones at the main OR desk where someone can triage incoming phone calls and messages.
Our January 28, 2020 Patient Safety Tip of the Week “Dang Those Cell Phones!” noted an AORN (Association of periOperative Registered Nurses) proposal having several recommendations to reduce distractions and interruptions in the OR (AORN 2019). Some focused on reducing overall sources of noise pollution in the OR. But others focused specifically on cell phones. One recommendation is to “Emphasize the importance of limiting non-essential conversations, muting cell phones or limiting their use, and limiting the number of people in the OR.” Another recommendation was to reiterate safe cell phone use, recognizing that some facilities allow surgical team members to carry their personal cell phone with them, Regular reminders about safe cell phone use can be helpful, such as “Personal devices may add to the overall noise pollution in the OR, which can distract personnel from clear communication and safe patient care.” It goes on to emphasize minimization of distractions during critical phases of the procedure, such as the time out, anesthesia induction and emergence, surgical counts, and specimen management. Especially during those critical times, “personal devices should be left outside the OR, turned off, placed on vibrate or silent mode, and handled only when needed.”
A number of questions about cell phones in the OR were addressed in a another AORN Journal article (Ogg 2019). The AORN "Guideline for a safe environment of care" recommends that personal electronic devices should be limited to use directly required for job performance. It states that health care organizations should have policies and procedures in place that specify when a cell phone may be brought into the OR. Furthermore, it states that perioperative personnel also should consider interventions to mitigate the known risks associated with bringing personal electronic devices into the OR.
They note the risks involved with bringing a personal electronic device into the OR include:
They cite statistics on microbial contamination of cell phones and note interventions that may reduce the risk of a surgical site infection (SSI) originating from contaminated personal electronic devices include cleaning the device regularly, handling the device sparingly, and performing hand hygiene after each use.
Overall, they recommend that, whenever possible, personal devices should be:
And the other issue related to cell phones is the issue of texting. Orders should never be texted (see our multiple columns on the subject below). But even for messages used for communication other than orders, care must be taken so that commonly used text abbreviations and shortcuts are not mistaken by these receiving the texts.
Every facility and organization needs to have a PED policy. A report from the ECRI Institute (Rose 2019) had some very good suggestions for facilities to develop policies for use of personal electronic devices. Such policies should balance the needs of staff members, residents, visitors, and the institution as a whole while clearly defining when, where, and for what purposes PED’s may be used. The policy should also include a clear definition of data ownership—that is, which data are considered owned by the facility and which are considered owned by the PED user—and clearly identify what constitutes sensitive information. It also discusses 3 approaches to allowing PED’s in the facility: (1) facility-provided devices, (2) “Bring your own device” (BYOD), and (3) a hybrid approach. The facility/organization should have a committee that decides where PED’s may be used. It may decide to ban PED’s from certain areas or to restrict them to certain areas, such as common areas or staff lounges. It also has practical recommendations on what information may be accessed or stored on PED’s, how PED’s will be managed, what to do if a PED is lost or stolen, and how restrictions on PED use or misuse will be enforced.
Prior Patient Safety Tips of the Week dealing with cell phones:
See our other Patient Safety Tip of the Week columns dealing with texting:
Prior Patient Safety Tips of the Week dealing with interruptions and distractions:
References:
Cohen TN, Jain M, Gewertz BL. Personal Communication Devices Among Surgeons—Exploring the Empowerment/Enslavement Paradox. JAMA Surg 2020; Published online December 23, 2020
Cohen TN, Shappell SA, Reeves ST, Boquet AJ. Distracted doctoring: the role of personal electronic devices in the operating room. Perioper Care Oper Room Manag 2018; 10: 10-13
https://www.sciencedirect.com/science/article/abs/pii/S2405603017300365?via%3Dihub
van Pelt M, Weinger MB. Distractions in the anesthesia work environment: impact on patient safety? Report of a meeting sponsored by the Anesthesia Patient Safety Foundation. Anesth Analg. 2017; 125(1): 347-350
AORN (Association of periOperative Registered Nurses). Can You Hear Me? 3 Reminders to Reduce OR Distractions. Periop Today 2019; December 11, 2019
Ogg MJ, Anderson MA. Clinical Issues—August 2019. AORN Journal 2019; 110(2): 199-202 First published: 29 July 2019
https://aornjournal.onlinelibrary.wiley.com/doi/full/10.1002/aorn.12767
Rose VL Foundations of a Personal Electronic Device Policy. Ann Longterm Care 2019; 27(6): e5-e7
https://www.managedhealthcareconnect.com/articles/foundations-personal-electronic-device-policy
Print “Cellphones and the OR”
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February 2021
Fatal errors due to inadvertent administration of neuromuscular blocking agents (NMBA’s) have been problematic. There have been numerous interventions intended to prevent them and no single one is likely to ensure success. But each individual intervention contributes to the defenses.
“Look-alike” vials have been one factor contributing to such errors. So, one important intervention has been labeling of vials containing NMBA’s. Form several years, warnings on the vial caps stating “Paralyzing Agent” have been required. However, ISMP (Institute for Safe Medication Practices) has just published a warning that vials of NMBA’s lacking this warning have again appeared (ISMP 2021a). ISMP notes that, due to drug shortages during the COVID-19 pandemic, the FDA has allowed temporary manufacturing of these drugs without the vial cap (seal) warning statement. The ISMP article names specific products affected.
One important point in the ISMP alert is that the expiration date on several of the products affected is in mid-2022. That means that, even if the shortages are resolved, some of these vials are likely to be in hospital stock for over another year.
Therefore, it is critical that nurses and pharmacists and any others who handle or administer these drugs be made aware of this danger. ISMP recommends having pharmacy affix auxiliary “Warning: Paralyzing Agent” labels to vial caps prior to storage in critical care units, the perioperative setting, and emergency departments.
In our multiple prior columns on NMBA incidents (see full list below), we have also discussed other important interventions to prevent such accidents. Appropriate segregation of NMBA vials from other drugs, especially “look-alike” vials, is critical. NMBA vials should also not be part of “floor stock”. When NMBA’s are included in automated dispensing cabinets (ADC’s), you should require acknowledgement that the patient is mechanically ventilated (or the NMBA is to be used during intubation) before allowing retrieval of the vial from the ADC.
We’d also recommend that, as the drug shortage is resolved and new vials having the appropriate warning on the caps arrive, you remove any of the unlabeled vials from stock.
It’s important you heed this ISMP warning. You don’t want to put your patients in jeopardy. And you don’t want to put any of your staff in jeopardy of being at the sharp end of a tragic error cascade.
But, shortly after that first warning, ISMP issued another alert requiring immediate attention (ISMP 2021b): an extremely hazardous packaging error involving certain cisatracurium products from Meitheal Pharmaceuticals. While the outer carton identifies the vials inside as cisatracurium, the vials contained in the carton are labeled phenylephrine injection. The vials actually contain cisatracurium and have caps appropriate for a paralyzing agent. But, if you don’t notice this cap warning, you may think you are injecting phenylephrine. Results in a non-intubated, non-ventilated patient would be disastrous. ISMP urges facilities to immediately examine any and all cartons of cisatracurium from Meitheal Pharmaceuticals for this serious packaging error and make sure that none of these vials were actually distributed. ISMP has confirmed that both the FDA and the manufacturer are aware of this situation and that a recall is imminent.
Some of our prior columns on neuromuscular blocking agents (NMBA’s):
June 19, 2007 “Unintended Consequences of Technological Solutions”
July 31, 2007 “Dangers of Neuromuscular Blocking Agents”
November 2007 “FMEA Related to Neuromuscular Blocking Agents”
May 20, 2008 “CPOE Unintended Consequences - Are Wrong Patient Errors More Common?”
January 31, 2012 “Medication Safety in the OR”
February 7, 2012 “Another Neuromuscular Blocking Agent Incident”
October 22, 2013 “How Safe Is Your Radiology Suite?”
December 9, 2014 “More Trouble with NMBA’s”
December 11, 2018 “Another NMBA Accident”
January 1, 2019 “More on Automated Dispensing Cabinet (ADC) Safety”
February 12, 2019 “From Tragedy to Travesty of Justice”
April 2019 “ISMP on Designing Effective Warnings”
References:
ISMP (Institute for Safe Medication Practices). Paralyzing agent vial caps without warnings into 2022. NurseAdvisERR® 2021; 19(1): 3-4 January 2021
https://www.ismp.org/nursing/medication-safety-alert-january-2021
ISMP (Institute for Safe Medication Practices). Hazardous Packaging Error. ISMP Alert 2021; January 26, 2021
https://www.ismp.org/alerts/hazardous-packaging-error
Print “February 2021 ISMP: 2 Alerts on NMBA’s”
This time of year is when all the “Top 10” lists on patient safety issues come out. Three big ones have come out from ISMP (Institute for Safe Medication Practices), ECRI Institute, and Becker’s Hospital Review.
ISMP’s “Start the Year Off Right by Preventing These Top 10 Medication Errors and Hazards from 2020” (ISMP 2021) has its list Top 10 Medication Errors and Hazards from 2020:
ECRI Institute’s “Top 10 Health Technology Hazards for 2021” (ECRI 2021)
(ECRI 2021):
Becker’s 10 top patient safety issues for 2021 (Carbajal 2021):
Even though the themes of these lists are slightly different for each organization, you can see there is still considerable overlap and issues related to COVID-19, directly or indirectly, dominate the lists. We refer you to the original articles for details of each item on the respective lists.
References:
ISMP (Institute for Safe Medication Practices). Start the Year Off Right by Preventing These Top 10 Medication Errors and Hazards from 2020. ISMP Medication Safety Alert! Acute Care Edition 2011; 26(2): January 27, 2021
ECRI Institute. Top 10 Health Technology Hazards for 2021. ECRI Institute 2021; January 2021
https://www.ecri.org/2021-top-10-health-technology-hazards-executive-brief/
Carbajal E, Masson G, Bean M. Becker’s 10 top patient safety issues for 2021; Becker’s Hospital Review 2021; December 30th, 2020
Print “February 2021 Top 10 Lists”
We’ve done many columns on the dangers of intrahospital transports and the need to do careful planning to avoid those dangers. But we’ve focused primarily on temporary transports to areas such as radiology or the OR. But there is a different sort of intrahospital transfer that is also problematic – the transfer of patients from beds on one unit to beds on another unit.
A recent study from the UK (Boncea 2021) found that intrahospital transfers are associated with increased odds of developing a healthcare-associated infection (HAI). The authors suggest that strategies for minimizing intrahospital transfers should be considered, and further research is needed to identify unnecessary transfers. Their reduction may diminish spread of contagious pathogens in the hospital environment.
The frequency of such intrahospital transfers should probably not surprise you. Only 27.8% of patients did not undergo any intrahospital transfers. 44.2% of patients underwent one intrahospital transfer, 17.1% underwent two transfers, and 11.0% underwent three or more transfers. Overall, 11.9% of patients developed an HAI. C. difficile infection accounted for almost a third of the HAI’s, but many other pathogens were implicated as well.
The multivariable logistic regression modelling showed that each additional intrahospital transfer was associated with a 9% increase in the odds of developing an HAI (OR=1.09).
The accompanying editorial (Escobar 2021) notes that cases and controls were well matched, and the statistical modelling provided very compelling results. But it notes the study did not adjust for the indication for transfer (eg, transfer to or from the intensive care unit based on patient acuity, transfer for isolation precautions or transfer due to bed capacity or staffing issues) to determine if the patient care needs, isolation status or hospital strain modify the observed risk. It therefore recommends, as do Boncea et al., that prospective studies are needed to better identify the clinical, administrative and systems factors that contribute to more frequent intrahospital transfers.
Boncea et al. note several factors that could underlie a possible association between HAIs and intrahospital transfers:
Especially in the COVID-19 era, where hospital bed shortages are rampant, we often move patients from one site to another, The Boncea study suggests we not simply act reflexly in such intrahospital transfers, but rather carefully consider the implications before carrying out such transfers. The 9% increased risk of an HAI associated with each transfer is a substantial consideration. There are, of course, other unwanted consequences of intrahospital transfers. For example, one study (Goldberg 2015) found that room transfers amongst hospitalized elderly medical patients substantially increased the risk of development of delirium (OR 9.69).
But one has to weigh the benefits of transfer against the risks. There are risks of keeping a patient on a unit not used to caring for such patients. We cohort patients on floors with special expertise in care for patients with certain conditions. A patient being followed by one service (eg. neurology) who is temporarily housed on a non-neurology floor gets less attention from the neurology staff than he would were he housed on the neurology floor. In addition, the nursing care on the specialty unit is much more attuned to the problems that neurology patient is likely to have. So, decisions about transferring patients from one location in the hospital to another can’t simply be based on the risk of HAI. Nevertheless, the substantial risk of HAI pointed out in the Boncea study should make us recognize that decisions about transfer of patients should not be made rashly.
Some of our prior columns on intrahospital transports and the “Ticket to Ride” concept:
References:
Boncea E, Expert P, Honeyford K. Association between intrahospital transfer and hospital-acquired infection in the elderly: a retrospective case-control study in one urban UK Hospital network. BMJ Qual Saf 2021; Published Online First: 25 January 2021
https://qualitysafety.bmj.com/content/early/2021/01/24/bmjqs-2020-012124
Escobar D, Pegues D. Healthcare-associated infections: where we came from and where we are headed. BMJ Quality & Safety 2021; Published Online First: 08 January 2021
https://qualitysafety.bmj.com/content/early/2021/01/08/bmjqs-2020-012582
Goldberg A, Straus SE, Hamid JS, Wong CL. Room transfers and the risk of delirium incidence amongst hospitalized elderly medical patients: a case-control study. BMC Geriatr 2015; 15: 69. Published 2015 Jun 25
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4478641/pdf/12877_2015_Article_70.pdf
Print “February 2021 Risk from Intrahospital Transfer: Healthcare-Associated Infection”
We’ve done many columns on potentially inappropriate medications (PIM’s) in older adults (see list below). We’ve often focused on drugs with prominent anticholinergic actions, sedative/hypnotic drugs, benzodiazepines, gabapentinoids, and others. But there is one class of PIM’s that has largely flown “under the radar”: skeletal muscle relaxants. And there has been a disturbing trend in prescribing patterns for drugs in this class.
The 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults (AGS 2019) notes that most muscle relaxants are poorly tolerated by older adults because some have anticholinergic adverse effects, sedation, increased risk of fractures; and their effectiveness at dosages tolerated by older adults questionable. Examples of skeletal muscle relaxants they note are: Carisoprodol, Chlorzoxazone, Cyclobenzaprine, Metaxalone, Methocarbamol, and Orphenadrine.
A recent analysis (Soprano 2020) found that skeletal muscle relaxant (SMR) use increased rapidly between 2005 and 2016. During the study period, office visits with a prescribed SMR nearly doubled. Actually, visits for new SMR prescriptions remained stable, but office visits with continued SMR drug therapy tripled. Older adults accounted for 22.2% of visits with an SMR prescription. Concomitant use of an opioid was recorded in 67.2% of all visits with a continuing SMR prescription.
So, what’s driving this trend? SMR’s have been increasingly used in long-term pain management, despite lack of data on efficacy and safety. It’s likely that the opioid epidemic and the resultant push to reduce opioid prescribing has made clinicians look for alternatives to opioids in management of chronic pain.
The major indication for SMR use is for acute low back pain. There is little evidence of SMR efficacy in managing chronic low back pain. And the use of SMR’s for all other types of chronic pain is “off-label” and based largely on anecdotal data.
That SMR use was associated with concomitant opioid use in 67% of visits is particularly bothersome. One study identified an elevated risk of overdose with concomitant use of opioids and skeletal muscle relaxants (Li 2020).
We, personally, have never been fans of skeletal muscle relaxants, even for acute low back pain. So, we were quite taken aback to see this disturbing trend in SMR prescribing. This is probably a situation in which use of clinical decision support tools in ePrescribing applications or CPOE might be useful. Clinical decision support tools could alert clinicians about dangers prescribing them to older adults, suggest long-term use of SMR’s is not appropriate, and to particularly flag issues with concomitant use of opioids.
Some of our past columns on Beers’ List and Inappropriate Prescribing in the Elderly:
References:
2019 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. J Amer Geriatr Soc 2019; First published: 29 January 2019
https://onlinelibrary.wiley.com/doi/abs/10.1111/jgs.15767
Soprano SE, Hennessy S, Bilker WB, Leonard CE. Assessment of Physician Prescribing of Muscle Relaxants in the United States, 2005-2016. JAMA Netw Open 2020; 3(6): e207664
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2767591
Li Y, Delcher C, Wei YJ, et al. Risk of opioid overdose associated with concomitant use of opioids and skeletal muscle relaxants: a population-based cohort study. Clin Pharmacol Ther 2020; Published online February 5, 2020
https://ascpt.onlinelibrary.wiley.com/doi/abs/10.1002/cpt.1807
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Print “February 2021 Risk from Intrahospital Transfer: Healthcare-Associated Infection”
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