What does it mean to be called in? Part 4- the PAUSE

When we last left Patient A, the case was about to begin. And the pause happens before incision, sometimes immediately prior.

The pause refers to an intentional pause in the activity of the case and everyone in the room focuses their attention on the patient and touches briefly on what has brought him to our OR.

The pause or time-out, as it is sometimes referred to, was started in 2003. Initially this was intended to ensure that the correct patient, correct procedure, and correct site were identified by all the team members in the room.

In his book the Checklist Manifesto, author and general surgeon Atul Gawande, explores the reasons behind the creation of this kind of checklist. I whole heartedly recommend this book, and Complications, his first book. They should both be required reading for healthcare professionals. Along with House of God by Samuel Shem but that is another post.

The idea was borrowed from airlines; they have a checklist for everything aviation.

This was where the pause or time-out began. The entire room has to agree to the correct patient, the correct procedure, and the correct site. I have memories of rolling this out to the OR in CA. Some surgeons didn’t care to mark the patient to indicate laterality. Until there was a wrong site surgery in our operating room and then they couldn’t get on the bandwagon fast enough. Too bad it took a tragedy to get some people to do what has been proven to increase safety.

The time-out has been expanding ever since.

There is a pre-procedure pause with the nurse who did the initial assessment and pre-op work with the patient. This involves much of the same elements of a pre-surgical pause. Correct patient as evidenced by name and birthdate, correct procedure as evidenced by the consent, correct site as evidenced by the laterality being marked, if there is a laterality. And the completion of a history and physical has been added. Also added is the appropriate antibiotic. I imagine that the next to be added to the pause will be a pregnancy test, if applicable. The medications that anesthesia uses are powerful and can be fetotoxic. That means dangerous to the fetus. And this is a discussion that some of us have added to our communication with the CRNA and anesthesiologist.

The pre-procedure time-out is also done with the nurse, the CRNA, and the anesthesiologist prior to any anesthesia procedure. This includes blocking of limbs, blocking of the abdomen during a TAP block. This refers to the Transverse Abdominis Plane as an exploratory laparotomy incision pain block. Also included is the spinal block. If the anesthesiologist is blocking a shoulder for example they should also mark the correct shoulder, in addition to the surgeon.

The pre-surgical time-out includes the same information as the pre-procedure time-out with the addition of the presence or availability of the correct instruments and implants, for an orthopedic case, the introduction of all people in the room, including sale representatives, and a discussion of the fire risk of the surgery. Some surgeons throw in a time estimation for the case, and with the exception of an orthopedic surgeon I am thinking of who does marvelous pauses, are invariably wrong.

The last part of the time out is the expected issues that may crop up during the surgery. This is usually patient condition related and may included discussions of the need for a higher level of care such as the intensive care unit.

The OR team uses this time-out to convey many pieces of information. This is all to keep the patient safe while they are in our care.

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