Smartphones and Facebook in the operating room

I hope everyone enjoyed posts about Colombian life and culture, but now that I am back in the United States – we will get back to our more serious discussions about patient safety and issues in health care.  One of the things we have talked a lot about in the past – and cover extensively in the Hidden Gem book series is operating room quality and safety measures.  This includes using objective measurement tools such as the Surgical Apgar score (created by physician and author, Dr. Atul Gawande) and the safety checklist.

Surgeon as pilot 

These checklists were designed to be similar to the mandatory checklists used by pilots.    They were originally designed in the 1930’s to prevent pilot errors and accidents as planes become more and more complex.

Tools to measure and improve practice

These tools do more than just rate (or grade) operating room safety procedures – they encourage a ‘culture of safety’ and adherence to practices and procedures designed to prevent errors or mistakes.  This means that the more people use (and become familiar with) these practices – the better they get at detecting and preventing errors.

The importance of these checklists has been recognized for years, but is just now gaining in traction. It wasn’t until 2009, that the World Health Organization recommended use of the checklist in hospitals internationally.

Checklists and hospital reimbursement

American hospitals now use the checklist religiously because ‘core measures’  – and reimbursement are tied to its use.  These ‘core measures’ were established a decade ago as part of quality assurance procedures for Medicare and Medicaid.  American hospitals that do not participate (or score poorly) on core measures such as surgical safety procedures – risk not getting paid for their services.  (There are core measures for other patient care items as well, such as the care of patients having a heart attack, or pneumonia).

Surgical Apgar Score

The surgical apgar score, (and similar scales) have been slower to catch on.  This is unfortunate in my opinion, because this tool has the greatest chance of really improving patient care and preventing patient harm.  The surgical apgar score works by basically rating and grading the actual care of the patient in the operating room.

When consumers think about patient care in the operating room – we tend to focus on the surgeon.  But surgery and surgical skill are only a part of the picture.  The anesthesiologist/ nurse anesthestist and anesthesia care team are critical to the safety and health of the patient – and their inattention / or distraction can be disasterous for patients.  But even when disaster is averted – frequent distractions can lead to increased complications.  Sometimes the effects are subtle; such as twenty or thirty minutes of ‘borderline’ low blood pressure and post-operative organ dysfunction from intra-operative ischemia.

But is anyone paying attention?

But is anyone paying attention?

We all know it happens, but too many anesthesiologists are busy playing on Facebook to address the realities of the situation.

Unfortunately, this is a common problem in operating rooms worldwide

Unfortunately, this is a common problem in operating rooms worldwide

None of this is news to long-time readers, but several new articles confirm the utility of safety checklists and operating room safety practices.  (One of the articles somewhat ironically reports that injuries to patients were not as reduced as anticipated by previous studies – because the checklist was not always used / or used correctly.  The authors note that the checklists reduced patient injuries and complications – when they were actually used.


Additional posts on this and similar topics:

Reputation, Ranking and Objective measures – talking about the ‘core measures’.

More about the surgical apgar score – from our sister site.

The original Surgical Apgar score

Additional references

I will be updating this section frequently over the next few days.

Medscape summary articles:

Hilt, Emma, (2012). Surgical checklist from WHO improves safety and outcomes.  Medscape, November 2012.

Source articles:

Fudickar, A., Horle, K., Wiltfang, J. & Bein, B. (2012). The effect of the WHO surgical checklist on complication rate and communication.  Dtsch. Artztebl Int 2012, 109(42): 695-701.  The authors of this German paper examined / analyzed 20 different studies looking at the use of surgical checklists.

Jorm CM, O’Sullivan G. (2012). Laptops and smartphones in the operating theatre – how does our knowledge of vigilance, multi-tasking and anaesthetist performance help us in our approach to this new distraction?  Anaesth Intensive Care. 2012 Jan;40(1):71-8.

Patterson P. (2012). Smartphones, tablets in the OR: with benefits come distractions.  OR Manager. 2012 Apr;28(4):1, 6-8, 10.  [no free full text available].

Pereira, Bruno Monteiro Tavares et al. Interruptions and distractions in the trauma operating room: understanding the threat of human error. Rev. Col. Bras. Cir. [online]. 2011, vol.38, n.5 [cited  2012-12-18], pp. 292-298 .

Pre & Post-operative Surgical Optimization for Lung Surgery

Update: 18 April 2011 – USAtoday published a nice new article on Shannon Miller (former Olympic gymnast) and how she’s using exercise to help recover from cancer.  The article really highlights some of the things we’ve been talking about here.

As most of my patients from my native Virginia can attest; pre & post-operative surgical optimization is a critical component to a successful lung surgery. In most cases, lung surgery is performed on the very patients who are more likely to encounter pulmonary (lung) problems; either from underlying chronic diseases such as emphysema, or asthma or from the nature of the surgery itself.

Plainly speaking: the people who need lung surgery the most, are the people with bad lungs which makes surgery itself more risky.

During surgery, the surgeon has to operate using something called ‘unilung ventilation’. This means that while the surgeon is trying to get the tumor out – you, the patient, have to be able to tolerate using only one lung (so he can operate on the other.)

Pre-surgical optimization is akin to training for a marathon; it’s the process of enhancing a patient’s wellness prior to undergoing a surgical procedure. For diabetics, this means controlling blood sugars prior to surgery to prevent and reduce the risk of infection, and obtaining current vaccinations (flu and pneumonia) six weeks prior to surgery. For smokers, ideally it means stopping smoking 4 to 6 weeks prior to surgery.(1) It also means Pulmonary Rehabilitation.

Pulmonary Rehabilitation is a training program, available at most hospitals and rehabilitation centers that maximizes and builds lung capacity. Numerous studies have show the benefits of pre-surgical pulmonary rehabilitation programs for lung patients. Not only does pulmonary rehabilitation speed recovery, reduce the incidence of post-operative pneumonia,(2) and reduce the need for supplemental oxygen, it also may determine the aggressiveness of your treatment altogether.

In very simple terms, when talking about lung cancer; remember: “Better out than in.” This means patients that are able to have surgical resection (surgical removal) of their lung cancers do better, and live longer than patients who receive other forms of treatment such as chemotherapy or radiation. If you are fortunate enough to have your lung cancer discovered at a point where it is possible to consider surgical excision – then we need you to take the next step, so you are eligible for the best surgery possible.

We need you to enhance your lung function through a supervised walking and lung exercise program so the surgeon can take as much lung as needed. In patients with marginal lung function,(3) the only option is for wedge resection of the tumor itself. This is a little pie slice taken out of the lung, with the tumor in it. This is better than chemotherapy or radiation, and is sometimes used with both – but it’s not the best cancer operation because there are often little, tiny, microscopic tumor cells left behind in the remaining lung tissue.

The best cancer operation is called a lobectomy, where the entire lobe containing the tumor is removed. (People have five lobes, so your lung function needs to be good enough for you to survive with only four.(4) This is the best chance to prevent a recurrence, because all of the surrounding tissue where tumors spread by direct extension is removed as well. Doctors also take all the surrounding lymph nodes, where cancer usually spreads to first. This is the best chance for five year survival, and by definition, cure. But since doctors are taking more lung, patients need to have better lung function , and this is where Pulmonary Rehab. comes in. In six weeks of dedicated pulmonary rehab – many patients who initially would not qualify for lobectomy, or for surgery at all – can improve their lung function to the point that surgery is possible.

Post-operatively, it is important to continue the principles of Pulmonary rehab with rapid extubation (from the ventilator), early ambulation (walking the hallways of the hospitals (5) and frequent ‘pulmonary toileting’ ie. coughing, deep breathing and incentive spirometry.

All of these things are important, where ever you have your surgery, but it’s particularly important here in Bogota due to the increased altitude.

One last thing for today:
a. Make sure to have post-pulmonary rehab Pulmonary Function Testing (PFTs, or spirometry) to measure your improvement to bring to your surgeon,
b. walk daily before surgery (training for a marathon, remember)

c. bring home (and use religiously!) the incentive spirometer provided by rehab.

ALL of the things mentioned here today, are things YOU can do to help yourself.

1. Even after a diagnosis of lung cancer, stopping smoking 4 to 6 weeks before surgery will promote healing and speed recovery. Long term, it reduces the risk of developing new cancers.

2. Which can be fatal.

3. Lung function that permits only a small portion (or wedge section) to be removed

4. A gross measure of lung function is stair climbing; if you can climb three flights of stairs without stopping, you can probably tolerate a lobectomy.

5. This is why chest tube drainage systems have handles. (so get up and walk!)