Time-Out Tips From the Trenches

Set and communicate expectations from the get-go.

Like so many aspects of outpatient care, clear and consistent communication is at the heart of the surgical time out.

During the time out — the pause before the surgical procedure to confirm the correct patient, procedure and site prior to the incision — the entire surgical team must be present, and must actively and verbally participate.

Golden opportunity

The time out should be viewed as an opportunity to make sure the entire OR team is aware of not only the basics (patient, procedure and surgical site), but also the risk and the intended risk mitigations involved. Buy-in is imperative to ensure active participation and collaboration around risk mitigation efforts that are implemented during the case.

Heather Kooiker, DNP, MSN, RN, CNL, CNOR, CRNFA, assistant professor of nursing and surgical immersion program manager at the College of Health Professions-Davenport University in Grand Rapids, Mich., says it all comes down to communication. “If the team knows that evidence-based practice is being implemented by nursing during the case to protect the patient, then the team will welcome any additional safety interventions,” says Dr. Kooiker.

Standard protocol

The goal is to prevent harm that would occur from a wrong-patient,wrong-procedure, or wrong-site event. Jennifer Hartz, MSN, RN, administrator at Bethel Park (Md.) Surgery Center, says the key to a successful time out is open communication with everyone on the team. “Ensure that the team trusts each other and knows that at any time they can stop the time out if they feel there is an error,” says Ms. Hartz. This of course starts with those at the top. “Staff need to feel supported by leadership to speak up if the policy is not followed by anyone in the room,” she says. Like all policies, Ms. Hartz says periodic impromptu checks to ensure time outs are being done are performed by management.

Who participates?

That is determined by the specific standards as established by each facility. Most often, the circulating nurse will initiate the time out. In some facilities, the surgeon does. Whoever does the initiating, everyone in the surgical field participates. The surgeon, anesthesiologist, surgical technician — whoever is in the sterile field — stops what they’re doing, listens and participates.

During the procedural time out, the team members confirm the patient’s name, date of birth, the side of the patient the surgery is on, allergies to any medications, and any risk factors, interventions or mitigations that will be completed during that case. Some guidelines also recommend performing an early time out before the patient is asleep, which enables the patient to participate in the time out.

Look to the guidelines

In the Universal Protocol Guidelines, The Joint Commission — a global driver of quality improvement in patient safety in health care — offers the following instructions for performing a time out, and notes that the procedure should not start until all questions or concerns are resolved:

• Conduct a time out immediately before starting the invasive procedure or making the incision.
• A designated member of the team starts the time out.
• The time out is standardized.
• The time out involves the immediate members of the procedure team: the individual performing the procedure, anesthesia providers, circulating nurse, operating room technician, and other active participants who will be participating in the procedure from the beginning.
• All relevant members of the procedure team actively communicate during the time out.
• During the time out, the team members agree, at a minimum, on the following: correct patient identity, correct site and procedure to be done.
• Document the completion of the time out. The organization determines the amount and type of documentation.

The Association of periOperative Registered Nurses (AORN) drills down on these guidelines to include:

• The entire surgical team must be present and actively participate in the time out. This means everyone should verbally confirm the patient’s name and the surgical site.
• The procedure site should be marked as close to the actual site as possible. Radiographic imaging can be used if the site is not visible. The site marking should be visible during key steps of the procedure, including during the time out and incision.
• The patient and the licensed independent practitioner should confirm the procedure and mark the body part being operated on.

Variable length

An average time out can take anywhere from 30 seconds to two minutes. To the surgical team, this can seem like a lifetime, but it’s critical that the time out be thorough and have a clear purpose or it can devolve into a meaningless task.

“The surgical team is often so focused on the surgery at hand — which they should be — they may lose focus on the importance of the time out,” says Dr. Kooiker. “So it’s up to the circulating nurse, who is really the protector of the sleeping patient, to ensure the team pauses and verbally agrees with the time out. The nursing plan of care and the delivery of that care relies on that nurse to communicate the evidence-based care and plan that will be delivered to the patient.”

Obstacles to overcome

While consents are reviewed and checked in the pre-op area, this check may sometimes be missed. The time out can be used to doublecheck that the consents are signed and completed.

“The other thing that can be worrisome sometimes is that people don’t actually pause,” says Dr. Kooiker. “You could be doing a time out and people would still be active. That means that they’re not listening to the time out. If you’re not listening, that increases the risk of a poor outcome. It’s the receptiveness and lack of participation with the surgical field — due to the urgency around the task at hand — that often can cause poor outcomes related to the time-out process.”

Additions to the time out

Ashley Brown, RN, BSN, CNOR, staff nurse at Kaiser Permanente South in San Francisco, says that in addition to the consents being confirmed during the time out, her facility has additional steps to protect the patient. Those include pre-procedure verifications, site marking, briefing and debriefing.

Pre-procedural verification starts before a patient is taken into the OR suite. The pre-op nurse, surgeon, RN circulator and anesthesia provider interview the patient, ensuring the right patient is having the right surgery for the right reason and at the right site, including laterality. “If any conflicts arise, they are resolved before taking the patient to the OR,” says Ms. Brown. “Also consents are obtained and site marking is done by the surgeon while the patient is awake and not under any sedative medications.”

Site marking is done by placing the surgeon’s initials on the operative site with a skin marker. The nurses involved with the patient’s care must verify the history and physical, site marking, consent and study results that all reflect the procedure the patient is to have.

Briefing happens once a patient is rolled into the OR but before they are put to sleep. It also involves all team members and allows the patient to actively participate. “The surgeon starts it, and we all stop what we are doing. The RN checks the patient’s name and medical record number while the surgeon is reading from the consent,” says Ms. Brown. Every team member then speaks to their roles, and once everyone has spoken the surgeon inquires if we all agree and if anyone has any safety concerns. “If all are in agreement, we proceed but if questions arise, we resolve it before we move forward,” she says.

After the patient is asleep and draped and site marking is visible, the time out is performed again with a collective pause and agreement. Any disagreements get resolved before the incision is made. The final step is debriefing, which occurs after surgery is completed. “The surgeon debriefs the team about what procedure was done, wound classification, blood loss, how much fluid was administered, and the RN and scrub tech announce the final status of surgical counts,” says Ms. Brown.

Mistakes can still happen

Everyone must understand that wrong-site surgeries occur, says Ms. Brown, but the time out has been instrumental in decreasing those occurrences. “Time outs are not an option. They’re mandatory for all surgeries,” she says. “Depending on the setting, there are variations in what is discussed, but all procedures and surgeries require a time out to ensure proper patient-proper procedure-proper side if applicable.”

Dr. Kooiker agrees. “Things are very hectic and there are lots of distractions. The team wants to move forward,” she says. “If you don’t have a time out that demands a pause to stop and actively listen, there is additional risk that mistakes may occur.”

Crystal clear communication

Surgical team staff members are trained in orientation and during annual competencies about the time out process, but the universal guidelines have been in place for two decades and time out protocols are well known by experienced OR nurses.

However, there can still be tweaking in regards to setting clear expectations for the surgical team.

“I think a strong voice of patient advocacy and safety based on their risk factors should be brought into it and added as a standard for the time out,” says Dr. Kooiker. “Clear expectations and communication builds collaboration in patient safety efforts. It makes the whole team get on the same page and want to work together to improve patient outcomes.” OSM