Distractions in the operating room are associated with increased mental strain, stress, and poor teamwork, according to findings of a cross-sectional, prospective observational study of 90 general surgery cases.

Ana Wheelock of the department of surgery and cancer, Imperial College, London, and her associates stated that previous studies have described a variety of distractions in the OR, but have failed to explore the impact of this factor on surgeons, anesthesiologists, and nurses (Ann. Surg. 2015;261:1079-84).

There is evidence to suggest that distractions such as noise and non–case-related conversation in the OR are linked to a higher rate of errors and adverse events, but the chain of events leading to these errors has been understudied (World J. Surg. 2008;32:1643-50; Qual. Saf. Health Care 2007;16:135-9).

Courtesy Council on Surgical and Perioperative Safety

For this study, to capture the variety of events and resulting impacts on the work process in the OR, two trained researchers – one surgeon and one behavioral scientist – observed each case. To prevent a Hawthorne effect, the researchers were present in the OR before the study began to acclimatize staff to their presence.

The case sample yielded 69 hours and 40 minutes of real-time observation. Both open and laparoscopic procedures were represented, and cases included appendectomy, inguinal hernia repair, thyroidectomy, varicose vein surgery, and mastectomy. Mean operative time for the cases was 46 minutes, and American Society of Anesthesiologists (ASA) classification of the cases ranged from I to IV. Data were collected from 85 staff (23 surgeons, 28 anesthesiologists, and 34 nurses).

The study focused on three factors with implications for performance: workload, stress, and teamwork. Workload was measured with the validated NASA-Task Load Index tool, widely used in aviation and other high-risk occupations. Six aspects of workload (mental, physical, and temporal demands; frustration; effort; and performance) were measured via interview in each team member after each procedure. Stress level was scored with the State Trait Anxiety Inventory (STAI) in the same way. Teamwork factors were reported with a validated Observational Teamwork Assessment for Surgery (OTAS) tool.

The findings show that distractions were ubiquitous: Fewer than 2% of cases occurred with zero distractions. The most prevalent distraction involved staff entering the OR (81% of which were deemed unnecessary), followed by case-irrelevant conversation, and equipment failures or absences.

The observers noted a wide variety of disruptions: cell phones ringing, missing equipment, malfunctioning lights, requests by an administrator for a few minutes of the surgeon’s time during the operation, overlapping and nonrelevant conversations among nurses about misplaced files and lunch, and external staff entering and leaving the OR. Distractions occurred in 98% of the operations observed and coincided with normal noise of OR machines, dropped instruments, and distant paging. The mean number of intraoperative distractions was 11 per case.

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How did these distractions affect surgeons? Teamwork scores (communication, coordination, leadership, and monitoring) were correlated negatively (r = –0.46) with distractions, case-irrelevant conversation initiated by fellow surgeons in particular. Equipment failures also had a negative impact on these teamwork elements for surgeons (r = –0.41). Workload and stress scores for surgeons showed a negative correlation between these factors and the amount of conversation initiated by other surgeons (r = –0.31 and –0.26, respectively). Acoustic distractions from cell phones, monitors, equipment, and dropped instruments were positively associated with higher stress levels among surgeons (r = 0.30).

Fewer distractions were observed, however, in longer cases and also in cases with a higher degree of patient morbidity.

The study is limited by the case mix of relatively short procedures and low patient ASAs. Only global scores were obtained, which did not allow a more detailed analysis of different stages of procedures. In addition, surgical outcomes were not assessed. The researchers noted, however, that “although there were no associations between external distractions and our outcome measures [ASA classification], the sheer number of unnecessary external visitors to the ORs that we observed should be a cause for concern, as high personnel flow through ORs has been significantly associated with hospital acquired infections” (Clin. Infect. Dis. 1991;13:S800-4).

The takeaway from this study, according to the researchers, is that many of these distractions that have a negative impact on workload, stress, and teamwork function are preventable. “Although some distractions may be inevitable, others, particularly during tasks that require undivided attention, should be proactively limited as they can induce human error and have negative consequences on patient safety ... a clearer understanding of the interaction between the team and the OR environment is imperative if we are to truly recognize and mitigate all factors that impact upon team performance and error.”

The (U.K.) National Institute for Health Research funded the study. The authors have no disclosures.

Distractions in the OR increase surgeons’ stress