Sunday, December 9, 2012

Surfing In The O.R.? Go Ahead. It's Okay.

Surgeons routinely complain that anesthesiologists aren't working hard enough. Whenever they peer over the ether screen, they see the anesthesiologist reading a book or newspaper, or more likely nowadays, surfing the internet. I've seen surgeons call up the O.R. director over their irritation with their anesthesiologist's inattentiveness to the patient.

Well now we have a study which says that distracted anesthesiologists may not be such a bad thing. Answering a question that many people have been wanting to know, David Wax, M.D., et. al. at Mount Sinai School of Medicine in New York has published a study in the December 2012 issue of Anesthesiology that looks at the consequences of anesthesiologists who are busy looking at the internet and not at their patients. In their study of 1,061 cases by 171 clinicians (anesthesiologists, residents, and CRNA's), they found that there was no correlation between how long somebody was using the computer to do something else besides charting the patients' anesthesia record and any hemodynamic instability in the patient. The results show that there were no differences in the rates of hypertension, hypotension, or tachycardia between the times spent on the computer for anesthesia record keeping vs. times not doing so. Zero. Nada.

They could accomplish this because the anesthesia workstations had internet access and were able to track what the clinicians was doing with the computer at that time (hello Big Brother). The researchers found that the clinician was more likely to be using the computer for non patient use if he was an attending anesthesiologist working alone in the room, the patient had a lower ASA score, the case lasted a longer period of time, and the patient was given general anesthesia.

For cases lasting less than one hour, the median time not used for record keeping was only one percent of the total case time. In cases that went on for 1-4 hours, the amount of time on the computer not used for the patient stretched to 21%. In a four hour case that would work out to 48 minutes of surfing time. For cases taking longer that four hours, a median of 29% of the time was being used for something else. A five hour case would presumably mean the anesthesiologist was not monitoring the patient for 87 minutes. Overall, a median 16 minutes of time was spent on non anesthesia related work on the computer over the course of a median 80 minute procedure.

There are some weaknesses in this study. The authors were not able to distinguish between the computer user surfing the net for pleasure or using the workstation to look up a patient's labwork.  They of course also couldn't tell if the clinician was busy using his own tablet or smartphone to surf the net instead of using the workstation.

In an interesting editorial, Drs. Karen Domino and Daniel Sessler compare the anesthetic experience to driving a car on a long boring stretch of road. Keeping your eyes fixed on the road soon lead to fatigue and boredom. Sometimes the brain needs some distractions to maintain its vigilance. They note that previous studies have shown that anesthesiologists spend less than 5% of their time actually looking at their patient's computer monitor. Only about 25% of an anesthesiologist's total time in the operating room is actually devoted to monitoring the patient. The rest of the anesthesiologist's time is presumably taken up moving the O.R. table up and down per surgeon's request, changing the radio station to the surgeon's preference, or turning down the thermostat to freezing so the surgeon feels comfortable.

Though this study shows that not staring at a patient's monitor every second in the O.R. isn't the sin it's been construed to be, if you ever get into a malpractice suit for not paying attention to the patient crashing on you, you'll pay for it. In the Anesthesiologists' Closed Claims database, thirteen claims of injury due to a distracted anesthesiologist have been filed. In 91% of the cases, the care was judged to be substandard. In 83% of the cases, money was paid to the plaintiffs at a median payout of $725,937. Ouch.

So doctors, surf the net in the O.R. at your peril. While this study says it is unlikely anything untoward will happen while you're looking up MarketWatch, if your patient crashes and burns, you and your malpractice insurance company will be paying for the transgression dearly.

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