Mobile Device Use

Formerly Position Statement Number 2.18

 

The American Association of Nurse Anesthetists (AANA) Scope and Standards for Nurse Anesthesia Practice emphasize that continuous clinical observation and vigilance are the basis of safe anesthesia care.1  Jorm and O'Sullivan define vigilance as "a state of readiness to detect and respond to small changes occurring at random intervals in the environment."2  Distractions and interruptions are not new in healthcare or the operating room (OR); however, anesthetized patients demand constant situational awareness.  Certified Registered Nurse Anesthetists (CRNAs) have an ethical responsibility to provide safe patient care by avoiding non-essential distractions.3  Non-essential distractions, especially those associated with use of mobile devices (e.g., smartphones, tablets, PDAs), may lead to significant patient safety lapses.  The purpose of this position statement is to describe the benefits and risks that using mobile devices has on patient safety.

Mobile device use is becoming more integrated with the delivery of patient care.  The prevalence of smartphone and tablet use for clinical care among CRNAs is currently unknown.   Recent studies have shown that 50%-60% of physicians and residents use smartphones to access clinical applications (apps).4, 5  Advocates of mobile handheld devices cite enhanced productivity and mobility, improved information access and communication, higher quality care, and reduced medical errors.6  Several reviews have praised smartphones for being user friendly tools that improve mentorship through increased communication, provide easy access to medical references and guidelines, and increase accessibility to medical apps that can guide clinicians during direct patient care.4, 5, 7-10  Specific to anesthesia, medical calculators, logbooks, and resuscitation algorithm apps are most accessed.4  One of the current challenges facing apps and emerging technology in healthcare is the lack of regulation and assurance of clinical content and validity.7, 10-12  The AANA urges CRNAs using medical mobile apps to use sound clinical judgment when applying the information provided.

A typical use of smartphones by healthcare professionals is for communication (e.g., placing calls or sending email).  Several studies and literature reviews have investigated the impact of mobile phone and hands-free technology on communication and team effectiveness among this group.9, 13-17  Healthcare professionals using mobile phone technology have demonstrated perceived improvement of communication efficiency and a lower failure-to-respond rate compared to pager users.13, 14, 17, 18  On the other hand, Richardson et al. found that many anesthesia professionals felt that such technology was useful for non-urgent matters, but may lead to unwanted interruptions.14  The AANA supports the use of mobile devices as established by institutional policy for patient-related communication among members of a patient care team to enhance the delivery of care.  CRNAs should avoid the unnecessary use of these tools when delivering anesthesia care services.

Additional concerns related to mobile device use in the OR are bacterial contamination and interference with medical equipment.  When investigating the risks of bacterial contamination, Jeske et al. found that even after 40 anesthesiologists used hand sanitizer, over the course of time most personal mobile devices had critical pathogens on them, indicating that these devices can easily transmit pathogens from hand to device and vice versa.19  Bacterial contamination may pose a problem when using mobile phones in patient care areas when current decontamination protocols are not known; therefore, anesthesia professionals should use caution and adhere to infection control policies and procedures where appropriate.

The issue of whether there is the potential for interference by mobile devices with medical equipment has also been studied.  In a 2003 survey, Soto et al. found that 98 (2.4% ± 0.5%) of 4,018 anesthesiologist respondents had observed interference with medical equipment during cell phone use.18  In laboratory tests with 76 types of medical equipment often found in the OR and intensive care unit (ICU), Wallin and colleagues determined that 85% of the tested medical equipment showed no interference from mobile device signals.  Clinical test findings among OR and ICU equipment when patients were present indicate that no significant interference was noted when mobile devices were placed away from equipment.20  Shielding from radiofrequency interference in newer medical equipment may lead to less interference.18, 20  Many authors suggest that mobile phone use further than three feet away from medical equipment should not create critical interference.15, 16, 20-22  If there is a question as to the proximity of mobile device use and its interference with a particular piece of medical equipment, the equipment manufacturer should be consulted.  Anesthesia professionals must assess the risk of mobile technology interference with life-support and monitoring equipment in anesthesia care.

In a 2011 observational pilot study evaluating the number of experienced and perceived interruptions and distractions during anesthesia induction, Pape et al. found that CRNAs may experience 68 interruptions and distractions per hour, most of which come from operating room personnel, conversation, and noise.23  With the rapidly evolving field of information technology, smartphones, and social media, little data is known about the prevalence of smartphone use for nonclinical purposes and its impact on clinician vigilance and patient care.  In a survey of 439 perfusionists working on cardio-pulmonary bypass cases, more than 55% of the respondents reported using their cell phone during the procedure in some form (i.e., phone calls, sending/checking email, internet surfing, social networking, texting).24  Additionally, 34.5% acknowledged that they witnessed a fellow perfusionist distracted with phone use during the procedure.  The use of mobile technology and wireless connectivity provides opportunity for distraction by giving users instant internet access and linking users to email, e-magazines, e-books, television shows, social networking outlets, blogs, games, and thousands of nonclinical mobile apps.  Any inattentive behavior during a procedure, such as reading, texting, gaming or using mobile devices to access nonclinical content, should be considered a potential patient safety issue.  In addition, the use of certain device accessories (e.g., head phones) that impact a user’s vigilance poses a similar patient safety issue.

With the advent of cameras and video capabilities on mobile devices, healthcare professionals must be cognizant and respectful of patient privacy and confidentiality.  As various social networking outlets have grown in popularity, concerns continue to increase regarding professional boundaries and patient privacy rights protected by the Health Insurance Portability and Accountability Act of 1996 (HIPAA).25  Inappropriate use of social media, such as posting patient protected health information or photographs/videos on social media sites, blogs, or discussion boards, can violate federal and state laws in place to protect patient privacy and confidentiality.  Healthcare employees should be aware that breaches in confidentiality may result in civil liability to patients,26, 27 job loss,28 disciplinary action by state licensing boards,29-31 and even criminal investigations and sanctions.32

Mobile technology has the potential to have a positive impact on healthcare; however, the extent of the benefits requires further research.  CRNAs are encouraged to discuss within their institution how adoption of mobile technologies may be integrated to improve delivery of care.  Similarly, the AANA encourages CRNAs to participate in the development of institutional policies regarding the appropriate and inappropriate use of mobile devices and clinician interaction using social media.33  The AANA supports the use of mobile technology as it pertains to direct patient care so long as it does not negatively affect provider performance and compromise patient care.

 

References

  1. Scope and Standards for Nurse Anesthesia Practice. Park Ridge, IL: American Association of Nurse Anesthetists; 2010.
  2. Jorm CM, O'Sullivan G. 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. Jan 2012;40(1):71-78.
  3. Code of Ethics for the Certified Registered Nurse Anesthetist. Park Ridge, IL: American Association of Nurse Anesthetists; 2010.
  4. Dasari KB, White SM, Pateman J. Survey of iPhone usage among anaesthetists in England. Anaesthesia. Jul 2011;66(7):630-631.
  5. Franko OI, Tirrell TF. Smartphone App Use Among Medical Providers in ACGME Training Programs. J Med Syst. Nov 4 2011.
  6. Prgomet M, Georgiou A, Westbrook JI. The impact of mobile handheld technology on hospital physicians' work practices and patient care: a systematic review. J Am Med Inform Assoc. Nov-Dec 2009;16(6):792-801.
  7. Al-Hadithy N, Gikas PD, Al-Nammari SS. Smartphones in orthopaedics. Int Orthop. Mar 17 2012.
  8. Bhansali R, Armstrong J. Smartphone applications for pediatric anesthesia. Paediatr Anaesth. Apr 2012;22(4):400-404.
  9. Dala-Ali BM, Lloyd MA, Al-Abed Y. The uses of the iPhone for surgeons. Surgeon. Feb 2011;9(1):44-48.
  10. Franko OI. Smartphone apps for orthopaedic surgeons. Clin Orthop Relat Res. Jul 2011;469(7):2042-2048.
  11. Draft Guidance for Industry and Food and Drug Administration Staff - Mobile Medical Applications.  U.S. Department of Health and Human Services: Food and Drug Administration. 2011; http://www.fda.gov/MedicalDevices/DeviceRegulationandGuidance/GuidanceDocuments/ucm263280.htm. Published July 21, 2011. Accessed February 24, 2012.
  12. Rodrigues MA, Brady RR. Anaesthetists and apps: content and contamination concerns. Anaesthesia. Dec 2011;66(12):1184-1185.
  13. Aziz O, Panesar SS, Netuveli G, Paraskeva P, Sheikh A, Darzi A. Handheld computers and the 21st century surgical team: a pilot study. BMC Med Inform Decis Mak. 2005;5:28.
  14. Richardson JE, Shah-Hosseini S, Fiadjoe JE, Ash JS, Rehman MA. The effects of a hands-free communication device system in a surgical suite. J Am Med Inform Assoc. Jan-Feb 2011;18(1):70-72.
  15. Ruskin KJ. Communication devices in the operating room. Curr Opin Anaesthesiol. Dec 2006;19(6):655-659.
  16. Soueid A. A new tool for the operating surgeon: a Bluetooth mobile phone headset. Burns. Nov 2006;32(7):927-928.
  17. Wu R, Rossos P, Quan S, et al. An evaluation of the use of smartphones to communicate between clinicians: a mixed-methods study. J Med Internet Res. 2011;13(3):e59.
  18. Soto RG, Chu LF, Goldman JM, Rampil IJ, Ruskin KJ. Communication in critical care environments: mobile telephones improve patient care. Anesth Analg. Feb 2006;102(2):535-541.
  19. Jeske HC, Tiefenthaler W, Hohlrieder M, Hinterberger G, Benzer A. Bacterial contamination of anaesthetists' hands by personal mobile phone and fixed phone use in the operating theatre. Anaesthesia. Sep 2007;62(9):904-906.
  20. Wallin MK, Marve T, Hakansson PK. Modern wireless telecommunication technologies and their electromagnetic compatibility with life-supporting equipment. Anesth Analg. Nov 2005;101(5):1393-1400.
  21. Mobile phones and hospital equipment. Evidence-Based Healthcare & Public Health. April 2005;9(2):173.
  22. Datta R. Mobile phones - ban or boon?. MJAFI. October 2008;64(4):363-364. http://download.journals.elsevierhealth.com/pdfs/journals/0377-1237/PIIS037712370880024X.pdf. Accessed March 21, 2012.
  23. Pape TM, Dingman SK. Interruptions and distractions during anesthesia induction: a pilot study. Plast Surg Nurs. Apr-Jun 2011;31(2):49-56.
  24. Smith T, Darling E, Searles B. 2010 Survey on cell phone use while performing cardiopulmonary bypass. Perfusion. Sep 2011;26(5):375-380.
  25. HIPAA - Health Insurance Portability and Accountability Act of 1996. Pub. L. 104-191 (Aug. 21, 1996).
  26. Anderson v Strong Memorial Hospital, 531 N.Y.S.2d 735 (N.Y. Sup. Ct. 1988).
  27. Hobbs v Lopez, 645 N.E.2d 1261 (Ohio App. 1994).
  28. Strod. Strodtbeck v. Lake Hosp. System, 2011 WL 1944187 (Ohio App. 11 Dist., May 13, 2011).
  29. US Department of Health & Human Services, Health Information Privacy, All Case Examples. http://www.hhs.gov/ocr/privacy/hipaa/enforcement/examples/allcases.html. Accessed April 20, 2012.
  30. Ill Comp Stat ch 225, §65/70-5(b)(25)(2007).
  31. Fla. Admin. Code §64B9-8.005(7)(2009).
  32. Facebook firings show privacy concerns with social networking sites. Healthcare Risk Manage. May 2009;31:49-52.
  33. Social Media in Healthcare. ECRI Institute. Healthcare Risk Control. 2011;Administrative Support Services 4. https://www.ecri.org/Forms/Pages/Social-Media-in-Healthcare.aspx. Accessed February 24, 2012.

  


Adopted by AANA Board of Directors June 2012.