Surgical Time-out Research Articles

Standardization and Visualization of the Surgical Time-Out.

The time-out (TO) can prevent adverse events but is subject to TO engagement. We hypothesize transforming the TO to an auditable, active process will improve compliance and engagement. The passive nature of the current TO was identified as a potential safety issue on staff patient safety culture surveys. Subsequently, the Time Out Engagement and Standardization quality improvement initiative was developed and included a whiteboard checklist to be used in the operating room. As a baseline, 11 TOs were audited concerning engagement and content. Key stakeholders were engaged to determine potential interventions. A TO consisting of 15 elements using a TO whiteboard checklist with role-specific objectives was developed. Plan, Do, Study, Act cycles commenced. After implementation, 17 TOs were audited based on engagement and content. Before intervention, engagement varied with nurse participating in 100% compared with anesthesia provider or surgeon participating in 18%. No TO included all 15 elements and only 13% of elements included in all TOs. After implementation of Time Out Engagement and Standardization, anesthesia and surgeon who participated increased to 100% and 76.5%, respectively (P < 0.0001, P = 0.006). The 15 standardized elements of the TO were discussed in 90% of cases. Overall, preintervention 88 elements (57.1%) were completed across all TOs, while postintervention 243 elements (98.8%) were completed (P < 0.001). We identified a need for increased engagement of the TO based on staff concerns, which were verified through auditing. Implementation of a team-driven intervention and 3 rapid Plan, Do, Study, Act cycles led to measurable improvement of the surgical TO.

Surgery and Anesthesia Preoperative "Virtual Huddle": A Pilot Trial to Enhance Communication across the Drape.

Effective communication between surgeons and anesthesiologists is critical for high-quality, safe, and efficient perioperative patient care. Despite widespread implementation of surgical safety checklists and time-outs, ineffective team communication remains a leading cause of patient safety events in the operating room. To promote effective communication, we conducted a pilot trial of a "virtual huddle" between anesthesiologists and surgeons. Attending anesthesiologists and surgeons at an academic medical center were recruited by email to participate in this feasibility trial. An electronic health record-based smartphone application was utilized to create secure group chats among trial participants the day before a surgery. Text notifications connected a surgeon/anesthesiologist pair in order to introduce colleagues, facilitate a preoperative virtual huddle, and enable open-ended, text message-based communication. A 5-point Likert scale-based survey with a free-text component was used to evaluate the utility of the virtual huddle and usability of the electronic platform. A total of 51 unique virtual huddles occurred between 16 surgeons and 12 anesthesiologists over 99 operations. All postintervention survey questions received a positive rating (range: 3.50/5.00-4.53/5.00) and the virtual huddle was considered to be easy to use (4.47/5.00), improve attending-to-attending communication (4.29/5.00), and improve patient care (4.22/5.00). There were no statistically significant differences in the ratings between surgery and anesthesia. In thematic analysis of qualitative survey results, Participants indicated the intervention was particularly useful in interdisciplinary relationship-building and reducing room turnover. The huddle was less useful for simple, routine cases or when participation was one sided. A preoperative virtual huddle may be a simple and effective intervention to improve communication and teamwork in the operating room. Further study and consideration of broader implementation is warranted.

MP06-12 STANDARDIZATION AND VISUALIZATION OF THE SURGICAL TIME OUT ACROSS SURGICAL SUBSPECIALTIES

You have accessJournal of UrologyCME1 Apr 2023MP06-12 STANDARDIZATION AND VISUALIZATION OF THE SURGICAL TIME OUT ACROSS SURGICAL SUBSPECIALTIES Brittany Levy, Sherry Lantz, Wesley Wilt, and Andrew Harris Brittany LevyBrittany Levy More articles by this author , Sherry LantzSherry Lantz More articles by this author , Wesley WiltWesley Wilt More articles by this author , and Andrew HarrisAndrew Harris More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003217.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The timeout (TO) can prevent adverse events but is subject to TO engagement. We hypothesize transforming the TO to an auditable, active process will improve compliance and engagement. METHODS: The passive nature of the current TO was identified as a potential safety issue on staff patient safety culture surveys. Subsequently, the Time Out Engagement and Standardization (TOES) quality improvement initiative was developed. 11 TOs were audited concerning engagement and content. Leadership and frontline stakeholders were engaged as members of the TOES team to determine potential interventions. A TO consisting of 15 elements utilizing a TO whiteboard with role specific objectives was developed. Plan, Do, Study, Act (PDSA) cycles commenced. Following implementation, 17 TOs in urology, general surgery, and vascular surgery were audited based on engagement and content. RESULTS: Engagement varied with nurse participating in 100% compared to anesthesia provider or surgeon participating in 18%. No TO included all 15 elements and only 13% of elements were standardized across TOs. Overall, 40% of the elements were discussed in 80% of TOs. Post-implementation of TOES, nursing, anesthesia, and surgeon participated in 100% of TOs. The 15 standardized elements of the TO were discussed 90% of the time. Voice of the customer audits revealed widespread acceptance of the active TO. Within the robotic OR, urologists noted a particular improvement in preoperative planning communication across the surgical team. CONCLUSIONS: We identified a need for increased engagement of the TO based on staff concerns which were verified through auditing. Implementation of a team driven intervention and rapid PDSA cycles led to measurable improvement of the surgical TO. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e57 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Brittany Levy More articles by this author Sherry Lantz More articles by this author Wesley Wilt More articles by this author Andrew Harris More articles by this author Expand All Advertisement PDF downloadLoading ...

Standardization and Visualization of the Surgical Time-Out

Standardization and Visualization of the Surgical Time-Out

Impact of a Hemoglobin Trigger Communication Tool on Perioperative Transfusion in Cardiac Surgery.

Blood transfusion represents an important and potentially modifiable risk in the daily practice of cardiac surgery. The risk profile and increasing cost of transfusion led us to study the effect of different maneuvers, interventions, or surgical techniques to minimize transfusion while maintaining patient safety. This study compares postoperative outcomes before and after incorporating a verbal hemoglobin (Hb) trigger during the surgical timeout in which the surgeon and anesthesiologist preemptively agree on a threshold for packed red blood cell (PRBC) administration in the perioperative period. The authors performed a chart review of patients who underwent cardiac surgery from July 2013 through June 2014 at our institution. Patients who underwent surgery from July 2013 through December 2013 served as the pre-Hb trigger group, and patients who underwent surgery from January 2014 through June 2014 served as the post-Hb trigger group. Information collected included patient demographics, type of cardiac surgery, preoperative Hb, Hb trigger, and intraoperative and postoperative variables. The primary outcome was the incidence of PRBC transfusions. Secondary outcomes included the incidence of frozen plasma (FP) transfusion, mechanical ventilation beyond postoperative day 1, and 30-day mortality. The study included 191 patients, with 84 in the pre-Hb trigger group and 107 in the post-Hb trigger group. Intraoperative PRBC transfusions did not decrease in the posttrigger group compared with the pretrigger group (pretrigger 51.4% vs posttrigger 52.4%, P = 1.0); however, intraoperative FP administration was lower in the posttrigger group (65.4% vs 50.0%, P = 0.038). Postoperative mechanical ventilation beyond postoperative day 1 also was significantly lower in the posttrigger group compared with the pretrigger group (27.1% vs 14.3%, P = 0.035). Implementation of a verbal Hb trigger during the surgical timeout was associated with a reduction in FP administration and duration of mechanical ventilation, but not a decrease in PRBC transfusion and mortality.

Optimizing Perioperative Venous Thromboembolism Chemoprophylaxis on a Gynecologic Oncology Service.

Perioperative venous thromboembolism (VTE) is a significant cause of morbidity and mortality after gynecologic cancer surgery. Here we report a quality improvement intervention to increase perioperative VTE chemoprophylaxis compliance. All operations performed by a gynecologic oncologist at a tertiary urban university medical center admitted to the hospital for at least one midnight were included. Using a pre/post design with a washout period, we sought to increase perioperative VTE chemoprophylaxis compliance from 22% in the historical control (HC) cohort to 90% in the quality improvement (QI) cohort. The perioperative VTE chemoprophylaxis process was standardized by addressing four domains: preoperative VTE chemoprophylaxis, surgical time-out, postoperative VTE chemoprophylaxis, and intervention education and compliance tracking. Pearson's chi-square test was used to compare HC vs QI cohort compliance. There were 130 surgical cases in the HC cohort and 131 in the QI cohort. Forty-two percent underwent laparotomy, and 57% had cancer at the time of operation. VTE chemoprophylaxis compliance improved from 22% in the HC cohort to 82% in the QI cohort (p < 0.001). Preoperative VTE chemoprophylaxis compliance improved from 76% in the HC cohort to 94% in the QI cohort (p < 0.001), and postoperative VTE chemoprophylaxis compliance improved from 27% to 87% (p < 0.001). Thirty-day postoperative VTE occurred in three patients (2%) in the HC cohort and none in the QI cohort (p = 0.08). A low-cost and low-technology QI initiative intervention improved perioperative compliance with VTE chemoprophylaxis.

Simple lighting system to improve compliance of surgical timeout.

Simple lighting system to improve compliance of surgical timeout.

Time-Out and Its Role in Neurosurgery.

Safety checklists have improved surgical outcomes; however, much of the literature comes from general surgery. To identify the role of time-outs in neurosurgery, understand neurosurgeons' attitudes toward time-out, and highlight areas for improvement. A cross-sectional study using a 15-item survey to evaluate how time-outs were performed across 5 hospitals affiliated with a single neurosurgery training program. Surveys were sent to 51 neurosurgical faculty, fellows, and residents across 5 hospitals with a 72.5% response rate. At all hospitals, surgeons, anesthesiologists, registered nurses, and circulators were involved in time-outs. Although all required time-out before incision, there was no consensus regarding the precise timing of time-out, in policy or in practice. Overall, respondents believed the existing time-out was adequate for neurosurgical procedures (H1: 17, 65.4%; H2: 19, 86.4%; H3: 14, 70.0%; H4: 20, 80.0%; and H5: 18, 78.3%). Of the respondents, 97.2% believed time-out made surgery safe, 94.6% agreed that time-outs reduce the risk of wrong-side or wrong-level neurosurgery, and 17 (45.9%) saw a role for a neurosurgery-specific safety checklist. Pragmatic challenges (n=20, 54.1%) and individual beliefs and attitudes (n=20, 54.1%) were common barriers to implementation of standardized time-outs. Multidisciplinary time-outs have become standard of care in neurosurgery. Despite proximity and overlapping personnel, there is considerable variability between hospitals in the practice of time-outs. This lack of uniformity, allowed for by flexible World Health Organization guidelines, may reflect the origins of surgical time-outs in general surgery, rather than neurosurgery, underscoring the potential for time-out optimization with neurosurgery-specific considerations.

The Cognitive Relevance of a Formal Pre-incision Time-out in Surgery.

Surgical time-outs are designed to promote situation awareness, teamwork, and error prevention. The pre-incision time-out in particular aims to facilitate shared mental models prior to incision. Objective, unbiased measures to confirm its effectiveness are lacking. We hypothesized that providers’ mental workload would reveal team psychophysiological mirroring during a formal, well-executed pre-incision time-out. Heart rate variability was collected during cardiac surgery cases from the surgeon, anesthesiologist, and perfusionist. Data were analyzed for six cases from patient arrival until sternal closure. Annotation of surgical phases was completed according to previously developed standardized process models of aortic valve replacement and coronary artery bypass graft procedures, producing thirteen total surgical phases. Statistical analysis revealed significant main effects. Tukey HSD post hoc tests revealed significant differences across provider roles within various phases, including Anesthesia Induction, Heparinization, Initiation of Bypass, Aortic Clamp and Cardioplegia, Anastomoses or Aortotomy, Separation from Bypass, and Sternal Closure. Despite these observed differences between providers over various surgical phases, the Pre-incision Time-out phase revealed almost negligible differences across roles. This preliminary work supports the utility of the pre-incision safety checklist to focus the attention of surgical team members and promote shared team mental models, measured via psychophysiological mirroring, using an objective mental workload measure. Future studies should investigate the relationship between psychophysiological mirroring among surgical team members and the effectiveness of the pre-incision time-out checklist.

Strabismus surgical time-out: an illustrated whiteboard modification

Errors in strabismus surgery-including wrong eye, wrong muscle, and wrong procedure-can occur when there is confusion about the surgical plan among members of the surgical team, including surgeons, anesthesia staff, nurses, and technicians. The purpose of this study was to assess whether implementation of a strabismus-specific whiteboard combined with oral statement of the surgical plan using nonophthalmological terminology could improve communication among the team before commencement of surgery. A strabismus-specific whiteboard with labeled diagram of the eyes and extraocular muscles was designed. Patient identifiers, diagnosis, deviation, and procedure name were included. This whiteboard was completed preoperatively and referenced during time-out. The surgeonsand operating room staff were trained in its use, and surveys were completed before and 6months after implementation of the whiteboard time-out. The pre-implementation survey was completed by 19 operating room staff members, of whom 15 completed the post-implementation survey. The strabismus specific whiteboard increased staff member understanding of procedure laterality (74% to 93%), muscle(s) to be operated (37% to 93%), and specific procedure(s) planned (37% to 87%). Surgeon surveysalso showed increased confidence in staff member understanding of each parameter with whiteboard use. A standardized time-out combined with an illustrated strabismus surgery whiteboard improvescommunication between team members and has the potential to reduce surgical errors.

Incorporating patient safety into early undergraduate medical education: teaching medical students to perform surgical time outs during anatomy

ObjectivesTo introduce surgical safety checklists and time outs to future physicians through early incorporation of time outs in the first year gross anatomy course.SettingThe Wayne State University School of Medicine...

Timeout procedure in paediatric surgery: effective tool or lip service? A randomised prospective observational study

BackgroundFor over a decade, the preoperative timeout procedure has been implemented in most paediatric surgery units. However, the impact of this intervention has not been systematically studied. This study evaluates...

Awake Laser Laryngeal Stenosis Surgery.

Awake Laser Laryngeal Stenosis Surgery.

Beyond the Surgical Time-Out: A National Needs Assessment of Preoperative Communication in US General Surgery Residency Programs

Perioperative communication is critical for procedural learning. In order to develop a periprocedural faculty development tool, we aimed to characterize the current status of preoperative communication in US General Surgery residency programs. After Association of Program Directors in Surgery approval, a survey was distributed to general surgery programs. Participants were asked about perioperative communication, including the frequency of preoperative briefings, defined as dedicated educational discussions prior to a procedure. Data were analyzed using descriptive statistics. An anonymous electronic survey was distributed to interested programs in early 2019. US General Surgery trainees and attending surgeons. A total of 348 responses were recorded from 27 programs: 199 (57%) attending surgeons and 149 (43%) surgical trainees. Most respondents (83%) were from a university-affiliated program. Attending surgeons indicated a higher frequency of performing preoperative briefings compared to trainees (p < 0.001). Both trainees and attending surgeons were more likely to select their own group when asked who initiates a preoperative briefing. The majority of respondents (58%) agreed that discussing autonomy preoperatively improves resident autonomy for the case. In regards to the timing of preoperative briefings, most took place in/adjacent to the operating room, with only 60 participants (17%) participating in preoperative briefings the day/night prior to the operation. The most frequent topic discussed during preoperative briefings was "procedural content." Most participants selected "time constraints" as the greatest barrier to preoperative briefings and indicated that attending surgeon engagement was necessary to facilitate their use. Trainees were less likely to report engaging in immediate postoperative feedback, but more likely to report postoperative self-reflection. Preoperative briefings are not necessarily routine and attendings and trainees differ on their perceptions related to their content and frequency. Efforts to address timing and scheduling and encourage dual-party engagement in perioperative communication are key to the development of tools to enhance this important aspect of procedural learning.

Deep learning-based smart speaker to confirm surgical sites for cataract surgeries: A pilot study.

Wrong-site surgeries can occur due to the absence of an appropriate surgical time-out. However, during a time-out, surgical participants are unable to review the patient’s charts due to their aseptic hands. To improve the conditions in surgical time-outs, we introduce a deep learning-based smart speaker to confirm the surgical information prior to cataract surgeries. This pilot study utilized the publicly available audio vocabulary dataset and recorded audio data published by the authors. The audio clips of the target words, such as left, right, cataract, phacoemulsification, and intraocular lens, were selected to determine and confirm surgical information in the time-out speech. A deep convolutional neural network model was trained and implemented in the smart speaker that was developed using a mini development board and commercial speakerphone. To validate our model in the consecutive speeches during time-outs, we generated 200 time-out speeches for cataract surgeries by randomly selecting the surgical statuses of the surgical participants. After the training process, the deep learning model achieved an accuracy of 96.3% for the validation dataset of short-word audio clips. Our deep learning-based smart speaker achieved an accuracy of 93.5% for the 200 time-out speeches. The surgical and procedural accuracy was 100%. Additionally, on validating the deep learning model by using web-generated time-out speeches and video clips for general surgery, the model exhibited a robust and good performance. In this pilot study, the proposed deep learning-based smart speaker was able to successfully confirm the surgical information during the time-out speech. Future studies should focus on collecting real-world time-out data and automatically connecting the device to electronic health records. Adopting smart speaker-assisted time-out phases will improve the patients’ safety during cataract surgeries, particularly in relation to wrong-site surgeries.

Prospective Investigation of the Operating Room Time-Out Process

Although the surgical pause or time-out is a required part of most hospitals' standard operating procedures, little is known about the quality of execution of the time-out in routine clinical practice. An interactive electronic time-out was implemented to increase surgical team compliance with the time-out procedure and to improve communication among team members in the operating room. We sought to identify nonroutine events that occur during the time-out procedure in the operating room, including distractions and interruptions, deviations from protocol, and the problem-solving strategies used by operating room team members to mitigate them. Direct observations of surgical time-outs were performed on 166 nonemergent surgeries in 2016. For each time-out, the observers recorded compliance with each step, any nonroutine events that may have occurred, and whether any operating room team members were distracted. The time-out procedure was performed before the first incision in 100% of cases. An announcement was made to indicate the start of the time-out procedure in 163 of 166 observed surgeries. Most observed time-outs were completed in <1 minute. Most time-outs were completed without interruption (92.8%). The most common reason for an interruption was to verify patient information. Ten time-out procedures were stopped due to a safety concern. At least 1 member of the operating room team was actively distracted in 10.2% of the time-out procedures observed. Compliance with preincision time-outs is high at our institution, and nonroutine events are a rare occurrence. It is common for ≥1 member of the operating room team to be actively distracted during time-out procedures, even though most time-outs are completed in under 1 minute. Despite distractions, there were no wrong-site or wrong-person surgeries reported at our hospital during the study period. We conclude that the simple act of performing a preprocedure checklist may be completed quickly, but that distractions are common.

A comparative study on patient safety attitude between nurses and doctors in operating rooms.

ObjectiveTo investigate and compare the attitudes of operating room nurses and doctors regarding patient safety, performance of surgical time-out and recognition of count error.MethodsThis cross-sectional study recruited operating room nurses, surgeons and anaesthesiologists between 1 August 2015 and 5 February 2016. A Safety Attitude Questionnaire was used to analyse the three elements in both groups of operating room staff (nurses and doctors).ResultsThe study analysed the questionnaires from 171 participants; 95 nurses (55.6%) and 76 doctors (44.4%). Differences exist between doctors and nurses regarding teamwork climate, working conditions, perception of management and the recognition of stress. On the performance of surgical time-out, nurses showed higher scores on way of counting, while doctors showed higher scores on the time-out procedure itself. Also, doctors believed they actively cooperated with the nurses, while nurses believed they did not receive cooperation. Scores for the recognition of count error were higher in nurses than in doctors. More experienced operating room staff showed higher scores than younger less experienced staff.ConclusionsPerceptual differences among doctors and nurses need to be minimized for the safety of the patient in the operating room.

Early Deep Periprosthetic Hip Infection of Odontogenic Origin (Case Report)

Deep periprosthetic joint infection (PJI) is a severe complication after primary and revision hip joint arthroplasty resulting in multiple interventions on the joint. The present paper describes a rare case of early deep hip PJI of odontogenic etiology. The patient suffered from early PJI after a planned procedure of left hip joint arthroplasty. Antibacterial therapy without surgical debridement was performed in an outpatient unit which resulted in a late, on day 12th after surgery, admittance of the patient to hospital with continued administration of antibiotics. Treatment tactics was selected upon patient’s admission basing on patient complaints, medical history of the disease, clinical signs and findings of roentgenological, laboratory and bacteriological examinations. Two-stage treatment consisting of revision, removal of implant, debridement, biopsy and wound drainage by a swab was performed and followed by empiric antibacterial therapy (for 5 days). Targeted antibacterial therapy was prescribed basing on bacteriological test findings. Together with dentists the authors examined oral cavity of the patient, identified a site of chronic infection and undertook the focused treatment by dental extraction and sanitation of the oral cavity. Postoperative period after the first stage was uncomplicated. Second stage of revision (re-arthroplasty of left hip joint) was performed on week 36 of the surgical time-out with a good clinical outcome: 80 points on Harris hip score in 40 weeks after the second stage. Presented clinical case illustrates the existence of hematogenous mechanism of postoperative microorganism dissemination from the chronic infection nidus with subsequent progression of inflammation at the surgical site, including PJI. In the present case the Actinomyces odontolyticus was isolated from periprosthetic tissues and parodontal recesses which allowed the authors to suggest a highly probable cause for early PJI by Actinomyces odontolyticus translocation into periprosthetic tissues of the hip joint. However, strain sequencing is required for the complete verification. The described case confirms the need for debridement of chronic infection nidus prior to joint arthroplasty aiming at prevention of hematogenous periprosthetic infection.

Impact of Pre-bypass Autologous Blood Collection on Blood Transfusion Rates

Pre-bypass acute autologous donation (PAAD) is a method of blood conservation that reduces exposure of blood to the cardiopulmonary bypass (CPB) circuit and may prevent the contact activation of platelets and clotting factors. The purpose of this study was to evaluate the impact of PAAD on product transfusion rates in cardiac surgical patients. This is a retrospective study of patients undergoing cardiac surgery between 2015 and 2017 for either a coronary artery bypass (CABG), valve replacement, or a combined valve/CABG procedure. PAAD was performed by removing blood from the venous line of the bypass circuit immediately before the institution of CPB. The amount of PAAD volume was determined during the surgical time-out. This was based on patient size, baseline hemoglobin, and type of case. Poisson logistic regression was used to determine whether PAAD was a significant predictor for blood product transfusion. After obtaining institutional review board approval, we reviewed 236 records on (n = 154, 65.3%) who received PAAD and (n = 82, 34.7%) with no blood withdrawal before CPB. The median PAAD volume in the PAAD group was 750 mL. Patients undergoing PAAD had a 14.3% red blood cell (RBC) transfusion rate (.27 ± .91 units), and without PAAD, the RBC transfusion rate was 62.2% (1.56 ± 1.79 units). The significant (p &lt; .05) odds ratios (ORs) for RBC transfusion were as follows: baseline hemoglobin .617 (.530–.719), PAAD .998 (.997–.999), CPB time 1.009 (1.003–1.015), age 1.034 (1.013–1.055), and BSA odds ratio (OR) .326 (.124–.857). PAAD could not be used in all patients. However, using the OR in the Poisson logistic regression model, a one-unit reduction in RBC transfusion is predicted for each 500 mL of PAAD. PAAD was also associated with a significant reduction in fresh frozen plasma and platelet transfusion.

Strabismus surgical time-out: an illustrated whiteboard modification

Errors in strabismus surgery can occur due to confusion about surgical plans. Timeout procedures are not standardized and terminology is not well-understood by all team members. We hypothesize that implementation of a strabismus surgery whiteboard during timeout will lead to improved understanding of surgical plans among all team members.