Kelly McDaniel R.N., illustrates the “timeout” protocol that care teams use to review essential checklists before beginning a procedure. (photo by John Russell)
‘Timeout’ protocol helps keep procedures on track
It can be a particularly dark day for patient safety when the wrong procedure is performed on a patient or, what is perhaps more likely, when a procedure is performed on the wrong site — on the left knee rather than the right knee, for example.
Regardless of whether the procedure in question is major or minor, regardless of whether the consequences for the patient are devastating or slight, the starkness of any such safety breach adds to the toll for all concerned.
To help avoid these situations, clinical teams at Vanderbilt University Medical Center and elsewhere have adopted the strict practice of calling a brief “timeout” to review an essential checklist before starting a procedure.
What may help distinguish use of these checklists at VUMC is the computer systems support here for an efficient, standardized, documented process, and the commitment of Vanderbilt quality and safety experts to assess how well teams carry out these checklists.
“Across the health care system the incidence of wrong-site surgery is very low. If we can make it zero, our efforts will have been well worth it,” said Jason Wendel, M.D., assistant professor of Plastic Surgery and a member of a task force that implemented new electronic tools supporting timeouts in VUMC operating rooms.
The industry term for this safety procedure is universal protocol. It's used not only to avoid wrong procedures but also to confirm signed patient consent and administration of preventive antibiotics, and to check that essential personnel, equipment and information are on hand, such as surgical implants, radiology images and the patient's known allergies.
Teams also confirm the presence of the person who, prior to sedation, marked the procedure site on the patient's skin (the person who marks the site doesn't always lead the procedure).
Holding room nurses start the checklist. In the OR, just prior to incision, the surgical team reviews and completes the full list in as little as 30 seconds.
VUMC has instituted mandatory training for residents and nurses on use of the universal protocol. Vanderbilt operating rooms are equipped with 42-inch monitors that make it easy for teams to review the checklist together. This year the use of electronic checklists will spread to VUMC hospital units and clinics where minor procedures are performed.
If anyone were to check items off the list without holding a timeout, it would invalidate the protocol. As with VUMC's hand hygiene campaign, certain personnel have been delegated to observe teams on an “undercover” basis and report on whether the timeout checklist is faithfully carried out.
Experts are also examining whether safety is measurably improving at VUMC with use of the protocol. Results of these assessments have not yet been reported.
Support for use of the checklists has already spread beyond the OR to VUMC intensive care units, where teams doing bedside procedures access the checklist on mobile workstations. The Cardiovascular Intensive Care Unit began piloting use of the checklist in 2009, first in printed form and later in electronic form. The CVICU uses the protocol for such procedures as inserting tubes into the chest or into veins.
“This has been well received by staff and faculty, because it comes down to patient safety. It's just the right thing to do, and basically it's not an option. It only takes a couple of minutes, so it's not a big deal,” said Aubrie Booth, R.N., dayshift assistant manager of the CVICU.
The Urology clinic will soon become the first Vanderbilt Medical Group clinic to pilot use of the electronic checklist. They've installed wall-mounted monitors in their three procedure rooms expressly to support team communication during timeouts before such procedures as prostate biopsy and cystoscopy.
The leaders for implementation of universal protocol at VUMC are Nancye Feistritzer, M.S.N., R.N., associate director of Vanderbilt University Hospital, and Shea Polancich, Ph.D., director of patient safety for VUMC.