'Timeouts' can be useful for ED procedures
Use of a checklist helps
Do you assume that the "timeout" requirements from the Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery only apply to operating rooms? That's a wrong and dangerous assumption, according to Richard J. Croteau, MD, executive director for strategic initiatives at the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), which created the protocol.
In fact, the requirement applies wherever invasive procedures are done, says Croteau. "In the ED, people often say that they don't have time. In some cases that may be true, but it's generally not," he says. "It takes only a couple of seconds and protects the patient from a significant error."
The Joint Commission's universal protocol requires a timeout process before any invasive procedure and surgery, and compliance is a requirement for accreditation.
At Ogden, UT-based McKay-Dee Hospital, ED nurses created a timeout checklist to comply with the Joint Commission requirement. The checklist is used before any invasive procedure or surgery such as central lines, chest tubes, tracheotomies, needle thoracostomies, pinning a distal femur for traction, incision and drainage, intracranial bolts or cervical traction, and some vaginal bleeding procedures such as a curettage. (See checklist.)
Staff caught on quickly, says Teri Howick, RN, nurse educator for the ED. The forms are readily available in the rooms that they do those procedures and surgeries in, Howick says. "Our ED physicians were great, but our trouble came with the consulting physicians," Howick says. "They are usually the most reluctant to change."
The patient is identified using two identifiers, such as name and birth date, and nurses verify with the patient or legal guardian that this is the procedure they understand is being done. Next, staff visually confirm that the correct site is marked, with X-ray verification when appropriate or indicated, and check to make sure the proper equipment is available and ready.
Before the procedure begins, timeout is called out by the charge nurse or physician, and the checklist proceeds. "Since putting an identifying armband on, getting X-rays, and collecting equipment happen at different times and stages, we stop prior to the procedure beginning and do the timeout," Howick explains.
Staff then go down the list, saying, "Two identifiers?" "Verbal and armband?" "X-rays?" "Right site?" and staff respond "check" to each.
Verify correct patient
At Orlando (FL) Regional Healthcare's ED, when the decision is made to perform any surgery or procedure that involves distinction between right and left sides, multiple structures such as fingers and toes, or multiple levels as in spinal procedures, the following is done:
- The correct person, procedure, and site are verified at the time the patient gives consent to surgery. Sylvie Simpson, RN, BSN, nurse clinician for the ED, says, "All surgical procedure timeouts are completed during the consent signing, just prior to procedures such as a chest tube insertion, thoracentesis, or lumbar puncture. Joint Commission recommends patient involvement if the patient is alert, coherent, and not a minor."
- The operative site is marked by the patient or ED nurses.
- The timeout period occurs right before the procedure, when all of the personnel involved are in attendance. "The purpose is to conduct a final verification of the correct patient, procedure, and site," says Simpson. "JCAHO's motto rings loudly: Wrong-site, wrong-procedure, and wrong-person surgery can be prevented."
The process ensures that you have the right patient, says Howick. "Patients often change rooms, especially in the ED when a particular room might be used for a specific procedure," she says. "It also verifies the correct side. We've all heard the horror stories of the wrong foot being amputated or the wrong breast."
When available, an X-ray acts as a reminder of which side the pneumothorax, tumor, or fracture is on, adds Howick. "When you have three, four, or more people all checking the same thing, you are less likely to make mistakes," she says.
Sources
For more information about the universal protocol, contact:
- Teri Howick, RN, Nurse Educator, Emergency Department, McKay Dee Hospital, 4401 Harrison Blvd., Ogden, UT 84403. Telephone: (801) 387-2286. Fax: (801) 387-2244. E-mail: [email protected].
- Sylvie Simpson, RN, BSN, Nurse Clinician, Emergency Department, Orlando Regional Healthcare, 1414 Kuhl Ave., Orlando, FL 32806. Telephone: (321) 843-4568. E-mail: [email protected].
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