New Tool from the Joint Commission to Improve Surgical Consultations

“From a personal standpoint, I have always reviewed the chart immediately before surgery to be certain the correct procedure and side is being done, in addition to the time out,” said Gerard J. Gianoli, MD, FACS, clinical associate professor of pediatrics and associate professor of otolaryngology–head and neck surgery at Tulane University School of Medicine in New Orleans and president of the Ear and Balance Institute in Baton Rouge, La. “The bigger difference is not specialty related but institution related. Each hospital or surgery center does it a little differently. Some require placing your initials on the operative side in the holding area before going to the OR, while the patient is alert and has input. This is probably better than the time outs we do in the OR.”

Whether a surgeon or nurse initiates a time out depends on each hospital, surgical center or health system. Everything is generally done the same way each time, and all surgical team members must be physically and mentally present, said Nwanmegha Young, MD, assistant professor of surgery and otolaryngology at Yale University School of Medicine in New Haven, Conn. “A nurse initiates it, but everybody participates,” Dr. Young said of Yale’s standard protocol. All other actions and conversations cease. “Everybody must face the patient during the time out, and everyone introduces themselves by name and role,” he said.

The exchange among Yale’s surgical team follows this fashion: First, a circulating nurse reads aloud the information on a patient’s armband. The surgeon then states the procedure and the side on which it will be performed. The circulating nurse reads from the consent form to confirm that it matches the surgeon’s description. In addition, the nurse notes the X-ray images, special equipment and supplies on hand. The anesthesiologist goes over allergies and antibiotics, and then the surgeon indicates whether the case will be routine or if any unusual challenges are expected.

“There’s a lot of redundancy in our time outs to make sure that everything has been double-checked or triple-checked,” Dr. Young said.

Aspects of the time out also may differ based on the organ involved in a procedure. “Obviously, right ear versus left ear is very important,” said Dean M. Toriumi, MD, FACS, professor in the division of facial plastic and reconstructive surgery, department of otolaryngology-head and neck surgery, at the University of Illinois at Chicago. About 70 percent of Dr. Toriumi’s practice is devoted to rhinoplasty, so the potential for operating on the wrong side is obviously limited, he said.