Transforming the Surgical "Time-Out" Into a Comprehensive "Preparatory Pause"

Abstract

We propose expansion of the standard "time-out" into a comprehensive "preparatory pause" encompassing five well-documented perioperative risk avoidance strategies: beta-adrenergic blockade, DVT prophylaxis, preoperative antibiotics, normothermia, and euglycemia. Although all members of the surgical team acknowledge the clear benefit of these five prophylactic strategies, published national compliance even in the target patient population is a disappointingly consistent 50%. We have developed and field-tested a "preparatory pause" form that we appended to our "surgical time-out." By politely challenging our surgical team as to the inclusion of these five risk avoidance strategies in 167 consecutive patients, we increased our compliance to more than 90% for each preventive measure. We have not attempted to quantify the physical and psychological benefit of complication avoidance due to the enhanced activation of these five prophylactic strategies. Using published surgical complication prevalence data, with and without these accepted risk avoidance measures, we estimate the number of complications per 100 patients avoided. Utilizing the Medicare payment schedule for each complication, we approximate the purely financial benefit of the "preparatory pause" to be $88,640 per 100 patients, or almost $900 per patient. The now standard surgical "time-out" is designed to avoid the gratifyingly uncommon problem of "wrong patient,""wrong procedure," and "wrong site." Many surgeons negotiate an entire career without stumbling over these disastrous problems. We propose expansion of the "time-out" to include five well-documented perioperative risk avoidance strategies that many of us overlook all too often.

The World Health Organization trauma checklist versus Trauma Team Time‐out: A perspective

“…Since its inception, this surgical checklist has become the standard of care in operating rooms . A key strength of the checklist is at the pre‐incision time point, where it is thought to reduce the potential for wrong site surgery, wrong procedure and near misses .…”

“…Since its inception, this surgical checklist has become the standard of care in operating rooms. 10 A key strength of the checklist is at the preincision time point, where it is thought to reduce the potential for wrong site surgery, wrong procedure and near misses. 4 Although difficult to establish a causal relationship between Time-out protocols and improvement in morbidity and mortality, checklists improve teamwork, staff retention, promote early reporting of issues or concerns and reduce complications.…”

Errors in Surgical Site Identification during Cutaneous Surgery for Skin Cancer: Review and Recommendations

“…Backster et al found that a "preparatory pause" to discuss a 5-point perioperative risk avoidance strategy raised compliance from 50% to 90% over 167 procedures [33]. In a review of data from the Pennsylvania Patient Safety Reporting System, Clarke et al found that 4.7% of reporting facilities had more than 1 wrong-site surgery in a 12-month span, and 427 cases of wrong-site surgery occurred over a 30-month period.…”

Surgical Education

“…It has been linked to safe practice, sound leadership, and expert judgement, in a broad array of professional domains (Sexton and Helmreich 2000). A recent succession of efforts to reengineer communication routines in the operating room has demonstrated that improvements in team communication result in better patient care (Haynes et al 2009;Lingard et al in submission, Awad et al 2005;Rivers et al 2003;Altpeter et al 2007;Backster et al 2007). In one report, patients had increased odds of complications or death when their surgical teams exhibited three communication behaviors less frequently: information sharing during intraoperative phases, briefing during handoff phases, and information sharing during handoff phases (Mazzocco et al 2009).…”