Hey Friends, welcome back to today’s blog where I talk about a ‘Time Out’. A couple of weeks ago in my instagram stories I asked if the Aussie Nurse Educator (ANE) community knew what a ‘time out’ was. Of the group who responded, almost 50% indicated they did not know what this was. I also had a number of DM’s requesting more information about the topic. Here it is…
In this post I am going to look at what a ‘time out’ is, where it came from and why we do it. Within the post, you will find the answers to the frequently asked questions among nurses in regards to time out. Let’s start with a tiny bit of history.
Over 20 years ago, wrong sided and wrong patient surgery was identified and the World Health Organisation (WHO) developed the Surgical Safety Checklist. These checklists were developed to facilitate patient care through operating theatres by providing a process for identification, equipment set up, imaging requirements and clinical care. These checklists were adopted globally and includes ‘time out’ as one of the checklists components. The ‘time out’ is an essential and necessary component of the WHO Surgical Safety Checklist (SCC)(1).
If you would like to see the WHO’s Surgical Checklist example: CLICK HERE
The WHO guidelines for safe surgery (2009) defines a ‘time out’ or ‘surgical pause’ as a “brief, less than one minute stop in the operating room immediately prior to skin excision”. At this time, all team members of the operating team verbally confirm the identity of the patient, the operative site and the procedure to be performed. It is a means to ensure clear communication among the team and avoiding wrong site and wrong patient errors (1).
Time out is performed immediately before incision, involving all members of the operating team. Elements of time out include the confirmation of name and role of team members, patient’s identity, surgical site and procedure, the review of anticipated critical events, confirmation that prophylactic antibiotics have been administered ≤60 min before incision is made or that antibiotics are not indicated, and confirmation that all essential imaging results for the correct patient are displayed in the operating room. Checks must be documented (1).
To further support the WHO Guidelines and implementation of surgical checklists and time out procedures here in Australia the Safety and Quality Commission implemented the ‘Ensuring Correct Patient, Correct Site, Correct Procedure’ protocol in conjunction with the college of surgeons (2). Check out the 5 step info graphic HERE on page 3 (or 5).
Frequently Asked Questions
When should a ‘time out’ it occur?
The WHO says the time out or surgical pause should occur immediately prior to the skin incision. However, the safety and quality commission say it is best performed prior to the commencement of anaesthesia with all team members including the patient involved. If the opportunity to perform the time out, prior to the anaesthetic, is missed, then it is recommended to perform the time out prior to the incision.
Who should initiate a ‘time out’?
Ideally the person performing the surgery. In this case, that being the surgeon. If they do not initiate, it is often commenced by a nursing team member.
Who marks the surgical site?
Again ideally the person performing the procedure. This talk may be delegated to other team members as required.
What mark should be at the surgical site?
An arrow pointing to the surgical area is the most common practice.
Issues & Recommendations
Key components of successful checklist implementation includes enlisting support from institutional leaders, training staff on using the checklist, adapting the checklist to incorporate staff feedback, avoiding the duplication of information, and a positive change in attitudes/culture that enforces teamwork (2).
The sustained use of surgical checklists is more successful if medical practitioners are actively engaged and leading implementation; as well as being involved in tailoring the checklist to their context and encouraging them to reflect on and evaluate the implementation process enables greater participation and ownership (2).
A team ‘time out’ or final check is a core part of the protocol and should be mandatory. Where an organisational decision is taken to remove part of the protocol, this must be clearly documented to all staff and an additional process of risk assessment and risk management should be added. This is to reduce the patient risk of procedural mismatching and must be undertaken and documented (2).
The person responsible for undertaking the procedure is also responsible for ensuring that the time out has occurred. Local procedures should specify who may initiate the time out process, but the responsibility remains with the lead clinician. For surgery, the surgeon, anaesthetist and anaesthetic and/or scrub nurse must confer and agree on the correct patient, side and procedure as part of the time out. If this check does not occur, none of these clinicians are authorised to proceed with the procedure (1).
Patient involvement in the time out reduces the risk of wrong site surgery. However this is not always possible or appropriate. If an organisational decision is made to conduct the time out after anaesthesia, an additional process of risk assessment and risk management to reduce patient risk of procedural mismatching must be undertaken and documented (1).
My piece
As a passionate Anaesthetic Clinical Nurse Specialist, medical consent validity, patient identification and the commencement of the Surgical Safety Checklists are all a part of my role in maintaining the safety of the patients I look after. ‘Time out’ and communication between the operating theatre team members is a vital aspect to delivering the safest possible care for our patients during their peri-operative period. I do find it annoying that as Nurses we seem to be always enforcing the time out procedure rather than the medical team who are responsible for providing the treatment. The more surgeons who are on board, lead and initiate time out procedures and help the nursing staff the better!
I am an advocator for time out procedures to keep our patients safe!
Here is an example of a surgical timeout. Although based in America, the foundations are the same –
Thanks for reading!
References
- Yap, G. & Melder A. 2017. Time Out – Informing best practice in using surgical checklists. A Rapid Review. Centre for Clinical Effectiveness, Monash Health, Melbourne, Australia.
- Australian Commission on Safety and Quality in Health Care. 2008. Ensuring correct patient, correct site, correct procedure protocol for surgery: Review of implementation and proposals for action. Available from: https://www.safetyandquality.gov.au/sites/default/files/migrated/19793-ReviewCPCSCP.pdf
- Dartmouth-Hitchcock. Time Out General Surgery [Video]. 2012. Available from:https://www.youtube.com/watch?v=IHWQPVY54pA[Accessed 29 August 2021].
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