Time-out Protocol Research Articles

Improving safety in anesthetized patients undergoing magnetic resonance imaging-Concept of time-out in the MRI suite and measures to improve adherence to time-out protocol.

The time-out protocol introduced by the Joint Commission is an important tool to prevent adverse events and improve safety in various health-care environments. However, its implementation and utilization involve human, social, behavioral as well as system issues. The SMART aim of the current project was to increase the utilization of the time-out protocol to more than 80% from baseline of 13%, over 6-month period in all the magnetic resonance imaging (MRI) procedures performed at a tertiary care, teaching institute in South India. The Plan, Do, Study, Act (PDSA) cycle and root cause analysis strategies were utilized in this quality improvement initiative. The time-out protocol was modified for MRI environment and put into practice to improve safety. Six months after the initiation of this safety protocol, our audit showed only a 13% compliance to the time-out protocol. A multimodal strategy was utilized by involving all the stakeholders, educational interventions, and placing reminders for following the time-out protocol, to affect change and achieve improvement in safety. The compliance to time-out protocol increased from 13% to 86% and the run chart showed that a special cause variation indicated by six points above the centerline at 86%. When analyzing individual components of the time-out, the greatest improvement was noted in the ferromagnetic check of the personnel involved, namely, the Anesthesiologist, radiographer, and anesthesia technician. There were no delays in the list because of adherence to the time-out protocol. Time-out protocol in an MRI suite provides a final check to the anesthesia team before the anesthetized patient is wheeled into MR gantry. Using quality improvement methodology, we increased the compliance of time-out protocol in the magnetic resonance imaging environment. Our study is an example how other institutions in India and elsewhere can adapt similar improvement strategies to enhance patient safety.

61. Evaluation of the Impact of a Micafungin Time-Out Protocol for Hospitalized Patients

BackgroundEchinocandin overuse is associated with increased prevalence of non-albicans Candida spp, resistance, and high costs. Prospective review of micafungin prescribing by an Antimicrobial Stewardship Pharmacist (ASP) has shown reduced rates of inappropriate therapy. The aim of this study was to describe ASP’s interventions following introduction of a micafungin time out (MTO) protocol.MethodsThe approved MTO protocol was implemented in November 2019. Active micafungin orders for hospitalized patients were reviewed Monday through Friday at initiation and on day five. The MTO algorithm assessed micafungin use based on patient risk factors for Candida infection and de-escalation was guided by clinical status, culture data, and susceptibility testing. Micafungin use and ASP’s interventions were reviewed post-implementation between 12/01/2019 and 02/29/2020. Micafungin use was also characterized between 12/01/2018 and 02/28/2019 to serve as a control.ResultsA random sample of 50 patients who received micafungin for ≥ 48 hours during the pre- and post- protocol periods were included. 39 (78%) and 38 (76%) patients in the pre- and post-MTO cohort had indications for micafungin initiation according to algorithm. In the post-MTO group, 9 (75%) of the 12 micafungin initiations outside of algorithm approval were intervened on successfully by the ASP, increasing appropriate antifungal therapy to 47 (94%) patients. On day five, 18 (50%) and 25 (65.8%) (p=0.17) micafungin orders were according to algorithm in the pre- and post-MTO groups, respectively. Culture data on day five revealed 18 (50%) in the pre-MTO and 13 (34.2%) in the post-MTO group were eligible for de-escalation. An ASP-initiated MTO on day five identified 23 opportunities for antifungal therapy optimization in the post-MTO group. Interventions included de-escalation (13; 61.9%), discontinuation (6; 28.6%), and dose optimization (4; 19%). Of the 23 ASP interventions on day 5, 10 (43.4%) led to micafungin discontinuation or de-escalation, increasing the overall antifungal appropriateness to 35 (92.1%) patients.ConclusionAn ASP-initiated MTO can facilitate appropriate and timely optimization of antifungal therapy. The most frequent interventions were de-escalation from micafungin or therapy discontinuation.Disclosures All Authors: No reported disclosures

Decision Tools and Studies to Improve the Diagnosis of Urinary Tract Infection in Nursing Home Residents: A Narrative Review.

The overdiagnosis of urinary tract infection (UTI) in nursing home residents that results in unnecessary antibiotic treatment has been recognized for more than 2 decades. This has resulted in the publication of several decision tools for the diagnosis of UTI in nursing home residents. Given all of the decision tools available, how does one decide on the approach to improve the diagnosis of UTI in nursing home residents in the context of an antimicrobial stewardship program? To address this question, this paper reviews: (a) published decision tools for the diagnosis of UTI in nursing home residents; (b) randomized controlled trials to improve the diagnosis of UTI in nursing home residents; and (c) non-randomized studies to improve the diagnosis of UTI in nursing home residents. Review of published decision tools indicates that the diagnosis of UTI is based on the presence of urinary tract signs and symptoms. However, there is considerable variation in the diagnostic criteria among the decision tools and there is no consensus as to the best clinical criteria for the diagnosis of UTI in nursing home residents. Review of four randomized controlled trials of interventions to improve the diagnosis of UTI in nursing home residents found that different interventions and outcome measures of varying complexity were utilized. Although randomized controlled trials were, to some extent, successful, it was not clear in any trial if one or more components of an intervention contributed the most to the success and there was no evidence that an intervention was feasible or sustainable after a trial was completed. Review of non-randomized trials to improve the diagnosis of UTI in nursing home residents all had methodologic limitations that make interpretation problematic. Randomized controlled trials and non-randomized studies all focused on the process before an antibiotic is prescribed. An alternative approach that focuses on assessment of the post-prescription process (antibiotic time-out protocol) is reviewed; initial studies of this protocol were inconclusive because of design limitations and additional studies are required. Regardless of what interventions are utilized, there must be provider and nursing staff commitment and motivation to improve the management of residents with suspected UTI and methods to achieve improvement must be demonstrated to be feasible and sustainable given the resources available in nursing homes.

Effects of a Brief Educational Program on Optimization of Fluoroscopy to Minimize Radiation Exposure During Endoscopic Retrograde Cholangiopancreatography

Fluoroscopy during endoscopic retrograde cholangiopancreatography (ERCP) is increasingly performed by therapeutic endoscopists, many of whom have not received formal training in modulating fluoroscopy use to minimize radiation exposure. Exposure to ionizing radiation has significant health consequences for patients and endoscopists. We aimed to evaluate whether a 20-minute educational intervention for endoscopists would improve use of fluoroscopy and decrease ERCP-associated exposure to radiation for patients. We collected data from 583 ERCPs, performed in California from June 2010 through November 2012; 331 were performed at baseline and 252 following endoscopist education. The educational intervention comprised a 20-minute video explaining best practices for fluoroscopy, coupled with implementation of a formal fluoroscopy time-out protocol before the ERCP was performed. Our primary outcome was the effect of the educational intervention on direct and surrogate markers of patient radiation exposure associated with ERCPs performed by high-volume endoscopists (HVEs) (200 or more ERCPs/year) vs low-volume endoscopists (LVEs) (fewer than 200 ERCPs/year). At baseline, total radiation dose and dose area product were significantly higher for LVEs, but there was no significant difference between HVEs and LVEs following education. Education was associated with significant reductions in median fluoroscopy time (48% reduction for HVEs vs 30% reduction for LVEs), total radiation dose (28% reduction for HVEs vs 52% for LVEs) and dose area product (35% reduction for HVEs vs 48% reduction for LVEs). All endoscopists significantly increased their use of low magnification and collimation following education. A 20-minute educational program with emphasis on ideal use of modifiable fluoroscopy machine settings results in an immediate and significant reduction in ERCP-associated patient radiation exposure for low-volume and high-volume endoscopists. Training programs should consider radiation education for advanced endoscopy fellows.

Development of simulation-based learning programme for improving adherence to time-out protocol on high-risk invasive procedures outside of operating room.

The aim of this study was to develop a simulation-based time-out learning programme targeted to nurses participating in high-risk invasive procedures and to figure out the effects of application of the new programme on acceptance of nurses. This study was performed using a simulation-based learning predesign and postdesign to figure out the effects of implementation of this programme. It was targeted to 48 registered nurses working in the general ward and the emergency department in a tertiary teaching hospital. Difference between acceptance and performance rates has been figured out by using mean, standard deviation, and Wilcoxon-signed rank test. The perception survey and score sheet have been validated through content validation index, and the reliability of evaluator has been verified by using intraclass correlation coefficient. Results showed high level of acceptance of high-risk invasive procedure (P<.01). Further, improvement was consistent regardless of clinical experience, workplace, or experience in simulation-based learning. The face validity of the programme showed over 4.0 out of 5.0. This simulation-based learning programme was effective in improving the recognition of time-out protocol and has given the participants the opportunity to become proactive in cases of high-risk invasive procedures performed outside of operating room.

백내장 수술 환자 안전을 위한 타임아웃 프로토콜 개발 및 효과

Purpose: This study was conducted to develop effective timeout protocol in coordination with current practice and test its clinical effectiveness in pursuit of safety management for patients undergoing cataract surgery. Methods: A total of subjects were 60 women, 50~65 years old, who visit C ophthalmology clinic in D city. They were assigned to 30 experimental group and 30 control group, respectively. Based on the comprehensive literature review, timeout protocol that was suitable for patients undergoing cataract surgery was developed, and then test its effectiveness by measuring blood pressure, pulse, anxiety and sense of well-being among surgical patients. Results: The timeout protocol was found to reduce blood pressure, pulse, and anxiety and increase well-being among surgical patients. Conclusion: As a results, it is necessary to introduce an effective timeout protocol giving positive responses to surgical patients, hence it should be develop a timeout protocol and explore the effectiveness of the protocol.

Development of simulation-based learning program for improving adherence to time-out protocol on high risk invasive procedures

Development of simulation-based learning program for improving adherence to time-out protocol on high risk invasive procedures

Realização do timeout pela equipe cirúrgica: facilidades e dificuldades

Objective: this study aimed to verify the opinion of the surgical team about the completion of timeout and identify the advantages and difficulties of its application. Method: it is an explanatory, descriptive study of quantitative approach carried out through the application of a structured questionnaire to 39 health professionals at the Surgical Center of a private institution in Sao Paulo. Results: all respondents (100%) know what timeout is; and most of them acknowledge its effectiveness (92,3%) and believe that its application provides safety to patients and the team itself (94,9%).The factors that facilitate the implementation of surgical timeout are collaboration of medical staff and knowledge, clarity and objectivity of the protocol; and those that hamper its implementation are lack of team collaboration, duration and repetitiveness, and delays of physicians and surgeries. Conclusion: implementation of timeout protocol is challenge for institutions and surgical teams, but contributes to reduced risks and adverse events, providing safety to the client.

Improving Team Performance During the Preprocedure Time-Out in Pediatric Interventional Radiology

The preprocedure time-out is a high-profile safety measure, and compliance is coming under increasing scrutiny. A checklist-based scoring system was developed to rigorously assess compliance, and a system of video monitoring and feedback was used to track performance and improve the time-out process in pediatric interventional radiology. A time-out "script" containing a series of observable behaviors to be performed collectively by the physician, nurse, and technologist before each interventional procedure was used to create a checklist. A procedure room equipped with an audio/video recording system allowed capture of time-outs for later review. The reviewer scored one or two time-outs each week, and the results were posted to provide feedback. The process of continual feedback and modification led to substantial improvements in time-out performance during a three-year period. Analysis of subscores revealed common failure modes that were subsequently addressed. The scoring checklist was also modified after analysis suggested redundant or unnecessary items. Gains were noted in the efficiency of the time-out protocol, which took more than 1 minute in the initial stages but soon shortened to 30-45 seconds as the team gained experience. Assessment of scoring consistency across three independent observers revealed 93% interobserver agreement and 95% intraobserver agreement. Clarification of the scoring criteria led to improved consistency (97% and 98% inter- and intraobserver agreement, respectively). The combination of a time-out checklist, recorded procedures, review, and feedback produced not only improvements in time-out performance but also improvements in the scoring system and time-out process.

Design and application of task administration protocols for collaborative production and service systems

Abstract This research investigates the design of Task Administration Protocols (TAPs) for effective task allocation and administration in collaborative production/service systems. Customer-focused and concurrent engineering service systems process tasks more effectively as a result of the power of collaboration among multiple participants. In such environments, however, complex situations might arise that require decisions that cannot be handled by simple Coordination Protocols (CPs). To design an effective control mechanism to manage complex situations, this research identifies basic problems in collaborative task administration and proposes the design framework of protocols to solve the problems. In the framework, TAPs consist of three component-protocols: (1) Task Requirement Analysis Protocol, (2) Shared Resource Allocation Protocol, and (3) Synchronization and Time-Out Protocol. Each component protocol is activated to address priority-based allocation, resource-aware allocation, and task re-allocation at a different task administration context, ranging from task initialization, task allocation, to task monitoring, respectively. To analyze feasibility and effectiveness of the proposed design, TAPs are applied to two collaborative production/service systems. Simulations are conducted to evaluate the performance achieved by different TAPs and non-TAP CPs under various load conditions. The results show that there is a significant performance improvement by TAPs over CPs in most cases, e.g., 84% vs. 64% in terms of task completion ratio. The advantage of TAPs can be explained by their design with relatively higher level of collaborative intelligence, addressing more complex control logic than non-TAP CPs.

Design of Protocols for Task Administration in Collaborative Production Systems

Customer-focused and concurrent engineering service systems process tasks more effectively as a result of the power of collaboration among multiple participants. In such environments, however, complex situations might arise that require decisions beyond simple coordination.Task Administration Protocols (TAPs) are designed as a control mechanism to manage complex situations in collaborative task environments. This article presents the design of TAPs for collaborative production systems in which tasks are performed by the collaboration of multiple agents. Three component protocols are found to constitute TAPs and are triggered at appropriate stages in task administration: 1) Task Requirement Analysis Protocol, 2) Shared Resource Allocation Protocol, and 3) Synchronization &amp;amp; Time-Out Protocol. A case study with TAPs metrics for task allocation in a collaborative production system is investigated to compare performance under TAPs, and under a non-TAP coordination protocol (which is considered to be simpler). In terms of task allocation ratio, the case study indicates that performance under TAPs is significantly better (up to 10.6%) than under the non-TAP coordination protocol, especially under medium or high load conditions. The advantage of TAPs can be explained by their design with relatively higher level of collaborative intelligence, addressing more complex control logic compared with non-TAP coordination protocols.

Protocol for Administration of Prophylactic Antibiotics within One Hour before the Surgical Incision in Total Hip and Knee Replacement

Purpose: We aimed that compliance could be improved by new protocol ensuring the adequate timing of intravenous antibiotic delivery onto an already existing time out system used to ensure exact surgical site. Materials and Methods: A group of 150 patients was administered prophylactic antibiotics just before entering operation room and performed only time-out protocol. Other group of 150 patients was administered prophylactic antibiotics directly after anesthetic induction and perfomed new protocol inclusive of checklist ensuring appropriate timing of antimicrobial prophylaxis. We compared mean time from prophylactic administration to surgical incision and compliance. Results: The average time from administration of the antimicrobial prophylaxis to the surgical incision for patients who was performed only time-out protocol was 43 minutes and compliance was 60.6%. The average time from administration of the antimicrobial prophylaxis to the surgical incision for patients who was performed new protocol was 18 minutes and compliance was 100%. There was a significant difference in compliance of two groups. Conclusion: New protocol ensuring the adequate timing of intravenous antibiotic delivery combined with administration of the antimicrobial prophylaxis directly after anesthetic induction were effective and easily adaptable method to ensure compliance with appropriate timing of prophylactic antibiotics.

Ensuring Appropriate Timing of Antimicrobial Prophylaxis

Delivery of intravenous antibiotic prophylaxis within one hour prior to surgical incision is considered important in helping to decrease the incidence of surgical site infections, but methods to ensure compliance have not been established. All patients at our institution are subjected to a surgical "time-out" protocol to prevent wrong-site surgery. During a seven-week period, all patients undergoing spine surgery, total hip arthroplasty, or total knee arthroplasty had another safety initiative, that of ensuring that prophylactic intravenous antibiotics were administered at least one hour prior to incision, "piggybacked" onto our existing time-out verification checklist. In addition, we compared compliance during the study period with compliance during a three-month period prior to institution of this protocol and compliance for eighteen months after institution of this protocol. The average time (and standard deviation) between the antibiotic administration and the incision was 26 +/- 12 minutes for all patients. The protocol was effective in ensuring antibiotic administration at the optimal time to 316 (99.1%) of the 319 patients. Analysis of a group of forty patients who had undergone total hip or knee replacement during the three months prior to the beginning of the study demonstrated a compliance rate of 65%. The difference between this baseline compliance rate and the rate during the study period was significant (p < 0.0001). The compliance rate was 97% for 160 patients who underwent similar procedures during the eighteen months after completion of the study. Independent audits demonstrated continuation of the significantly better compliance with timing of antibiotic prophylaxis for patients undergoing total hip and knee arthroplasty since the implementation of the protocol in our institution. Piggybacking of verification of prophylactic antibiotic administration onto the wrong-site-surgery time-out protocol is an effective, cost-free, and easy-to-adopt method to ensure compliance with appropriate timing of prophylactic antibiotics.

Fault-tolerant sensor integration for micro flow-sensor arrays and networks

Distributed micro flow-sensor arrays and networks (DMFSA/N), built from collections of spatially scattered, cooperating intelligent and redundant micro flow-sensor nodes, can improve the accuracy and reliability of system. However, it is unrealistic to expect all the sensor nodes and communication links in the system to function properly all the time. This paper is based on an earlier research, in which a DMFSA/N with a cluster architecture and fault-tolerant time-out Protocol (FTTP) was developed. In this paper, a fault-tolerant sensor integration algorithm (FTSIA) is proposed and evaluated in simulations. Experimental results showed that the FTSIA could always give reliable results even when certain portion of the sensors yielded faulty information. Furthermore, the results from FTSIA were significantly more accurate than the mean of sensor readings (popularly applied in industry) if some of the sensors produced faulty readings. Finally, the application of the proposed FTSIA is illustrated by measuring flow pressure using a pressure sensor array of eight sensors.

Distributed microflow sensor arrays and networks: design of architectures and communication protocols

Distributed microflow sensor arrays and networks are built from collections of spatially scattered, intelligent microflow sensor nodes. They can enhance the reliability and fault tolerance of the system. A new cluster network architecture and two original alternatives of fault-tolerant time-out communication protocol are described. Teamwork integration evaluator/micro-electromechanical system, a micro-electromechanical system sensor network simulation tool, was developed to evaluate the effectiveness of the network architectures and communication protocols.

Analysis of a time-out protocol and its applications in a single server environment

The use of time-out protocols can improve distributed system performance by utilizing equipment and resource-time that otherwise would be wasted. In time-out protocols for traditional computer communication networks, set-up time reduction is a major issue. An interesting area of development in networked production and test systems is the inclusion of costs other than set-up time in the evaluation, such as scrap rates and rework, or the effect on neighbouring or upstream client work-centres. The applications of time-out protocols in single, shared server production environments, such as automatic guided vehicle systems (AGVs) and shared testers in assembly processes, are described in this article. Analytical models have provided some insight into the application of time-out protocols but are cumbersome. The focus of this investigation has been in the context of networked task administration, including: (1) quantitative guidelines to evaluate time-out protocols in the context of task administration protocols, and (2) a new model for numerical evaluation, identifying the recommended time-out threshold and the regions where time-out protocols are, or are not, useful. Discrete event simulation models and empirical data from recent research on task administration protocols are described.

A head movement image (HMI)-controlled computer mouse for people with disabilitiesAnalysis of a time-out protocol and its applications in a single server environment

Purpose : This study proposes image processing and microprocessor technology for use in developing a head movement image (HMI)-controlled computer mouse system for the spinal cord injured (SCI). Method : The system controls the movement and direction of the mouse cursor by capturing head movement images using a marker installed on the user's headset. In the clinical trial, this new mouse system was compared with an infrared-controlled mouse system on various tasks with nine subjects with SCI. Results : The results were favourable to the new mouse system. The differences between the new mouse system and the infrared-controlled mouse were reaching statistical significance in each of the test situations ( p <0.05). Conclusions : The HMI-controlled computer mouse improves the input speed. People with disabilities need only wear the headset and move their heads to freely control the movement of the mouse cursor.

Time-out protocol for task allocation in multi-agent systems

In multi-agent system, the implementation of a time-out protocol can improve workflow coherence and reduce the communication congestion due to the coordination process among agents. This approach is part of effective CIM workflow planning and control for agent-based operations emerging in assembly, manufacturing, service, and logistics. The case study illustrated in this article concerns industrial testing and rework services provided by a shared resource. Results of analyses have been verified by simulation to illustrate how performance improves or deteriorates when different time-out protocols are applied. A general model is introduced for numerical evaluation, identifying the recommended time-out threshold, and the regions where time-out protocols are, or are not useful for better workflow. Measures of workflow coordination performance, including time-oriented and viability-oriented measures are discussed.

TestLAN approach and protocols for the integration of distributed assembly and test networks

In increasing distributed production facilities there is a greater need to coordinate and integrate activities to achieve cost-effective, collaborative performance. As a step in this direction, this research introduces the design approach of TestLAN, a computer-integrated method of testing giving increased throughput and reducing the time spent in the testing phase of assembly via a client/server production configuration. Three types of task protocols--priority assignment protocol, time-out protocol and resource allocation protocol--are discussed, whose purpose is to improve the performance of TestLAN. The advantages of the TestLAN approach and its protocols are quantified and demonstrated through analysis of a wire harness assembly case.

Simulation comparison of collaboration protocol-based testing models

This paper uses a stimulation modelling approach to investigate two collaboration protocols: timeout and frequent request collaboration protocols. The models presented here are very generic and can be adopted in general testing environments with a single tester shared by many types of jobs and with the repair process. This research presents different results from earlier studies, while addressing their misleading simplifying assumptions that are a common pitfall in practice. The two collaboration protocols are redefined based on the results. The timeout protocol improved system performance by collaborating with the SPT rule in the gamma repair time distributions with left biased shape. This collaboration is simple to implement and does not require the parameter estimation that is often a drawback of most heuristics for the combination of dispatching rules. The frequent service request (FSR) dispatching rule showed as good performance as the SPT rule with respect to overall mean flow time in this problem. Research is being continued to further investigate the properties of the timeout collaboration protocol with various factors.