Sunday, July 7, 2013

Sterile Cockpit


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.


 

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