You're watching the patient's vital signs. You turn to give your patient a jaw thrust during their endoscopy and, whack! You hit your head on the monitor, temporarily dazing you while your patient's airway remains obstructed. This is just one example of the hazards that jeopardize the anesthesiologist's ability to safely care for patients in the perioperative setting. Physical, radiological, biological, and chemical risks may also contribute to the epidemic of burnout, leading to costly turnover of anesthesia staff. Therefore, it is crucial that the OR environment is safe – not only for the patient, but also for the anesthesiologist and others. We suggest that our state and national organizations provide guidance on procedural site design to minimize hazards, improve ergonomics, enhance both patient and anesthesiologist safety, and reduce burnout. Additionally, we call upon hospitals to enact these changes to protect all staff.

The Bureau of Labor statistics lists the top three causes of loss of work in the hospital as “overexertion” causing musculoskeletal strain (~50%), slips, trips, and falls (25%), and blunt force and crush injuries (10%-13.7%).1 Falls may occur when floors are slippery from spillage of I.V. fluids, irrigation, or bodily fluid. The OR and nonoperating room anesthesia (NORA) environment are a jungle of I.V. poles, wires, gas supply lines, suction tubes, C-arms, cautery cords, and monitors. These devices often migrate into the foot and headspace that the anesthesiologist needs to occupy. Suspended equipment causing head injury is common enough that the ASA Committee on Occupational Health coined the term “boom strike” to describe the phenomenon.2 

Newer equipment is often deployed in crowded rooms that were not built to accommodate it. Even modern ORs may not be designed with the ergonomic needs of the anesthesia team in mind. When seconds count, a well-designed environment can help the anesthesiologist to move effectively.

Conversely, a suboptimal setup risks incapacitation of the anesthesiologist and jeopardy of the patient.

Although the World Health Organization (WHO) recommends that noise levels be less than 35dB in an OR, average levels can be 60-65dB.3,4,Table 1 shows common OR volume levels.4 With layering, noise levels of 100 dB or more can be reached. According to the Centers for Disease Control and Prevention, prolonged noises >70dB can cause hearing damage, loss, or tinnitus. Fifteen minutes of noise at 100dB can cause hearing damage, as can five minutes at 120dB.5 Loud noises, especially sudden, unexpected ones, can trigger stress responses, such as tachycardia, hypertension, insulin resistance, stress ulcers or cardiovascular disease.6 Some solutions are obvious (turn down the music)7, but others will require innovation (loud machines).

Table 1: Volume of common operating room equipment. Adapted from Interv Med Appl Sci 2017;9(2):61-6.

Table 1: Volume of common operating room equipment. Adapted from Interv Med Appl Sci 2017;9(2):61-6.
Table 1: Volume of common operating room equipment. Adapted from Interv Med Appl Sci 2017;9(2):61-6.

Radiation effects include short-term exposure (hair loss, burns, cataracts, etc.) or long-term exposure (cancer, teratogenesis, etc.).8 Although there is no safe exposure level, the International Commission on Radiological Protection (ICRP) recommends a limit of 20 mSv per year for health care workers and 1 mSv per year for the public.9,10,Table 2 shows common radiation exposure levels.11 The general rule is to use an amount that is “as low as reasonably achievable.”12 Minimizing the amount of radiation generated and the duration of exposure, while maximizing the distance from the source and shielding, provides some protection.13 Although radiation exposure is almost nonexistent at distances about five feet from the emitter, the anesthesiologist cannot always maintain this distance.14 Therefore, anesthesia team members must use shielding. Standard 0.5 mm lead gowns prevent >98% of transmission; 0.5 mm lead shields and leaded glasses are equally effective.13 Lead gowns can weigh up to 7 kg, causing orthopedic issues, especially back, neck and leg pain, or disc herniation.15 Note that the emitter is typically placed under the patient, aiming away from the proceduralist to minimize their exposure. However, this may inadvertently aim the emitter toward the anesthesiologist. Though effects of radiation itself may not present immediately, leaded gowns and shields or the radiation equipment can impede access to the patient. Creative design solutions for the interventional suite could obviate some of these dangers.

Table 2: Radiation exposure comparison chart. Adapted from Anaesthesia 2016;71(4):455-61.

Table 2: Radiation exposure comparison chart. Adapted from Anaesthesia 2016;71(4):455-61.
Table 2: Radiation exposure comparison chart. Adapted from Anaesthesia 2016;71(4):455-61.

Smoke from electrocautery or lasers can contain toxic compounds such as benzene and cyanide, viruses, cancer cells and other ultra-fine particles.16 Typical disposable surgical masks do not provide complete protection from inhalation of these particles.17 While acute exposure to electrocautery smoke may cause transient symptoms such as headache, eye watering, and cough, long-term exposure may cause chronic disease or disability in an anesthesiologist.18 Local exhaust ventilation devices have been developed to reduce surgical smoke exposure, but widespread adoption thus far has not taken place.19 

Distractions in the OR can impact patient safety and increase liability.20 Loud music, conversations, and equipment noise can disrupt essential communication, harm hearing, and distract from critical patient care.3-5,7 Environmental threats to personal safety also impact clinician well-being.21,22 A decreased sense of well-being has been linked to increased medical errors and decreased patient safety.23-26 A safe working environment can contribute to patient safety.24 When added together, the total effect of seemingly minor hazards can be greater than the sum of their parts.27 Burnout decreases employee retention.26 Loss of key personnel will negatively affect efficiency and safety in the hospital.25,28,29 

The ASA Committee on Occupational Health emphasizes that occupational injury is related to patient safety. A recent survey showed occupational injury is a concern to the ASA membership. A resolution on the physical demands of anesthesiologists has been presented to the ASA House of Delegates. The resolution emphasizes the need for multiple committees and experts to collaborate and address this issue.30 The committee identified head trauma from overhead procedural equipment (“boom strikes”) as one subject of concern that can impact patient safety.2 The ASA Committee on Occupational Health and Wellness statement on “Boom Strikes – Identification of an Operating Room Hazard” emphasizes the gravity of an anesthesia team member becoming suddenly incapacitated, particularly in remote anesthetizing locations. Anesthesiologists are urged to name hazards and report related injuries to their institution.

The U.S. Department of Labor's Occupational Safety and Health Administration (OSHA) sets the standards for protection from ionizing radiation, blood-borne pathogens, and COVID-19.31-33 OSHA ensures safeguards for workers who report unsafe working conditions.34 No official standards exist for common aspects of an anesthesiologist's workplace (e.g., minimum distance from radiation source), making it difficult to effect change on an institutional level or receive compensation in case of harm. We can, however, look toward the 2018 book released by the Brazilian Society of Anesthesiologists on “Occupational Well-Being in Anesthesiologists” as a potential starting point in the U.S.35 

Anesthesiologists who incur injury may be able to turn to workers' compensation for relief. Governed by state law, such benefits vary, but the concept is to protect employees from loss of income and the burden of medical expenses they suffer from a work-related injury or illness. In most situations, the income benefits are capped and indexed to the average worker, not the income of the average anesthesiologist. This may result in a situation where an incapacitated anesthesiologist feels financially compelled to work in an impaired state. Employees should always report and document a work-related injury to employers. Independent contractors such as 1099 locum workers are not considered employees and as such are not covered by state workers' compensation laws at all.

“The ASA Committee on Occupational Health emphasizes that occupational injury is related to patient safety. A recent survey showed occupational injury is a concern to the ASA membership. A resolution on the physical demands of anesthesiologists has been presented to the ASA House of Delegates. The resolution emphasizes the need for multiple committees and experts to collaborate and address this issue.”

The first step is to raise awareness of the problem. Submitting incident reports and communicating with hospital leadership are essential for highlighting the risks anesthesia personnel face. Documenting work-related injuries will provide data for further studies and innovation in human factors engineering. Resident curriculum, continuing medical education, and departmental discussions regarding risks can also increase clinician awareness of the issues.

Next, it must be emphasized to all hospitals and employers that investment in safer environments for health care workers is valuable, for clinician and patient safety alike. The OR/NORA suite must be designed to accommodate not only the proceduralist needs, but also the movements, safety, and ergonomics of the anesthesia care team. Involvement of an anesthesiologist on the planning team for any newly built or renovated OR or NORA suite is essential.

Our state and national organizations must take the lead in establishing safety standards for the anesthesia work environment. We recommend that a generic framework of essential elements of safe OR/ NORA environments should be created on a national level. This framework could then be used by hospitals to design better ORs, by OSHA to develop specific safety guidelines, and by state agencies/legislatures to enact policies and laws governing workplace safety.

Disclosure: Dr. Parr is a consultant for FlexiCare and an expert witness for NorthGauge.

Jennifer A. Feldman-Brillembourg, MD, ASA Committee on Patient Safety and Education, Vice President, District of Columbia Society of Anesthesiologists, and Anesthesiologist, Department of Anesthesiology, Sibley Memorial Hospital and Howard University Hospital, Washington, District of Columbia.?

Jennifer A. Feldman-Brillembourg, MD, ASA Committee on Patient Safety and Education, Vice President, District of Columbia Society of Anesthesiologists, and Anesthesiologist, Department of Anesthesiology, Sibley Memorial Hospital and Howard University Hospital, Washington, District of Columbia.?

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K. Gage Parr, MD, FASA, ASA Committee on Patient Safety and Education, Associate Professor, Vice Chair for Quality, Department of Anesthesia and Critical Care Medicine, George Washington University School of Medicine and Health Sciences, and Peri-Operative Safety Officer, George Washington University Hospital, Washington, DC.

K. Gage Parr, MD, FASA, ASA Committee on Patient Safety and Education, Associate Professor, Vice Chair for Quality, Department of Anesthesia and Critical Care Medicine, George Washington University School of Medicine and Health Sciences, and Peri-Operative Safety Officer, George Washington University Hospital, Washington, DC.

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Christian M. Taylor, MD, FASA, ASA Committee on Patient Safety and Education, ASA Committee on Pediatric Anesthesia, Speaker, Missouri Society of Anesthesiologists, and Associate Professor of Anesthesiology, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri.

Christian M. Taylor, MD, FASA, ASA Committee on Patient Safety and Education, ASA Committee on Pediatric Anesthesia, Speaker, Missouri Society of Anesthesiologists, and Associate Professor of Anesthesiology, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri.

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P. Grace Harrell, MD, MPH, ASA Committee on Patient Safety and Education, Medical Director of Anesthesia, and Associate Clinical Professor of Anesthesia, City of Hope Orange County, Irvine, California.

P. Grace Harrell, MD, MPH, ASA Committee on Patient Safety and Education, Medical Director of Anesthesia, and Associate Clinical Professor of Anesthesia, City of Hope Orange County, Irvine, California.

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