Time Out for Patients

Earlier this weekend, a friend told me about her "time out" before a cardiac defibrillator was implanted in her chest wall.

Time out? Was she naughty? Did her cardiologist make her sit in the corner for bad language or some other infraction?

As it turns out, "Time Out" is a widely-practiced technique to help prevent health-care providers from performing the wrong procedure at the wrong site on the wrong patient. The wrong procedure could be a joint aspiration, a biopsy, an amputation or a heart transplant. The consequences of this are equally widespread, ranging all the way from minor inconvenience to death.

This issue has been of considerable interest to physicians for some time, as indicated by the Sentinel Event Policy published by the Joint Commission in 1998 and a Statement of the American College of Surgeons in 2002. Beginning in July 2004, Joint Commission-accredited hospitals in the United States were required to adhere to the Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery by implementing time outs and site verifications for all invasive procedures.

The Joint Commission promotes a robust approach to avoiding this type of error on their website. The exact implementation of this protocol varies among patients according to their specific needs.

This is extremely relevant to me and other radiologists, since we perform quite a few invasive procedures on our patients. While we don't do heart transplants, we do perform biopsies, angiograms, joint aspirations, abscess drainage, stent placements, embolizations and other techniques. Therefore, we also implement a time out immediately before starting any procedure. During this time out, we ask a set of standard questions of our patient, such as their name and date of birth. Other questions, such as, "Which joint did your internist want us to inject?", help us to do the right thing, even if the wrong side or wrong procedure is listed on the procedure requisition form.

So, how has this "Time Out" been working since it was mandated by the Joint Commission in 2004? The returns are just now starting to come in. The PubMed search I did today for "wrong site procedure", "wrong side procedure", "wrong side surgery" and "wrong site surgery" gave a total of 50 results for 2004 through 2008. Among these results, only two case reports were related to radiologic error. However, I strongly suspect that most of the results observed in other specialities will translate well to mine.

While my search was neither systematic nor comprehensive, it does show how the wrong-side/wrong-procedure/wrong-patient problem crosses the borders between both specialties and nations. Some of the studies I turned up give early estimates of the prevalence of this problem and of the impact of policies such as the Universal Protocol.

For example, an anonymous survey of members of the American Academy of Neurologic Surgeons was recently reported in Spine. From the data reported by surgeons answering the survey, the authors estimated the prevalence of wrong level spine operations to be 1 in 3110 procedures, with 1 of every 2 spine surgeons performing a wrong level surgery during his or her career.

A recent-published study of wrong-site surgery among hand surgeons estimated a prevalence of 1 case in 27,686 procedures. However, seventy percent of the responding orthopaedic surgeons were aware of a "Sign Your Site" campaign, and 45% had changed their practice habits as a result.

A recent report from the New Zealand Orthopaedic Association describes their first 6 months experience of using the "Time Out" procedure to avoid wrong site/side surgery. During this period, a total of 10,330 procedures were performed. Of these, three ‘near miss’ situations were captured by the time out procedure.

Besides avoiding the usual sequelae of wrong-side/wrong-procedure/wrong-patient surgery, other authors have expanded their 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. This study estimated the purely financial benefit of this "preparatory pause" to be almost $900 per patient.

So, how did my friend fare during her procedure? For starters, they gave her the correct defibrillator in the correct position in her chest wall. On a personal note, she recalls her "Time Out" as a moment of peace in the midst of a busy whirl of activity. When everyone in the cardiology suite paused momentarily to silently review what they were about to do, she experienced it as an "almost spiritual moment" that she liked very much.