Safety Sunday, Volume 1. Issue 6 (7/7/13)
Sterile Cockpit for EMS. Are you setting up for a safe ride?
The term “sterile cockpit” obviously originated in the
airline industry, which has done a lot in recent decades to increase the safety
of flying, and until just yesterday, has had quite a good streak going of
non-fatal accidents on commercial airlines. The overall concept is about
decreasing distractions, especially during key points during a flight. In 1981
the FAA made it a requirement for pilots to not engage in any “non-essential”
activities or conversations during critical phases of flight, mainly below
10,000 feet.
Different aspects of healthcare have taken this approach and
created some interesting safety mechanisms. One study in Oregon found that approximately
20% of adverse events were rooted in some type of distraction. These dangerous distractions
occur at key phases in the care of patients, notably during patient handoff,
medication administration, medication pickup, and surgery. Many hospitals have
implemented initiatives like “distraction-free” zones and “sashes” to wear
during interactions. These are often around medication dispensing and
preparation areas or ORs. Sashes are sometimes worn by nurses during medication
preparation or patient handoffs. This is to prevent the
death-by-thousand-paper-cuts phenomenon. If 5 people come up to you and ask “do
you have a sec?” while you are trying to get report about a new patient that
you have, you will surely forget some, potentially vital, details.
Luckily for EMS we usually are dealing with one patient, but
similar issues from hospitals can still occur. Though for EMS the sterile
cockpit generally refers to our “cockpit,” the cab of the ambulance. I’ve added a picture of an example of my
ambulance with some examples of a non-sterile cockpit. The key is finding the
distractors and setting up processes that keep those items from being
distractors. Here are some of the common distractors and risk mitigation
techniques:
·
Items in the dash.
o
I have seen jackets, stethoscopes, computers, glasses,
clipboards, food, and many other items on the dash in an ambulance. These items
all clog up important visual space, especially if the items are reflective
vests or white paper during heavy sunlight. They can also be projectiles in
sudden turns or accidents, possibly even rolling under driver.
o
Simply clear ALL items from the dash.
·
Mobile data terminal/computer/GPS
o
After the driver has gotten a good idea of where
they are going they should turn any screens around or close the screen, getting
rid of a distractor. GPS’s, if used at all, should be out of direct eye-line.
·
Dispatch Radio.
o
When both EMS providers are up front, the driver
should not be actively communicating on the radio. Place the radio away from
the driver.
·
Music Radio.
o
Besides acting as a general distractor, some “heavier”
music may add extra adrenaline to a situation that doesn’t need more speed.
·
Electronic PCR.
o
If you use an ePCR and your computer-aided-dispatching
doesn’t automatically link to your ePCR the passenger is likely busy entering
information and can’t assist in identifying potentially hazardous situations.
Proper role by a passenger in emergency driving is a topic for another day.
·
Idle conversation. Common emergency
communication.
o
When you are driving lights and sirens is not
the time to have a discussion about what to have for lunch, current
relationship statuses, or how stupid your boss was when he gave you a write-up
for something everyone does. If your passenger doesn’t have anything to do they
should be helping with identifying hazards.
o
I intentionally didn’t use the term “clearing
intersections” because as a driver I don’t want to rely fully on a partner to
clear a side, because he may be doing something else at another intersection
and not hearing anything may make me think it is clear when it is not. Simply
adding another set of eyes will add another layer of protection. Commonly
agreed upon terms like “clear right,” “vehicle not stopping,” “driveway on
right,” “driver/(vehicle descriptor) in left lane is on phone,” etc. will help
with any confusion.
·
Phone.
o
This should be obvious. Anyone that has worked EMS
for any amount of time has seen the results of texting and other phone-call
related distraction MVCs. Over 3,000 lives were lost in 2010 by texting alone. Leaving
your phone out of reach will limit this distraction.
·
Clutter.
o
Your whole work area should be free of extra
wires, unsecured drinks, loose items, radio straps, etc.
Hopefully with some of these you can help prepare yourself
to provide the best care to your patients, while arriving safely to the scene. I’ve
added some reference material and other information on the sterile-cockpit
concept.
Wikipedia entry on sterile cockpit rule.
Oregon patient safety commission discussion with links.
EMS World article on a sterile cockpit in EMS.
Scholarly article talks about sterile cockpit later in the
paper.
