Universal Protocol Guide for Anesthesia Nerve Blocks

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Universal Protocol Guide for Anesthesia Nerve
Blocks

• Mount Auburn Hospital
• Department of Quality and Safety

Instructions To proceed through this tutorial
mouse click on the blue forward gt or back lt
navigation buttons.
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Goals of this guide

• This guide is designed to help all care providers
  (anesthesiologists, CRNAs, and RNs) who perform
  nerve blocks at Mount Auburn Hospital
• Understand the rationale behind the universal
  protocol
• Correctly perform all of its elements

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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

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How well do you know the universal protocol?

• Please take this brief quiz
• The answers will be discussed within this module
• Disclaimer The case described is a composite
  based upon cases in the public domain

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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.

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Bob Jones knee replacementIn the holding room

• The nurse in the holding room greets Mr. Jones
  and initiates the pre-operative verification
  checklist. Dr. Smiths 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.

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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 OR
• The nurse should notify Dr. Smith of the
  discrepancies
• Dr. Smith should review his notes and the films,
  and re-confirm the decision with the patient
• Dr. Smith should insert a correction into the H
  P with his signature, date and time
• b, c, and d

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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 OR
• The nurse should notify Dr. Smith of the
  discrepancies
• Dr. Smith should review his notes and the films,
  and re-confirm the decision with the patient
• Dr. Smith should insert a correction into the H
  P with his signature, date and time
• b, c, and d

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Bob Jones knee replacementIn 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
  patients right mid-tibia with an arrow pointing
  upward toward the right knee. He then marks No
  on the left knee.

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Which of the following actions should now be
initiated?

1. No action need be taken
2. The markings on the right tibia and left knee
   should be scrubbed off
3. Dr. Smith should re-mark the right knee, Yes
4. Dr. Smith should re-mark his initials directly at
   the incision site on the right side only
5. b and d

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Which of the following actions should now be
initiated?

1. No action need be taken
2. The markings on the right tibia and left knee
   should be scrubbed off
3. Dr. Smith should re-mark the right knee, Yes
4. Dr. Smith should re-mark his initials directly at
   the incision site on the right side only
5. b and d

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Bob Jones Knee Replacement Holding Room, contd

• 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
  surgeons initials
• b) anywhere on the operative extremity
• c) at the nerve block site, so that the mark is
  visible after prepping and draping

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Bob Jones Knee Replacement Holding Room, contd

• 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
  surgeons initials
• b) anywhere on the operative extremity
• c) at the nerve block site, so that the mark is
  visible after prepping and draping

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Bob Jones knee replacementIn 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 patients identification with
  the anesthesiologist after which Mr. Jones is
  given general anesthesia. His blood pressure
  drops moderately below his baseline.

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Bob Jones knee replacementIn 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 patients
  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.

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Which elements of the time out were performed
incorrectly?

1. The time out was not initiated by the surgeon
2. The entire team was not present
3. The stated procedure was not cross-checked with
   the informed consent
4. The site marking was not visualized and verbally
   confirmed by the team
5. a, b, c, and d
6. b, c, and d

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Which elements of the time out were performed
incorrectly?

1. The time out was not initiated by the surgeon
2. The entire team was not present
3. The stated procedure was not cross-checked with
   the informed consent
4. The site marking was not visualized and verbally
   confirmed by the team
5. a, b, c, and d
6. b, c, and d

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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 site
• These guidelines apply to invasive procedures
  anywhere in the hospital

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Background

• 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

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

• By specialty
• Orthopedic/podiatric 41 of cases
• General surgery 20
• Neurosurgery 14
• Urologic surgery 11
• The rest were dental/oral maxillofacial,
  cardiovascular-thoracic, ear-nose-throat, and
  ophthalmologic surgery

• Wrong body part or site
• 76 of cases
• Wrong patient
• 13 of cases
• Wrong procedure
• 11 of cases

http//www.jointcommission.org/SentinelEvents/Sent
inelEventAlert/sea_24.htm
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Background

• 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

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Background

• 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.2005141353-358
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What does the universal protocol include?

• The protocol includes 3 steps
• Pre-procedure verification to confirm correct
• Patient
• Procedure
• Site/side
• Site marking
• Time out immediately before beginning the
  procedure

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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 materials
• Not included under the protocol are routine
  procedures such as venipuncture, placement of
  simple IVs, NG tubes, and Foley catheters

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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.

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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
  patients 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)

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Pre-procedure verification components-Documentatio
n Review

• 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 patients and teams
  understanding of the intended procedure and site

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Site marking essentials for Anesthesia

• 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

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Site 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

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Site marking examples (1)
Left wrist ganglion
PIP joint
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Site marking examples (2)
Left hernia
Right shoulder
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Site marking examples (3)
Right hip
Right elbow
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Site marking examples (4)
L2 L3 L4 L5
L4 laminectomy
Left eye surgery
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Anesthesia Nerve Block Marking Example

• Anesthesiologists initials (RW)
• At exact block site
• After verification of surgical site marking
• Visible after prep/draping

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Site marking examplesCorrect or incorrect?
Left 4th distal interphalangeal joint
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Site marking examplesCorrect or incorrect?
Left 4th distal interphalangeal joint
Incorrect
Correct
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The time out

• What A pause to verify that
• Patient identification has been confirmed
• Surgeons articulation, prior to surgical
  incision, that procedure, site and side agree
  with informed consent
• Anesthesiologists articulation, prior to nerve
  block, that block procedure, site, and side agree
  with informed consent
• Both surgeons and anesthesiologists 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

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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

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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 teams final fail-safe
  prior to the nerve block or surgical procedure

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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.
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Barriers

• It wont 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 elses responsibility to initiate
• Its yours and everyones
• I must be mistaken, its probably ok
• If youre uneasy, speak up

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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 studies
• Are available
• Have been reviewed
• Are consistent with each other
• Are consistent with the patients and teams
  understanding of the intended procedure and site

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Pre-Procedure Verification Take homes

• If 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

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Site Marking Take homes

• The nerve block site should be marked
• With the anesthesiologists initials only
• By the person performing the procedure
• With the patients (or surrogates) 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

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Time 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
• Anesthesiologists and surgeons articulation
  that procedure, site and laterality agree with
  both informed consents and OR schedule
• Both surgeons and anesthesiologists site
  markings are clearly visible
• Correct equipment/implants is/are immediately
  available

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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

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Credits

• 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, MD
• Leslie Schneiderhan, RN, CNS
• Nancy Masoian, RN

• Technical Support
• Al Ghilardi, Orthopedic First Assistant
• Special Thanks To
• J. Michael Haering, MD
• Mary Jo Sharkey, RN

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Questions?

• Contact the Mount Auburn Hospital Department of
  Quality and Safety
• Extension 5073

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