Presentation on theme: "Universal Protocol Guide for Anesthesia Nerve Blocks"— Presentation transcript:
1 Universal Protocol Guide for Anesthesia Nerve Blocks Mount Auburn HospitalDepartment of Quality and SafetyInstructions:To proceed through this tutorial mouse click on the blue forward > or back < navigation buttons.
2 Goals of this guideThis guide is designed to help all care providers (anesthesiologists, CRNA’s, and RN’s) who perform nerve blocks at Mount Auburn Hospital:Understand the rationale behind the universal protocolCorrectly perform all of its elements
3 Contents Case example What is the universal protocol? Background The impact of errorsWhat does the universal protocol include?What procedures fall under the protocolPre-procedure verificationSite markingThe “time out”BarriersTake home points
4 How well do you know the universal protocol? Please take this brief quizThe answers will be discussed within this moduleDisclaimer: The case described is a composite based upon cases in the public domain
5 Bob Jones’ knee replacement Bob Jones is an 80 year old retired engineer with bilateral knee osteoarthritis. His right knee is more severely damaged and symptomatic. He meets with Dr. Smith, his orthopedic surgeon, and they agree upon the need for surgery.
6 Bob Jones’ knee replacement: In the holding room The nurse in the holding room greets Mr. Jones and initiates the pre-operative verification checklist. Dr. Smith’s history and physical indicate that he plans to do a left knee replacement. The nurse checks with Mr. Jones who is fairly certain that he had agreed with Dr. Smith on a right knee replacement. The patient signed an informed consent for a right knee replacement.
7 Which of the following actions should now be initiated? The nurse should assume the history and physical are incorrect and allow the patient to proceed into the ORThe nurse should notify Dr. Smith of the discrepanciesDr. Smith should review his notes and the films, and re-confirm the decision with the patientDr. Smith should insert a correction into the H & P with his signature, date and timeb, c, and d
8 Which of the following actions should now be initiated? The nurse should assume the history and physical are incorrect and allow the patient to proceed into the ORThe nurse should notify Dr. Smith of the discrepanciesDr. Smith should review his notes and the films, and re-confirm the decision with the patientDr. Smith should insert a correction into the H & P with his signature, date and timeb, c, and d
9 Bob Jones knee replacement: In the holding room Dr. Smith reviews his notes and the films, and re-confirms with Mr. Jones the plan for right knee replacement. He marks his initials on the patient’s right mid-tibia with an arrow pointing upward toward the right knee. He then marks “No” on the left knee.
10 Which of the following actions should now be initiated? No action need be takenThe markings on the right tibia and left knee should be scrubbed offDr. Smith should re-mark the right knee, “Yes”Dr. Smith should re-mark his initials directly at the incision site on the right side onlyb and d
11 Which of the following actions should now be initiated? No action need be takenThe markings on the right tibia and left knee should be scrubbed offDr. Smith should re-mark the right knee, “Yes”Dr. Smith should re-mark his initials directly at the incision site on the right side onlyb and d
12 Bob Jones’ Knee Replacement: Holding Room, cont’d The anesthesiologist verifies that Dr. Smith has correctly marked the surgical site, and proceeds to site mark for the nerve block. Where should the site mark for the nerve block be placed? a) at the surgical site, directly above the surgeon’s initials b) anywhere on the operative extremity c) at the nerve block site, so that the mark is visible after prepping and draping
13 Bob Jones’ Knee Replacement: Holding Room, cont’d The anesthesiologist verifies that Dr. Smith has correctly marked the surgical site, and proceeds to site mark for the nerve block. Where should the site mark for the nerve block be placed? a) at the surgical site, directly above the surgeon’s initials b) anywhere on the operative extremity c) at the nerve block site, so that the mark is visible after prepping and draping
14 Bob Jones knee replacement: In the operating room Mr. Jones is brought into the OR. The OR is set up for a left knee replacement. The circulator nurse verifies the patient’s identification with the anesthesiologist after which Mr. Jones is given general anesthesia. His blood pressure drops moderately below his baseline.
15 Bob Jones knee replacement: In the operating room Dr. Smith enters the OR and begins to prep and drape the left knee. His favorite music is playing on the radio. The scrub technician is not yet in the room. The circulating nurse is at the computer with her back to the patient. She initiates the “time out” stating the patient’s name, planned procedure, site, position and equipment present. Dr. Smith makes his incision in the left knee.When Mr. Jones’ BP stabilizes, the anesthesiologist looks up and questions which knee is being replaced.
16 Which elements of the “time out” were performed incorrectly? The “time out” was not initiated by the surgeonThe entire team was not presentThe stated procedure was not cross-checked with the informed consentThe site marking was not visualized and verbally confirmed by the teama, b, c, and db, c, and d
17 Which elements of the “time out” were performed incorrectly? The “time out” was not initiated by the surgeonThe entire team was not presentThe stated procedure was not cross-checked with the informed consentThe site marking was not visualized and verbally confirmed by the teama, b, c, and db, c, and d
18 What is the universal protocol? Guidelines to assure that the correct surgery and invasive procedures are done on the correct person, on the correct side and siteThese guidelines apply to invasive procedures anywhere in the hospital
19 BackgroundThe universal protocol was developed by the Joint Commission on Accreditation of Healthcare Organizations (TJC) in 2003 in collaboration with numerous professional organizationsEffective July 1, 2004, compliance with the protocol has been required of all TJCaccredited institutions
20 Background126 wrong-site surgery cases were reported to The Joint Commission in Root cause analyses found the following:By specialty:Orthopedic/podiatric: 41% of casesGeneral surgery: %Neurosurgery: %Urologic surgery: %The rest were dental/oral maxillofacial, cardiovascular-thoracic, ear-nose-throat, and ophthalmologic surgeryWrong body part or site:76% of casesWrong patient:13% of casesWrong procedure:11% of cases
21 BackgroundFactors contributing to increased risk for wrong-site surgery/procedures:Emergency procedureUnusual physical characteristics (morbid obesity, physical deformity)Unusual time pressures to begin or complete procedureUnusual equipment or set-up in the ORMultiple surgeons involved in the caseMultiple procedures being performed during a single surgical visit
22 BackgroundCRICO experience: analysis of 40 cases of wrong-site surgeryData from malpractice claims and surgical loss observations38% (15 cases) wrong vertebral level orwrong-side laminectomy of the spine62% (25 cases) non-spine12 wrong side12 wrong site – no laterality, 8 involving multiple structures, 4 involving multiple lesions1 wrong patientKwaan MR, et al. Arch Surg.2005;141:
23 What does the universal protocol include? The protocol includes 3 steps:Pre-procedure verification to confirm correctPatientProcedureSite/sideSite marking“Time out” immediately before beginning the procedure
24 What procedures fall under the universal protocol guidelines? Any invasive procedure that involves puncture or incision of the skin, insertion of an instrument, or foreign materialsNot included under the protocol are routine procedures such as venipuncture, placement of simple IV’s, NG tubes, and Foley catheters
25 Pre-procedure verification What: A process to ensure that the correct patient is undergoing the correct procedure, including procedure site (and side, if applicable)When: This step begins with the decision to do the procedure and continues through all settings and interventions in the pre-op preparation of the patient, up to and including the “time out.”
26 Pre-Procedure Verification Components-Patient Identification Assuring correct patient identification includes:Any two of the following unique patient identifiers:Name, date of birth, medical record number, or account number.Patient stating name and date of birth, when possible.Active confirmation of two identifiers to the patient’s name band.Verification of the patient name and unique identifier to the surgical consent (if available) or OR schedule (if surgical consent is not available)
27 Pre-procedure verification components-Documentation Review Comparison of all relevant documents and studies to ensure thatSurgical consent, Anesthesia consent, OR schedule all availableHave been reviewedAre consistent with each otherAre consistent with the patient’s and team’s understanding of the intended procedure and site
28 Site marking essentials for Anesthesia Mark all cases involving:Right or left lateralityMultiple levels (neuraxial or pain procedures involving multiple spinal levels)The person performing the procedure should do the site markingThe mark must be:Unambiguous (initials only)On the exact anesthesia block site only, after verification of correct surgical site markingVisible after patient is prepped and draped
29 Site marking essentials When?Before the patient is sedated to the point at which s/he cannot be meaningfully involvedPatient involvementThe marking should occur with patient involvementIf the patient is unable to participate, whoever has authority to provide informed consent should participate
30 Site marking examples (1) Left wrist ganglionPIP joint
31 Site marking examples (2) Left herniaRight shoulder
33 Site marking examples (4) L4 laminectomyLeft eye surgery
34 Anesthesia Nerve Block Marking Example Anesthesiologist’s initials (RW)At exact block siteAfter verification of surgical site markingVisible after prep/draping
35 Site marking examples: Correct or incorrect? Left 4th distal interphalangeal joint
36 Site marking examples: Correct or incorrect? Left 4th distal interphalangeal jointIncorrectCorrect
37 The “time out” What: A pause to verify that Patient identification has been confirmedSurgeon’s articulation, prior to surgical incision, that procedure, site and side agree with informed consentAnesthesiologist’s articulation, prior to nerve block, that block procedure, site, and side agree with informed consentBoth surgeon’s and anesthesiologist’s site markings are clearly visibleNecessary equipment to perform procedure is at bedsideWhen: Immediately before starting the procedure or nerve blockWhere: In the location where the procedure or nerve block is to be done
38 The “time out”Who:The “time out” must involve the entire team that will be present during the nerve block procedure or at surgical incisionAt Mount Auburn Hospital, the surgeon initiates the OR “time out”Additional team members may participate in the procedure but must also participate in the entire process, beginning with the “time out.”Unanimous agreement among the team that all questions or concerns are resolved is required in order for the case to begin
39 The “time out” The “time out” is a conversation, not a checklist It is a time when each person who has responsibility for the outcomes of a procedure takes a moment to reflect on whether every aspect of the protocol has been followed, and the chance of error minimizedThe “time out” is the team’s final fail-safe prior to the nerve block or surgical procedure
40 Video: The “time out” at Mount Auburn Video Instructions: Turn computer speaker and volume ON and mouse click on the embedded video below to play.If you are outside the hospital or cannot play the embedded video click on the link to the video stream below or from the Physician Education webpage.Click Here for Video Stream of the "Time Out" at Mount Auburn
41 Barriers It won’t happen to me One more external regulation It could and has happened to competent, vigilant practitionersOne more external regulationMaybe so, but it might protect you and the patientSomeone else’s responsibility to initiateIt’s yours and everyone’s“I must be mistaken, it’s probably ok”If you’re uneasy, speak up
42 Pre-Procedure Verification Take homes Pre-procedure verification ensures that the correct patient is receiving the correct procedure on the correct site and side.The purpose of pre-procedure verification is to ensure that all relevant documents and studiesAre availableHave been reviewedAre consistent with each otherAre consistent with the patient’s and team’s understanding of the intended procedure and site
43 Pre-Procedure Verification Take homes If inconsistencies are noted during the pre-procedure verification process, the procedure site and side should beVerified by the surgeon and patientThe verified site/side should be correctly and consistently documented, andCorrectly communicated to the staff setting up the OR room, implants, and equipment
44 Site Marking Take homes The nerve block site should be markedWith the anesthesiologist’s initials onlyBy the person performing the procedureWith the patient’s (or surrogate’s) involvementDirectly over the nerve block site, following verification of correct surgical site markingVisible after drapingDo not:Use “Yes” or “No”Mark the non-operative site
45 Time Out Take homes The “time out” Is initiated by the anesthesiologist for nerve block and surgeon for surgical procedureMust take place with the entire team present immediately before the planned procedureIncludes verification thatPatient identification has been confirmedAnesthesiologist’s and surgeon’s articulation that procedure, site and laterality agree with both informed consents and OR scheduleBoth surgeon’s and anesthesiologist’s site markings are clearly visibleCorrect equipment/implants is/are immediately available
46 Verification of Training Please complete the brief online verification of training using the link on the Physician Education page or click here:Universal Protocol Online Quiz
47 Credits Teaching module: Videographer: Technical Support: Created by Susan Abookire, MD, Yvonne Cheung, MD, Beth Lown, MD and G. Tracey Phillips, RN.Videographer:Gary Goldsmith, MDTime Out players:Rowland Wu, MDLeslie Schneiderhan, RN, CNSNancy Masoian, RNTechnical Support:Al Ghilardi, Orthopedic First AssistantSpecial Thanks To:J. Michael Haering, MDMary Jo Sharkey, RN
48 Questions?Contact the Mount Auburn Hospital Department of Quality and SafetyExtension: 5073Back to Beginning