Universal Protocol Guide for Anesthesia Nerve Blocks

Universal Protocol Guide for Universal Protocol Guide for Anesthesia Nerve BlocksAnesthesia Nerve Blocks

Mount Auburn HospitalDepartment of Quality and

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Goals of this guideGoals of this guide

This 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 protocol

Correctly perform all of its elements

Contents Contents Case example What is the universal protocol? Background The impact of errors What does the universal protocol include? What procedures fall under the protocol Pre-procedure verification Site marking The “time out” Barriers Take home points

How well do you know the How well do you know the universal protocol?universal protocol?Please take this brief quiz The answers will be discussed within

this moduleDisclaimer: The case described is a

composite based upon cases in the public domain

Bob Jones’ knee Bob Jones’ knee replacementreplacementBob 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.

Bob Jones’ knee Bob Jones’ knee replacement:replacement:In the holding roomIn the holding roomThe 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.

Which of the following Which of the following actions should now be actions should now be initiated?initiated?a) The nurse should assume the history and physical

are incorrect and allow the patient to proceed into the OR

b) The nurse should notify Dr. Smith of the discrepancies

c) Dr. Smith should review his notes and the films, and re-confirm the decision with the patient

d) Dr. Smith should insert a correction into the H & P with his signature, date and time

e) b, c, and d

Bob Jones knee replacement:Bob Jones knee replacement:In the holding roomIn the holding roomDr. 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.

Which of the following Which of the following actions should now be actions should now be initiated?initiated?a) No action need be takenb) The markings on the right tibia and left

knee should be scrubbed offc) Dr. Smith should re-mark the right

knee, “Yes” d) Dr. Smith should re-mark his initials

directly at the incision site on the right side only

e) b and d

Bob Jones’ Knee Replacement: Holding Bob Jones’ Knee Replacement: Holding Room, cont’dRoom, 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

Bob Jones knee replacement:Bob Jones knee replacement:In the operating roomIn 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.

Bob Jones knee replacement:Bob Jones knee replacement:In the operating roomIn the operating roomDr. 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.

Which elements of the “time Which elements of the “time out” were performed out” were performed incorrectly?incorrectly?a) The “time out” was not initiated by the

surgeonb) The entire team was not presentc) The stated procedure was not cross-

checked with the informed consentd) The site marking was not visualized and

verbally confirmed by the teame) a, b, c, and df) b, c, and d

Which elements of the “time Which elements of the “time out” were performed out” were performed incorrectly?incorrectly?a) The “time out” was not initiated by the

surgeonb) The entire team was not presentc) The stated procedure was not cross-

checked with the informed consentd) The site marking was not visualized and

verbally confirmed by the teame) a, b, c, and d f) b, c, and d

What is the universal What is the universal protocol?protocol?Guidelines to assure that the correct

surgery and invasive procedures are done on the correct person, on the correct side and site

These guidelines apply to invasive procedures anywhere in the hospital

BackgroundBackground

The universal protocol was developed by the Joint Commission on Accreditation of Healthcare Organizations (TJC) in 2003 in collaboration with numerous professional organizations

Effective July 1, 2004, compliance with the protocol has been required of all TJC

accredited institutions


Wrong body part or site: 76% of cases

Wrong patient: 13% of cases

Wrong procedure: 11% of cases

By specialty:Orthopedic/podiatric: 41% of casesGeneral surgery: 20%Neurosurgery: 14% Urologic surgery: 11% The rest were dental/oral

maxillofacial, cardiovascular-thoracic, ear-nose-throat, and ophthalmologic surgery

http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_24.htm

126 wrong-site surgery cases were reported to The Joint Commission in 2001. Root cause analyses found the following:


Factors contributing to increased risk for wrong-site surgery/procedures:– Emergency procedure– Unusual physical characteristics (morbid obesity,

physical deformity)– Unusual time pressures to begin or complete

procedure– Unusual equipment or set-up in the OR– Multiple surgeons involved in the case– Multiple procedures being performed during a

single surgical visit


CRICO experience: analysis of 40 cases of wrong-site surgery

Data from malpractice claims 1985-2003 and surgical loss observations 1994-2004– 38% (15 cases) wrong vertebral level or

wrong-side laminectomy of the spine– 62% (25 cases) non-spine

• 12 wrong side• 12 wrong site – no laterality, 8 involving multiple

structures, 4 involving multiple lesions• 1 wrong patient

Kwaan MR, et al. Arch Surg.2005;141:353-358

What does the universal What does the universal protocol include?protocol include?The protocol includes 3 steps:

1. Pre-procedure verification to confirm correct• Patient• Procedure• Site/side

2. Site marking3. “Time out” immediately before beginning

the procedure

What procedures fall under What procedures fall under the universal protocol the universal protocol guidelines?guidelines?Any invasive procedure that involves

puncture or incision of the skin, insertion of an instrument, or foreign materials

Not included under the protocol are routine procedures such as venipuncture, placement of simple IV’s, NG tubes, and Foley catheters

Pre-procedure verificationPre-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.”

Pre-Procedure Verification Pre-Procedure Verification Components-Patient Components-Patient IdentificationIdentificationAssuring 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)

Comparison of all relevant documents and studies to ensure that–Surgical consent, Anesthesia consent, OR schedule all available–Have been reviewed–Are consistent with each other–Are consistent with the patient’s and team’s understanding of the intended procedure and site

Pre-procedure verification Pre-procedure verification components-Documentation components-Documentation ReviewReview

Site marking essentials for Site marking essentials for AnesthesiaAnesthesia Mark all cases involving:

– Right or left laterality– Multiple levels (neuraxial or pain procedures

involving multiple spinal levels) The person performing the procedure should

do the site marking The mark must be:

– Unambiguous (initials only)– On the exact anesthesia block site only, after

verification of correct surgical site marking– Visible after patient is prepped and draped

Site marking essentialsSite marking essentials

When?– Before the patient is sedated to the point at which

s/he cannot be meaningfully involved Patient involvement

– The marking should occur with patient involvement– If the patient is unable to participate, whoever has

authority to provide informed consent should participate

Site marking examples (1)Site marking examples (1)

Left wrist ganglion PIP joint


Right shoulderLeft hernia


Right elbow Right hip

Site marking examples (4) Site marking examples (4)

L2L3L4L5

L4 laminectomy Left eye surgery

Anesthesia Nerve Block Marking Anesthesia Nerve Block Marking ExampleExample Anesthesiologist’s

initials (RW) At exact block site After verification of

surgical site marking Visible after

prep/draping

Site marking examples:Site marking examples:Correct or incorrect?Correct or incorrect?

Left 4th distal interphalangeal joint

Site marking examples:Site marking examples:Correct or incorrect?Correct or incorrect?

Left 4th distal interphalangeal joint

Incorrect Correct

The “time out”The “time out” What: A pause to verify that

– Patient identification has been confirmed– Surgeon’s articulation, prior to surgical incision, that

procedure, site and side agree with informed consent– Anesthesiologist’s articulation, prior to nerve block, that

block procedure, site, and side agree with informed consent– Both surgeon’s and anesthesiologist’s site markings are

clearly visible– Necessary equipment to perform procedure is at bedside

When: Immediately before starting the procedure or nerve block

Where: In the location where the procedure or nerve block is to be done

The “time out”The “time out” Who:

– The “time out” must involve the entire team that will be present during the nerve block procedure or at surgical incision

– At 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

The “time out”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 minimized

The “time out” is the team’s final fail-safe prior to the nerve block or surgical procedure

Video: The “time out” at Mount Video: The “time out” at Mount AuburnAuburnVideo 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

BarriersBarriers

It won’t happen to me– It could and has happened to competent, vigilant

practitioners

One more external regulation– Maybe so, but it might protect you and the patient

Someone else’s responsibility to initiate– It’s yours and everyone’s

“I must be mistaken, it’s probably ok”– If you’re uneasy, speak up

Pre-Procedure Verification Pre-Procedure Verification Take homesTake 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 studies– Are available– Have been reviewed– Are consistent with each other– Are consistent with the patient’s and team’s

understanding of the intended procedure and site

Pre-Procedure Verification Pre-Procedure Verification Take homesTake homesIf inconsistencies are noted during the

pre-procedure verification process, the procedure site and side should be – Verified by the surgeon and patient– The verified site/side should be correctly

and consistently documented, and– Correctly communicated to the staff setting

up the OR room, implants, and equipment

Site Marking Take homesSite Marking Take homes

The nerve block site should be marked– With the anesthesiologist’s initials only– By the person performing the procedure– With the patient’s (or surrogate’s) involvement – Directly over the nerve block site, following verification

of correct surgical site marking– Visible after draping

Do not:– Use “Yes” or “No”– Mark the non-operative site

Time Out Take homesTime Out Take homes

The “time out” – Is initiated by the anesthesiologist for nerve block and

surgeon for surgical procedure– Must take place with the entire team present

immediately before the planned procedure– Includes verification that

• Patient identification has been confirmed• Anesthesiologist’s and surgeon’s articulation that procedure,

site and laterality agree with both informed consents and OR schedule

• Both surgeon’s and anesthesiologist’s site markings are clearly visible

• Correct equipment/implants is/are immediately available

Verification of TrainingVerification 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

CreditsCredits Teaching module:

Created by Susan Abookire, MD, Yvonne Cheung, MD, Beth Lown, MD and G. Tracey Phillips, RN.

Videographer:Gary Goldsmith, MD

Time Out players:Rowland Wu, MDLeslie Schneiderhan, RN, CNSNancy Masoian, RN

Technical Support:Al Ghilardi, Orthopedic First Assistant

Special Thanks To:J. Michael Haering, MDMary Jo Sharkey, RN

Questions?Questions?

Contact the Mount Auburn Hospital Department of Quality and Safety

Extension: 5073

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Universal Protocol Guide for Anesthesia Nerve Blocks

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