Time Out
This comes from a loyal reader who I will keep anonymous. Just like the VA mess, there are ways to game any system. That is what they pay administrators for:
As I’m sure you know, the new ‘fad’ in surgery to minimize mistakes is the “Time Out”. With all personnel and the patient in the OR, everything stops and all practitioners are to give 100% of their attention to review the operative plan. With everyone looking directly at the surgical site, consent in anesthesia’s hand, the surgeon IDs the patient with DOB and reviews what he’s going to do, that all equipment etc. has been checked and is available. The nurse confirms sterility,etc and anesthesia reviews their concerns, plan, and confirms the consent. Not a bad concept to make sure we’re all on the same page with the patient! However, our institution has decided that the patient will have anesthesia induced FIRST followed by the surgeon scrubbed up at the field with all equipment checked and ready to go before initiating the time out. Besides the obvious, that the patient can no longer be part of this conversation which includes verifying surgical site and side (if appropriate), the ‘policy’ as written is a lie. No one at my institution can answer the simple questions, “How can I possibly give 100% of my attention to the time out with a patient under anesthesia?” and “How can I leave my patients bedside to stand by the surgical site and be looking at the consent, rather than my patient?” Not to mention the fact that this patient has JUST been induced. That’s like telling the pilot, right after takeoff, “Ok, now that we’re just off the ground, let’s divert our attention from our instruments and first review our plan.” It makes me crazy.
During a procedure, I asked one of the physician policy makers my question. His response was, “You know you can pay attention to the patient too and stop the time out if necessary.” And I said, “And when the lawyer says, how could you have been paying attention to the patient when you are giving 100% of your attention to the Time Out? What should I reply?” He looked away from me and starting talking baseball with the scrub tech.
One other thing. This is all being monitored on camera by people in India! We have to actually go over and point to the surgical site since there is no audio. And since we have our masks on…for all they’d know we could be singing a round of ‘row row row your boat’ while pointing to the patient and the consent. While the idea of a Time Out can be beneficial, this is a total waste of money.
Hey, Dr. Atul Gawanade, how do you like your checklist manifesto now?
This policy is a perversion of patient safety. In the OR, as the surgeon (pain management), when we first get into the room, I make the patient tell me their their name and date of birth, what we are doing (if they say “I don’t know”, everything stops and we discuss it again), which side, any allergies, and then ask if they have any questions. I started this policy when I was in the VA – the vets were often hard of hearing, and one day we had the wrong patient with the wrong arm band. Luckily, he was being done under local, and asked why I had him lying on his stomach when it was his stomach that was hurting.
In and around this lively discussion, it still strikes me that we spend far more effort in medicine “proving” that we do things, rather than actually doing them.
WOW ! what a discussion. this is why I love this site and the thoughtful debates.
RFT’s comment is good indeed. Another empty ritual to do things that either have been done already, or which the team has not thought useful. There is a horrible habit that is strongly embedded in American business; to grind through hours of dull and uninformative spoken material that is INTENDED to be dull and uninformative; but which the Lawyers insist must be read out loud to the suffering audience.
It is watched with all the attention of a network commercial – pizza pizza
I offered that “The participants are no longer under the massive burden of duty to the patient; they are merely checklist-readers and surgical-site-pointers, and consent-readers, and such.” Adding on layers of mental midazolam and cognitive propofol adds nothing to the quick and intelligent minds that are NEEDED to prevent mistakes. I can think of NOTHING worse that seizing the minds of an operating staff and making them go through a mind-numbing drill. Perhaps a TV showing SpongeBob for the operative staff; even that is not as dulling, I would expect. [One can speculate on the relative intelligence of Patrick Star and hospital administrators.]
Here is the problem. When one is confused in diagnosis, one needs to examine the unquestioned premises that have brought you to this point. If those premises are faulty, there is no way to proceed correctly further into the diagnostic workup – you are starting on unsteady ground.
Start with this premise: “Given that a surgical team needs outside guidance to diminish avoidable errors….”
Time-out.
Surgical teams are traditionally led by two well-trained physicians, an anesthesiologist and a surgeon, each with a sense of professionalism and duty to demonstrate excellence. They are composed of a number of highly-trained operative specialists, each with a mind and a duty to demonstrate excellence and ability. They are charged with the life and wellness of a sick human being. They all have minds, and with experience, can recognize when things are amiss.
The presumption is therefore one of two things, if not both:
1) First, even with all this skill and capacity, errors are made. Are we certain that the classical heuristic and observational methods are insufficient, and that algorithmic methods (checklists, rules, regulations, laws &c) are going to find errors that classical methods have missed? How do we know that we have not inadvertently disrupted the classical error-finding methods themselves, and are now trying to fix only what we broke in the first place? Heuristic and observational methods have their own time limits and requirements – they are not done until they are done, and not before. They will finish under their own measures and self-controlled limits. Are we not interrupting THOSE methods to artificially impose a “time-out” checklist? Hurry up and cut short the error-checking, so we can do the official “error-checking?”
2) What if instead, the entire surgical team is IMMORAL – greedy, ignorant, careless and indifferent to good surgical practice, uninterested in excellence, unmotivated by honor, dignity or ability? What if they are so awful that only a checklist will make them do what is necessary in the care of the surgical patient? One needs to stop right there and look at the greater evil. How could such a surgical team take the operating room? How could the ethics and morality of medicine be so broken, that criminals are doing the surgeries?
We are steeped in the myth of control, and there is no way through it. Either one must develop a system of professionalism and trust, or abandon the enterprise entirely. One must then concede that our society is not morally advanced enough to trust each other with our lives and health. There is no checklist for honor. If we cannot fill a surgical suite with enough professionalism to proceed to surgery – even when the combined training constitutes dozens of years of study – then what is the point of surgery at all?
For many decades, the presumption is that doctors are gaming the system, and will take any deceitful advantage to do things that are profitable, at the expense of the patient. These are the morals of Wall Street, at least since the 1980’s. It is assumed that the more highly educated and powerful a person is, the more driven they are by greed and immoral selfishness. If that is true, the problem is far bigger than what comes under the bright surgical lights.
That’s not wholly true. While I agree that the actual “process” of the timeout is pretty mechanical and has become so rote, that the participants sometimes get lax, the “concept” behind it is extremely important. As far as the patient being asleep, that’s pretty much a given. The timeout is done IMMEDIATELY prior to incision so if you had to THEN administer anesthesia AFTER the timeout, it would pretty much defeat the purpose. The patient at this time, has ALREADY been asked about surgical site and the site has been marked by the operative surgeon with R or L and his/her initials. This is done before ANY anesthesia/sedation is given so that the patient is totally alert. And as far as anesthesia “paying attention”, all they have to do is listen for 15 seconds. The patient is already anesthetized. The circulating nurse reads the actual timeout. Trust me. It is worth the 15 seconds. Non-surgeons would be amazed at how very possible it is to do a surgery on either the wrong patient, or the wrong site. Especially in a very busy surgery department.
Dr. Bonz and I have posted at the same time; I just noted that new comment.
In some ways I agree with Dr. Bonz; fundamentally, I energetically disagree and must explain why.
The Institute of Medicine published To Err Is Human in 1999, a wonderful treatise on error reduction in medical care. The fundamentals have been methodically ignored and disobeyed in such a way as to make the problem far worse since then; all the while, taking note of certain of the incidentals of the report out of context.
I trust Dr. Bonz is a surgeon, even though I do not see any operative anecdotes. I am not a surgeon.
It is intuitively most obvious that given sufficient time, redundant error-checking will most often decrease the error rate. It is a very respectable method to use a checklist to organize one’s work.
“Solutio, quod aliud est solvere quaestionem.” The solution is only that which solves the problem. The responsibility for solving the problem has been taken from those MOST HIGHLY MOTIVATED to prevent errors, i.e. the surgical team; and has been scattered here and there to the checklist and the video viewer and the problem reader, and such. The participants are no longer under the massive burden of duty to the patient; they are merely checklist-readers and surgical-site-pointers, and consent-readers, and such. But under such circumstances where time is no object, each iteration of error checking may improve things. But there is no implication that additional time will be allocated for each new iteration; rather, each iteration must be jammed into a time interval that reduces the time for other things to be done – things that themselves are error-checking and problem-correcting things. Dr. Gawande’s laws and regulations act to worsen the problem, not improve it. They are a bureaucrat’s solution – they allow for the accurate attribution of blame to the participants by the non-participant regulators. For anyone who has actually READ the IOM publication, that is the CAUSE of errors, not the SOLUTION – individual blame, not systemic repair.
You missed the point. You obviously didn’t read what is actually done at that particular institution and it was acknowledged that the time out can be a good thing. If, as you say, each person has already checked and verified the patient’s ID and the consent with the patient before anesthesia is induced and if the patient has ALREADY been asked about surgical site and the site has been marked by the operative surgeon than what exactly is the purpose of the time out prior to incision? If its just to say OK, left side is the correct side, than what do you need a checklist for? In addition, at many institutions the surgeon, anesthesiologist, and the nurse all have their own checklists to read off. And they should not be just listening, they should all be participating. To say, anesthesia just has to listen and that the patient is ALREADY anesthetized is ridiculous. A patient isn’t already ‘anesthetized’, a patient is undergoing an anesthetic and one of the most critical times is right after the actual induction. This is even more so now as patients are getting older and present with multiple medical problems that need to be managed while undergoing the anesthetic and surgery.
Steve, you are correct, I am a surgeon. RFT, I assume you are an anesthesiologist?
While I agree that even though the pt is anesthetized and this is obviously an ongoing process, I can honestly say that 99% of the time, the anesthesiologist has already left the room and the CRNA is running the show from there on out. If it were such a critical process that required such constant close attention, so much in fact that the attention of the person responsible shouldn’t (in your opinion) be “distracted” for a matter of 15-20 seconds by the surgical time out, then tell me, why doesn’t the doctor stay in the room? Why don’t the doctor AND the CRNA both participate? That way, the doc could keep an eye on the pt and the CRNA could do the timeout?
As far as why is it still needed if the pt was already marked? I can tell you first hand, that without this timeout, the wrong pt and the wrong operative site can still be operated on. In a busy operating department with multiple rooms, a pt could conceivably be marked, given their preop meds, and TAKEN INTO THE WRONG ROOM!
Even though the pt’s say, right knee has been marked, the circulating nurse could still prep the wrong leg, and the resident/intern could still drape the wrong limb as a result of this, and then the operative surgeon could work on the wrong site.
Trust me, I have seen both occur. Both were before the timeout was ever used. If it had been in effect, both of these errors would have been avoided.
The process the original poster lays out is a little cumbersome, I agree. We have the circulator read the timeout stuff, no one is taken away from their “post” (i.e. the CRNA stays at the head of the table) and simply calls out that he/she agrees with what the nurse has just read and says if the preoperative antibiotics were given as ordered. It truly is not a big deal and takes less than 20 seconds.
My problem with it is that over time, it can become sort of mundane, automatic, and rote and we can fall into complacency. But if done right, it is most definitely safe and effective.
By the way, we don’t have anyone looking in via TV monitor so I can’t really comment on that, but it sounds pretty ridiculous that they have to do what they do just for the “viewers” in TV Land.
Aw, not EVEN! I’m just an Internal Medicine guy. My opinion about surgeries, for what it’s worth, is that nothing should be done in an OR that is not considered valuable by the surgical team and operator.
I don’t have a particular opinion on the “Time-Out.” It has the potential of being immensely worthwhile in reducing errors. If it’s something that the team values, understands and “owns” as their own process, it’s fine.
If, however, it’s an “add-on,” a kluged, redundant, half-organized duplicate process imposed by regulation, it’s a bad thing.
It’s much less a matter of WHAT the team does, than WHY. “the “concept” behind it is extremely important.” Sadly, many Americans have jobs that they go about half-attentive, annoyed and bored. If that dead-mindedness spreads into an OR, people can die. The average Joe is afraid that HIS surgical team is as zoned-out as just about everyone else at HIS work. That’s scary. He’s beset with stupid regulations, rote procedures, and not asking “why.” A “time-out” in the OR can be part of the solution – or part of the problem.