Time-out Procedure Research Articles

Variability in Uremic Control during Continuous Venovenous Hemodiafiltration in Trauma Patients

Introduction. Acute kidney injury (AKI) necessitating continuous renal replacement therapy (CRRT) is a severe complication in trauma patients (TP). We wanted to assess daily duration of CRRT and its impact on uremic control in TP. Material and Methods. We retrospectively reviewed adult TP, with or without rhabdomyolysis, with AKI undergoing CRRT. Data on daily CRRT duration and causes for temporary stops were collected from the first five CRRT days. Uremic control was assessed by daily changes in serum urea (Δurea) and creatinine (Δcreatinine) concentrations. Results. Thirty-six TP were included with a total of 150 CRRT days, 17 (43%) with rhabdomyolysis. The median (interquartile range (IQR)) time per day with CRRT was 19 (15–21) hours. There was a significant correlation between daily CRRT duration and Δurea (r = 0.60, P≤0.001) and Δcreatinine (r = 0.43; P = 0.012). CRRT pauses were caused by filter clotting (54%), therapeutic interventions (25%), catheter related problems (10%), filter timeout (6%), and diagnostic procedures (6%). Rhabdomyolysis did not affect the CRRT data. Conclusions. TP undergoing CRRT had short daily CRRT duration causing reduced uremic control. Clinicians should modify their daily clinical practice to improve technical skills and achieve sufficient dialysis dose.

AN EVALUATION AND COMPARISON OF TIME-OUT PROCEDURES WITH AND WITHOUT RELEASE CONTINGENCIES

A common recommendation for implementing time-out procedures is to include a release contingency such that the individual is not allowed to leave time-out until no problem behavior has occurred for a specific amount of time (e.g, 30s). We compared a fixed-duration time-out procedure to a release contingency time-out procedure with 4 young children (3- and 4-year-olds) using a reversal and multielement design. Results demonstrated that both time-out procedures were effective at reducing problem behavior outside time-out, problem behavior occurred in time-out during both procedures, and problem behavior in time-out was not predictive of problem behavior outside time-out.

Safety of Routine Magnetic Resonance Imaging in Critically Ill Preterm Infants at 30 Weeks Gestational Age

Background and aims: Preterm infants are at risk of brain injury with consequent neurodevelopmental impairment. As part of standard clinical care, we screen for possible brain injury by performing cerebral MRI at 30 weeks postmenstrual age. Our aim was to evaluate safety of MRI procedures in this population.Methods: We retrospectively collected data regarding patients‘ safety and (avoidable) adverse events of 41 VLBW infants, whose MRI scans were routinely performed at 30 weeks of gestation. MRI procedures were carried out according to our multidisciplinary based guideline. This includes a time-out procedure and registration of vital parameters, adverse events and safety incidents related to the procedure.Results: Mean gestational age (GA) and weight at image acquisition were 30.05 weeks (29.43-30.57) and 1112 grams (659-1580) respectively. No major adverse events occurred, but (preventable) incidents and minor adverse events were encountered: MRI procedure was interrupted in 3 infants (7.3%) because of respiratory instability. Minor increased respiratory support within 24 hours after the MR procedure was necessary in 10 infants (24.4%). Hypothermia (temperature < 36°C) occurred in 7 infants (17.1%). There was no significant correlation between temperature and GA at birth, weight at image acquisition, mode of respiratory support or hemodynamic instability.Conclusions: Although MRI scanning at 30 weeks gestational age is relatively safe for preterm infants, adverse events are common and should not be underestimated. A tailored guideline for MRI procedures in preterm infants including registration of patient data, time-out procedures and incident review is essential and the guideline should continuously be re-evaluated.

Risk factors in patient safety: minimally invasive surgery versus conventional surgery

BackgroundThis study aimed to identify the frequency of events in the different patient safety risk domains during minimally invasive surgery (MIS) and conventional surgery (CS).MethodsA convenience sample of gynecologic MIS and CS was observed. Events were observed and categorized into one of the predefined patient safety risk domains.ResultsA total of 53 procedures were observed: 26 CS and 27 MIS procedures. The general characteristics were comparable between the two groups. A large number of environmental events were observed, averaging one every 2.5 min. Technical events and events of an organizational nature occurred more often in MIS (P < 0.01) than in CS (P < 0.01). The relative risk for the occurrence of one or more technical events in MIS compared with CS was 1.7, and the risk for two or more technical events was 4.1. A time out according to protocol showed no relationship to the occurrence of the different types of patient safety-related events.ConclusionThe technological complexity inherent in MIS makes this type of surgery more prone to technology-related problems than CS, even in a specially designed minimally invasive surgical suite. A regular time-out procedure developed for CS lacks the attention necessary for the complex technology used in MIS and therefore is insufficient for MIS procedures briefing. Incorporating a specially designed technology checklist in a regular briefing protocol could be a solution to decrease the number of events in MIS.

Efectos comparativos de la extinción y el tiempo-fuera del reforzamiento en la imitación generalizada

The differential effect on imitative behavjor of non-reinforcement with the model present (ex tinction) and non-reinforcement with the model absent (time-out) was com­ pared in three normal children. Extinction practically did not affect imitative perfor­mance, while the time-out procedure virtually eliminated it. Results indicate the impor­tance of social variables in generalized imitation.

Variation in Surgical Time-out and Site Marking Within Pediatric Otolaryngology

To determine variation in surgical time-out and site-marking within pediatric otolaryngology. Survey e-mailed via the American Society of Pediatric Otolaryngology (ASPO). A total of 167 Children's Hospital Corp of America (CHCA) operating room (OR) directors and ASPO members were asked about perioperative preparation of their patients. Most respondents who operate at children's hospitals report policies that do not require site marking for bilateral placement of ventilation tubes, adenotonsillar surgery, airway endoscopy, or nasal surgery. Policies allowing assistants to perform site marking were identified by 45.0% of respondents from children's hospitals. Community hospitals were 3.68 times (range, 1.31-10.31 times) more likely than other facilities to permit only the attending to perform site marking. Most respondents operating at children's hospitals (84.4%) were satisfied with their hospital's site-marking policy and with their hospital's surgical checklist policy for pediatric otolaryngology procedures (87.1%). There seems to be a relationship between ear tube insertion marking policy and surgeon's age (χ² = 12.9; P = .045), area of country (χ² = 29.1; P = .004), and ambulatory centers for children (χ² = 8.1; P = .02). Twenty-one percent of survey respondents reported involvement in a wrong-site surgery at some point in their career. This survey of ASPO members and CHCA OR directors reveals substantial variation in the time-out and site-marking procedures. There is a dynamic tension between universal, national mandates, and allowing local variation to encourage hospitals to tailor policies to unique needs. Further study is needed to determine if the observed variations are beneficial or harmful.

Patient safety during anaesthesia: incorporation of the WHO safe surgery guidelines into clinical practice

WHO makes clear recommendations on how to improve patient safety during surgical procedures by using the WHO Surgical Safety Checklist. We will review the scientific basis of these recommendations and the practical problems encountered during introduction. Perioperative severe complications and death are a major health issue in both developed and developing countries. Nearly half of these complications can be avoided. The systematic use of checklists and structured preprocedural and postprocedural briefings like a time-out procedure reduces perioperative morbidity and mortality. A broader use of checklists to cover the whole surgical pathway gives additional benefit, further reducing perioperative morbidity and mortality.Introducing patient safety procedures can be met with some resistance from healthcare workers and is helped by an organization-wide safety policy and a systematic approach. There is sufficient scientific evidence to make the use of checklists and structured perioperative briefings and debriefings mandatory for the broad spectrum of operative procedures.

An Intervention to Maximize Research Sample Collection for Pregnant Subjects at Delivery

regnant women enrolled in clinical researchstudies requiring samples to be collected atdelivery aiord the researcheronly one opportunityto collect those samples, which if not collected re-sult in incomplete data sets. We hypothesized thatthe inclusion of a‘‘time out’’ review forall Cesareanand vaginal births would increase research samplecollection.We sought to evaluate the eiectivenessof implementinga time-out intervention whenpreg-nant study participants deliver in order to enhancethe collectionof biological research samples.Literature ReviewPerinatal research literature is mostly void in de-scribing speci¢c methods for identifying pregnantstudy subjects in labor and delivery and how re-search samples are collected at the time ofdelivery. Recent obstetric studies describe speci¢cbiological samples being collected at delivery;however most studies do not describe how themedicalandnursingstaiknowstocollect thedata.In 2006, aspartofthe national patient safety goals,the Joint Commission on the Accreditation ofHealthcare Organizations (JCAHO) recommendeda perioperative veri¢cation process, or ‘‘time out,’’to include identi¢cation of correct patient, correctsite, correct side, correct procedure, correct posi-tion for the procedure, and the availability ofspecial equipment ifneeded (2007).MethodologyStudy subjects included pregnant women deliver-ing at Duke University Medical Center (DUMC) whopreviously consented to IRB approved studies re-quiring research samples at delivery.Obstetric staiwere educated on the implementation of a vaginaldelivery time out that included research participa-tion.Collection rates of research samples obtainedat delivery were collected retrospectively from wo-men delivering by Cesarean and prospectivelyafterimplementationofresearchinthetimeoutpro-cedurefor those subjects delivering vaginally.Data Analysis & InterpretationPrior to study implementation, 105 subjects deliv-ered vaginally and were on one or more studies.Ofthose, 65.7% (69/105) had research samples col-lected forall studies. After study implementation, 83of 97 (85.6%) subjects who delivered vaginallyhadsamples collected for all studies (p5.001). Eighty-fourofthe 97 subjects (86.6%) had documentationof the time out procedure; of these 89.3% (75/84)had all samples collected. Of the 13 without timeout documentation, only 8 had all samples col-lected (61.5%, p5.008). Implementation anddocumentation of time out in vaginal deliveriesimproved research sample collection.Implications for Nursing PracticeByimplementingasuccessfulinterventiontocollectblood and tissue samples at delivery, the re-searcher is able to obtain those data that arecrucial to answering important perinatal researchhypotheses. Including research in all obstetric timeout procedures provides additional assurance thatcompliance with the JCAHO patient safety goals isbeing met. The inclusion of research participationinobstetrictimeoutproceduresisaneiectiveinter-vention maximizing research sample collection atdelivery that maybe implementedbyothers.

Diffusing Aviation Innovations in a Hospital in the Netherlands

Many authors have advocated the diffusion of innovations from other high-risk industries into health care to improve safety. The aviation industry is comparable to health care because of its similarities in (a) the use of technology, (b) the requirement of highly specialized professional teams, and (c) the existence of risk and uncertainties. For almost 20 years, The Rotterdam Eye Hospital (Rotterdam, the Netherlands) has been engaged in diffusing several innovations adapted from aviation. A case-study methodology was used to assess the application of innovations in the hospital, with a focus on the context and the detailed mechanism for each innovation. Data on hospital performance outcomes were abstracted from the hospital information data management system, quality and safety reports, and the incident reporting system. Information on the innovations was obtained from a document search; observations; and semistructured, face-to-face interviews. Aviation industry-based innovations diffused into patient care processes were as follows: patient planning and booking system, taxi service/valet parking, risk analysis (as applied to wrong-site surgery), time-out procedure (also for wrong-site surgery), Crew Resource Management training, and black box. Observations indicated that the innovations had a positive effect on quality and safety in the hospital: Waiting times were reduced, work processes became more standardized, the number of wrong-site surgeries decreased, and awareness of patient safety was heightened. A near-20-year experience with aviation-based innovation suggests that hospitals start with relatively simple innovations and use a systematic approach toward the goal of improving safety.

A review of timeout ribbons.

Timeout, when used effectively, is a powerful management tool (Turner & Watson, 1999). Timeout is defined as withdrawal of the opportunity to earn positive reinforcement or the loss of positive reinforcers for a specified time, contingent upon the occurrence of a behavior; the effect to reduce the future probability of that behavior (Cooper, Heron, Heward, 2007, p. 357). Thus, timeout has two necessary conditions. First, the current environment must have reinforcing qualities. Second, a removal of those qualities must be less reinforcing than a removal from that environment. In other words, there must be a discrepancy between time-in (i.e. the environment with reinforcement) and timeout (i.e., the environment without reinforcement; Friman & Finney, 2003; Harris, 1985; Marlow, Tingstrom, Olmi, & Edwards, 1997). In early studies, researchers demonstrated timeout by placing an animal on extinction following some behavior, which subsequently decreased that behavior's probability (Anderson & King, 1974). However, as timeout was applied in more and more settings, variability rather than conformity appeared (Friman & Finney, 2003). Even with response variability, timeout is now one of the most common disciplinary tactics used with children in the United States (Friman & Finney, 2003). There are three types of timeout: isolation or total removal from a reinforcing environment, exclusion from reinforcement within an environment, and non-exclusionary or reinforcement is stopped (Harris, 1985). Additionally, three types of nonexclusionary timeout include a removal of the reinforcing stimulus (i.e., withholding food or the cessation of music), ignoring the subject (i.e., turning away from the subject), and contingent observation (i.e., the subject must sit out and watch the appropriate behaviors of peers; Harris, 1985). With different variations available, considerations must be made when choosing a timeout procedure. For a timeout to be effective it must be applied immediately following each occurrence of the target behavior, which is not always possible with isolation and exclusion (Hugenin & Mulick, 1981). Additionally, moving an individual during isolation, exclusion, or contingent observation timeout procedures usually involves physical guidance, which has been shown to reinforce misbehavior (Kern, Delany, Hilt, Bailin, & Elliot, 2002). Recently, the Council of Children with Behavioral Disorders (2009) has released a position statement concerning the use of seclusion and isolation. The considerations include secluding the individual too long (i.e., the loss of a considerable amount of educational time), the potential for abuse, and additional paradoxical effects (i.e., timeout as a positive or negative reinforcer for inappropriate behavior). In summary, timeouts have heightened detrimental effects when used ineffectively by inexperienced people (Harris, 1985). On the other hand, non-exclusionary timeout procedures do not have the same negative concerns as other timeout techniques. A modified non-exclusionary timeout, the timeout ribbon procedure, combines contingent observation and the removal of a reinforcing stimulus. The availability of reinforcement is contingent upon the presence of some discriminative stimulus of which reinforcement has been paired. That stimulus is removed contingent upon the appearance of inappropriate or target behaviors and returned after a short period of time. The timeout ribbon procedure controls for some of the negative side effects of timeout, but also raises additional concerns. The potential risk of abuse and paradoxical effects are reduced. During timeout, the child is not touched or removed from the educational environment. Also, earning a timeout does not allow the child to escape from educational demands; they are expected to continue working. However because the child remains in the educational setting, the environment must be able to maintain higher intensity inappropriate behaviors. …

"Time-out" procedure and the enlightenment to safety management of surgical patient in our province

Objective To popularize preoperative Time-out procedure in order to strengthen safety management of surgical patient. Methods A feasible scheme was raised up by learning from the practical experience of Hongkong Mary Hospital and combining the medical system in Guangdong province and nursing model. Results No surgical accident happened after application of Time-out procedure in opera tion room of Hongkong Mary Hospital. Conclusions Preoperative Time-out procedure is one of the important measure to ensure the safety of surgical patients and prevent surgical accident. Managers in operation room should popularize this process according to actual situation in order to guarantee correct surgery on correct part of correct patients. Key words: Time-outprocedure; Operation room; Safety control

An Empirical Investigation of Time-Out With and Without Escape Extinction to Treat Escape-Maintained Noncompliance

The present study evaluates the effectiveness of two time-out (TO) procedures in reducing escape-maintained noncompliance of 4 children. Noncompliant behavioral function was established via a functional assessment (FA), including indirect and direct descriptive procedures and brief confirmatory experimental analyses. Following FA, parents were taught to consequate noncompliance with two different TO procedures, one without and one with escape extinction following TO release. Although results indicate TO without escape extinction is effective in increasing compliance above baseline levels, more optimal levels of compliance were obtained for all 4 children when escape extinction was added to the TO procedures already in place. Results indicate efficacy of TO with escape extinction when applied to escape-maintained noncompliance and are discussed as an initial example of the successful application of TO to behaviors maintained by negative reinforcement.

Using Time-Out Effectively in the Classroom

Teachers of students with disabilities frequently use time-out as a behavior management strategy. When implemented properiy, time-out procedures can be effective in reducing maladaptive behaviors across a wide range of student populations. Time-outs, however, are subject to abuse when educators faii to understand and apply the behavioral principles that make the procedures effective in reducing problem behaviors. Some teachers continue to use time-outs even when they are not effective in reducing a student's inappropriate behavior. Moreover, the inappropriate use of time-out may lead to legal problems; recent court cases have tilled that extreme use of time-out procedures may violate students' individual rights (Yell, 2006).

State Policies Concerning the Use of Seclusion Timeout in Schools

The use of seclusion timeout in school settings has again become controversial. For more than 35 years there have been recommendations that states and schools develop policies and procedures regarding the use of seclusion timeout in school settings. Recent lawsuits brought against school districts accusing them of violating student rights through the improper use of timeout procedures among a variety of other factors have again brought this issue to prominence. In addition, advocacy organizations have now begun to lobby for the elimination of seclusion timeout in all child caring agencies including schools. In order to identify whether states currently have policies in this area, the State Education Agency for each state was contacted, and their websites searched for policies on seclusion or timeout. Only 24 states were identified in the present study which have an established policy or provide guidelines to their respective school districts concerning the use of timeout procedures with students. The difficulty in locating and identifying these policies even when they do exist, indicates that they may not be viewed as a high priority by states or school systems in spite of the litigation and advocacy. These policies were then reviewed to determine whether they included a subset of the components called for in the literature. The content of these policies varied significantly, indicating that it was not likely that states were providing common comprehensive requirements or guidance to schools on this issue.

Teaching Time-Out and Job Card Grounding Procedures to Parents: A Primer for Family Counselors

Time-out procedures are proven effective methods for reducing undesirable behavior in children. However, such procedures are often taught incorrectly or used improperly and are therefore of little value in reducing such behaviors. The authors present a review of literature, empirically based instruction methods, and a case scenario to assist family counselors in educating and training parents in the appropriate use of time-out strategies. A form of time-out, known as job card grounding, is also presented as a derivative more applicable to adolescent children.

An evaluation of three time-out procedures for children with attention-deficit/hyperactivity disorder

Behavior modification is an evidence-based treatment for children with attentiondeficit/hyperactivity disorder (ADHD). Time-out from positive reinforcement is one behavior-modification procedure commonly recommended to manage disruptive or noncompliant behavior. This investigation examined the effects of time-out on children's behavior within the context of an intensive summer treatment program at two sites. Short (5-minute), long (15-minute), and escalating/de-escalating time-out conditions were compared to no time-out for 71 children. Results indicated that the time-out conditions were superior to no time-out in reducing the occurrence of intentional aggression, intentional destruction of property, and repeated noncompliance in the recreational and classroom settings regardless of child age or parent reported oppositional or conduct problems. There were no effects of time-out on staff member ratings of time-out effectiveness or the pleasantness of staff-child interactions. All three time-out conditions were equally effective in the group analyses, though analyses of normalization of functioning indicated there were individual differences in response to the time-out conditions. The results indicated that time-out is an effective means of reducing negative behavior in children with ADHD.

Negotiated time-out: a de-escalation tool for couples.

Many state domestic violence intervention standards mandate that treatment for offenders should be separate from any treatment offered to victims. In this article we advocate that in cases of low-level violence, when couples choose to remain together, certain aspects of treatment should be offered conjointly. Specifically, our feedback from victims and offenders suggests that one tool generally taught to offenders-time-out--is often ineffective and can be used abusively when partners are not taught the tool concurrently. We describe the negotiated time-out procedure that we developed and use feedback from our clients to illustrate its usefulness.

The Development of a High-Intensity Parent Training Program for the Treatment of Moderate to Severe Child Conduct Problems

Objective A home-based parent training program for the treatment of moderate to severe conduct problems was developed in two stages. Method Study 1, a case study, examined the inverse covariation between child compliance to parental instruction and aversive responding. Study 2, which used a multiple-baseline-across-subjects experimental design with two families, examined the effectiveness of a multicomponent treatment strategy for the reduction of aversive child behavior. Treatment was conducted as in Study 1 with the addition of high-intensity training in a time-out procedure. Direct observations of parent and child behavior were conducted in the home setting. Results Study 1 demonstrated the inverse covariation effect. Study 2 demonstrated significant treatment gains in parent and child behaviors in both training and test settings, which were maintained at 3-month follow-up. Conclusions A home-based parent training program that includes high-intensity training in time-out is an effective treatment method for moderate to severe child conduct problems.

Time-out as a Means of Shaping Whole-task Completion as a Precursor to Establishing Rule-following Behaviour with a Severely Noncompliant Preschool Child

A preschool girl who displayed severe noncompliant and disruptive behaviour was taught to successfully complete a card-matching task, to verbalise the task requirements, and to report successful task completion by means of a time-out procedure in combination with correspondence training. In order to bring about this success, time out was successively introduced for three preparatory behaviours (sitting still, keeping hands down, and looking at the task materials), for completion of simple tasks interspersed between trials of card-matching, and for stating the card-matching task requirement. The conditions for implementing time-out were gradually changed from allowing two chances to comply (implemented only after a second request was not complied with) to allowing only one chance (implemented after the first request was not complied with). This changing criterion time-out procedure was used in place of the more commonly used, but possibly more lengthy procedure whereby tasks not performed adequately are broken down into smaller steps and successive approximations are contingently shaped. The success of the time-out procedure is discussed as a potential means of conducting powerful early interventions with young children at risk for diagnoses of attention-deficit/hyperactivity disorder or similar disorders where a failure to correct severe behaviour problems observed at an early age is predictive of the need for more intrusive and expensive interventions later.

The Use of a Time-Out Ribbon and Precision Requests to Improve Child Compliance in the Classroom

To increase the compliance of a preschool student with disabilities, the combined and separate effects of a time-out ribbon procedure and a precision request format were examined. A time-out ribbon and precision request format were evaluated with an ABACBC single subject replication design. The percent of child compliance was recorded during circle time. When the time-out ribbon procedure was used, compliance increased. When precision requests were added to the time-out ribbon procedure, there was an even greater increase in compliance. Implications for using the time-out ribbon procedure and precision request format with preschool children with disabilities in a classroom are discussed.