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Sterile Cockpits and Sterile Operating Rooms

A while back, I was asked by some hospital administrators how our surgery program’s results were so good with such a low infection rate.   Without thinking too much about it, I answered, “I really insist on a sterile operating room”.  They gave me the raised eyebrow look that meant they thought I’d given them a glib and silly answer but the true meaning of what I said had nothing to do with bugs and germs.

The “sterile OR” concept is derived from some hard learned lessons in the aviation world and is referred to as the “sterile cockpit” rule.  This has been written into aviation law (U.S. FAR 121.542/135.100) and describes “Flight Crewmember Duties”.  There are two essential elements of this law and we will see how they can map directly to healthcare:

1.  During any critical phase of flight (includes all ground operations involving taxi, takeoff and landing, and all other flight operations conducted below 10,000 feet) no flight crewmember may engage in any activity except those duties required for the safe operation of the aircraft.   2.  No flight crewmember may engage in, nor may the pilot in command permit, any activity during a critical phase of flight that could distract any flight crewmember from the performance of his or her duties or that could interfere in any way with the proper conduct of those duties. Such activities as eating meals, engaging in nonessential conversations within the cockpit and nonessential communications between the cabin and cockpit crews, and reading publications not related to the proper conduct of the flight that are not required for the safe operation of the aircraft are prohibited.

As fellow students of “error producing conditions” we already know that distraction is among the most common causes of mistakes and these laws mandate some very important and common sense behavior that is clearly in the public interest.   Let’s look at the only recent fatal aviation accident – Continental Connection (Colgan) Flight 3407 bound for Buffalo, NY on February 12th, 2009 that serves as a critical example of failure of the sterile cockpit rule.  The FAA and NTSB conducted extensive investigations of this accident and determined that one of three central factors that caused the accident was “violation of the sterile cockpit rule”.  The cockpit voice recorder (“black box”) showed that the captain and first officer engaged in “almost continuous and extraneous conversation” throughout the flight and even during their approach to landing which was carried out at night in icy and cloudy conditions.  Because of this, the “flight crewmembers squandered time and their attention, which were limited resources that should have been used for attending to operational tasks, monitoring flight conditions, maintaining situational awareness, managing possible threats, and preventing potential errors.”  As a result, the NTSB concluded that “the captain’s failure as an effective leader to manage the flight deck environment enabled conversation that delayed checklist completion and conflicted with sterile cockpit procedures.  This created an environment that impeded timely error detection leading to improper management of deteriorating airspeed due to ice build-up on the wings and ultimate loss of control and crash.”

 So, if you and your family are on an airliner getting ready to land at a busy airport, wouldn’t you like to know the flight crew is paying attention to the task at hand and not chatting about what they are going to have for dinner?  The same applies to one of our patients lying on an operating table.  They should go to sleep knowing that while they are having surgery, the surgeon and the OR team members are not on the phone, not distracted by loud music and pagers ringing and not gossiping about co-workers.  A sterile cockpit and a sterile OR have some critical similarities but it has nothing to do with the cleanliness of the physical environment.  It has everything to do with a pure mental environment. Doing several things at once means that something important will fall through the cracks or go unnoticed at a critical time.

Here are my personal sterile OR policies: leave pagers and cell phones at the OR desk, turn the phone ringer off in the OR and only have a light flash if there is a call, mandate only conversation about the case be carried out at the OR table during critical phases, no conversations in the room away from the OR table that don’t pertain to the case, no web surfing, text messages or cell phone conversations by the OR team, no loud or distracting music playing during the case and only pertinent conversation from anesthesia during the operation.  It works; demand it in your facility, in the ICU and in the operating room during all critical procedures.

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6 Responses

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  1. Tony Kern says

    Great post, and one that we aviators also need to relearn. Even though 2011 was the safest on record, if you go back through the last few major aviation mishaps (Comair in Lexington, Air France 447, American Airlines in Cali Columbia), they all have their origins in lost SA due to a less than sterile cockpit. There is also the challenge of internal distractions we bring with us to work every day (preoccupation) that I hope you will address in the future. Its all about keeping our heads in the game.

  2. Billy Schmidt says

    The first 5 minutes on the fire ground, like the critical minutes during a surgical procedure or an airplane taking off, demands attention to mission and keeping our heads in the game. Not easy when responding apparatus are arriving at a chaotic scene (police cars parked everywhere, citizens running around, and fire blowing out of a window) while trying to balance a constant flow of radio traffic, sizing up the scene, and directing initial tactical operations. Recently at our fire department, we determined that there was “too much talk” during these stressful first minutes, sometimes causing confusion and information overload. We used the “sterile cockpit” model to develop an operational procedure to reduce non-critical radio traffic. Whole lot of stuff going on during the first 5 minutes of a fire call and we need to stay in the game! I look forward to more thoughts on error producing conditions as they relate to high-risk professions. There’s so much from aviation and healthcare that we can apply to the fire service.

    • kenstahl says

      Very true thank you for the comments to our discussion. Our efforts are aimed at understanding and managing those times of information and situational overload. By understanding how we make decisions and cope with the chaos we can understand the mechanisms of human error and build into the system in each of our professions ways to avoid mistakes. Please keep following the blog postings and add your comments we all enjoy reading your thoughts.

    • Tony Kern says

      Billy, I agree that the issues associated with situation awareness are deeply compounded by chaotic communications in all high risk activities (including driving). Communication protocols and a way to say “knock it off” are key. I look forward to continuing to cross pollinate ideas. Tony

  3. skulljockey says

    Love the ideal of a sterile cockpit but wonder about a couple a things that constantly arise in the operating theater . There is this paradoxical situation with sub specialty surgeons that when system safety processes are entertained ( such as the surgical check list) we hear either…”I am in my zone..I don’t want to interrupt my routine and share my mental picture with the will throw me off my game….( a favourite with cardothoracic surgeons) or I am used to a certain distracting enviroment…( particular I tunes playlist) works for me !
    Distraction is not only a folly for our medical teams but has become such for our patients. An alarming number of trauma victims are distracted. Distracted drivers and distracted pedestrians all focussed on being in the “zone” complete with earphones and ignoring the risks entailed.

    • kenstahl says

      Agree – and thanks for your observations. I won’t defend cardiac surgeons, but as a cardiac surgeon I can tell you that I don’t mind a little music in the OR but for me the “sterile OR” applies to ALL times I’m on cardiopulmonary bypass and the “approach and landing” which is obvisouly the most critical time in the cockpit when I need silence is weaning and seperating the patient from bypass. It is interesting the the NTSB comments on the accident I cited in the original blog post faulted the pilot for failing to insist on a sterile cockpit environment leading to the crash. The same is true in the OR – just because the surgeon is not distracted by noise or music does not mean that the rest of theteam we depend on for safe outcomes is not distracted. In any human endeavor distraction leads to errors and accidents – that’s the nature of the human brain (you know that all too well).

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