Time-Out and Distraction: Performing Checklists After the Plane Has Taken Off.

Abstract

To the Editor Freundlich et al1 make a valuable contribution to understanding checklist performance in real-world clinical practice. In doing so, they raise important issues related to distraction. These issues have important implications regarding both the timing of and elements within checklists, and would likely affect both the implementation of checklists and any study of their effectiveness. For a checklist to be effective, full attention needs to be given to the checklist to the exclusion of all other tasks.2 Indeed, in the description of the implementation of the checklist at Vanderbilt, a photo is shown of the team turned away from the patient, looking up at the wall where the video screen is mounted, to appropriately give their full attention to the checklist process.3 Freundlich et al1 report that ≥1 member of the team was distracted in 10.2% of time-outs. But is focusing on the video screen to the exclusion of other tasks (eg, the patient) appropriate? Is not attending to the time-out sometimes appropriate? Time-out is performed postinduction, preincision when the patient is potentially unstable, and in need of constant vigilance, a time when the anesthesia provider must be free of distraction. To use an aviation analogy, the induction and early stabilization of the patient are equivalent to the process of take-off, one of the critical stages of flight. Because of the need to prevent distraction of pilots during critical stages of flights, US regulations encode the concept of sterile communications in the cockpit. This is to prevent pilots focusing on extraneous task when they should be attending ONLY to processes involved with the critical stage of fight: “No flight crewmember may engage in, nor may any pilot in command permit, any activity during a critical phase of flight which could distract any flight crewmember from the performance of his or her duties or which could interfere in any way with the proper conduct of those duties...”2 Although Vanderbilt checklist is performed after the anesthesia provider hands over to the surgeon, the patient is often still in a “critical stage of flight” and the anesthesia provider must, necessarily, be focused on stabilizing the patient; is this the time to be “verifying patient medications”? Timing of tasks, and when the checklist should be performed, is also relevant to the timing of antibiotic administration. Vanderbilt checklist items include both “allergy” and “antibiotics.” Has the patient already had their antibiotic? Yet, life-threatening allergies are often likely to be caused by antibiotics. If the antibiotic has not already been commenced/given, then a positive response to the antibiotic item on the checklist will merely be an intention to give the antibiotic. This intention is based on the premise that the anesthesia provider does not forget, exactly the situation a checklist is meant to prevent. Alternatively, should antibiotics only be given at the time of checklist, a time when the patient is still physiologically vulnerable after “take-off”? The anesthesia provider would then have to dedicate their attention to giving the antibiotics, and the whole time-out process would have to be suspended while this took place. Michael J. Keane, FANZCADepartment of AnaesthesiaCasey HospitalBerwick, Victoria, AustraliaCentre for Human PsychopharmacologySwinburne UniversityMelbourne, Victoria, AustraliaDepartment of Epidemiology and Preventive MedicineMonash UniversityMelbourne, Victoria, Australia[email protected]Shashikanth Manikappa, FANZCADepartment of AnaesthesiaCasey HospitalBerwick, Victoria, Australia