New Tool from the Joint Commission to Improve Surgical Consultations

For endoscopic sinus surgery, however, confirming the correct side is crucial during the time out. More than 250,000 of these surgeries are performed annually in the U.S. (Laryngoscope. 2012.122(1):137-139). “Although overall complication rates are low,” the authors wrote, “errors can lead to significant morbidity due to the close proximity of the sinuses to the orbit and skull base and the resultant potential for blindness, cerebrospinal fluid leak, and catastrophic bleeding.”

To limit preventable adverse events, most operating rooms have adopted surgical checklists endorsed by the World Health Organization (see “Surgical Safety Checklist,”). The WHO Safe Surgery Checklist identifies three phases of an operation: before the induction of anesthesia (“sign in”), before the incision of the skin (“time out”) and before the patient leaves the operating room (“sign out”). A checklist coordinator must confirm completion of the listed tasks in each phase before the team is permitted to continue. However, standardized surgical checklists, designed for general or orthopedic procedures, often do not address specifics related to endoscopic sinus surgery.

A surgeon in this subspecialty directs supplemental items during the time out. “First, the surgeon informs the team that a topical vasoconstricting agent will be used (often high-dose epinephrine, cocaine or oxymetazoline), and that this agent has been stained (usually fluorescein or marking ink), is labeled appropriately and is not to be used for injection,” the authors explained in Laryngoscope. “This step is critical, as injection of these potent agents is a genuine risk and can precipitate hypertension, arrhythmia, and even stroke, myocardial infarction, or death.”

Effectiveness

While it’s difficult to quantify how much the time out has lowered the incidence of wrong-site surgery, the process has certainly helped, said Rahul K. Shah, MD, associate surgeon-in-chief at George Washington University School of Medicine and Children’s National Medical Center in Washington, D.C. Any distraction interferes with the intense focus of an ideal time out. “If it gets interrupted, start over; or if there is any ambiguity, start over,” he said.

A recent study, led by Dr. Shah, revealed substantial variation in the time out and site-marking procedures within pediatric otolaryngology. The survey was e-mailed via the American Society of Pediatric Otolaryngology (ASPO). Researchers asked 167 Child Health Corporation of America hospital operating room directors and ASPO members about peri-operative preparation of their patients (Arch Otolaryngol Head Neck Surg. 2011;137(1):69-73).

Most respondents performing surgeries at children’s hospitals reported that the policies do not mandate site marking for bilateral placement of ventilation tubes, adenotonsillar surgery, airway endoscopy or nasal surgery. Policies allowing assistants to perform site marking were identified by 45 percent of respondents from children’s hospitals.