The Timeout Process

The implementation of the timeout processes could well be the most important procedure to be introduced to the operating theatre in recent times. This seemingly small change has had a dramatic impact on patient outcome, staff cohesion and cost reduction in medical institutions. However, there are still issues that are obstructing the effectiveness of the timeout, namely poor compliance by some team members who believe that the fast turnover of cases does not allow for the timeout, that they have never had a problem in the past or that the timeout is questioning their competence.
This essay will look at the positive outcome that the timeout process has had in the operating theatre, why it is working and how to ensure that it remains a priority. The writer will also address the problem of poor compliance by some members, why they are resistant to the timeout process and what can be done to ensure their co-operation thereby creating a positive outcome for more patients. In order to place the checklist process in a proper perspective the following historical event is provided: In aviation, pilots have been using checklist since 1935.
It was formulated after the crash of the new Boeing Model 299 on its test flight, which killed two of the five crew members. One of the fatalities was Major Ployer P. Hill the Air Corps’ Chief of Flight Testing. The ensuing investigation ruled that the accident was pilot error and not mechanical failure. As the result of this ruling a group of test pilots took it upon themselves to investigate the reason for the pilot error.

They concluded that the new technology had a lot more sequential steps for the pilot to follow than the older aircrafts, which made it easier for Major Ployer P. Hill, a highly experienced pilot, to have missed a crucial step. The solution they formulated to rectify this dilemma was a simple checklist. By following this checklist the Model 299 was flown for 1. 8 million miles without an accident. Gawande (2010, p. 32 – 34). Likewise, the nursing profession has been using checklists in various forms, from the implementation of routine recording of vital signs to medication charts.
However, it was only in 2001 that a critical care specialist, Peter Pranovost, decided to formulate a simple checklist to try and reduce central line infections in the ICU at the John Hopkins Hospital, where he was working at the time. Peter Pranovost and his colleagues monitored the results of their idea for a year. In that time the ten-day line infection rate went from 11 percent to zero. They proceeded to test other checklists with equally impressive results. (Gawande 2010, p. 7- 39) Several studies were done on surgical outcomes that showed that about half of the complications experienced could have been prevented through the use of this checklist. In these studies it was shown “that in industrial countries major complications occur in 3% to 16% of inpatient surgical procedures, and permanent disability or death rates are about 0. 4% to 0. 8%. In developing countries, studies suggest death rates of 5% to 10 % during major operations.
Mortality from general anaesthesia alone is reported to be as high as one in 150 in parts of sub-Saharan Africa. Infections and other postoperative complications are also a serious concern around the world. ” WHO (2007). In 2007 the World Health Organization (WHO) decided that something must be done to improve the situation A team of experts, led by Dr Atule Gawande, was brought together to find a solution. They formulated the surgical checklist and challenged the world to use it. The group investigated the impact of the WHO checklist in eight hospitals worldwide, four in high-income settings and four in low and middle-income settings. Data on in-hospital complications occurring within the first 30 days after surgery were collected prospectively from consecutively enrolled adult patients undergoing non-cardiac surgery, 3733 before and 3955 after the implementation of the checklist. The overall death rate was reduced from 1. 5% to 0. 8% (P= 0. 003) and in-patient complications from 11. 0% to 7% (P< 0. 001)”. Haynes (2009) What does this surgical checklist entail?
As stated by WHO “The checklist identifies three phases of an operation, each corresponding to a specific period in the normal flow of work: Before the induction of anaesthesia (“sign in”), before the incision of the skin (“time out”) and before the patient leaves the operating room (“sign out”). In each phase, a checklist coordinator must confirm that the surgery team has completed the listed tasks before it proceeds with the operation”. Many institutions worldwide have adopted the surgical timeout; they have changed a few points of the WHO checklist to better meet their needs, with impressive results.
A study following 8000 surgical procedures, found that the implementation of the timeout resulted in a 30% reduction in the rate of surgical complications and deaths (Hayes 2009). Not only has patient mortality and expenditure decreased but its application showed an increase in staff cohesion. The surgical checklist has helped to increase communication by ensuring that all members as a team take the time to check and discuss potential problems and expected outcomes for the patient.
This enhanced interaction between the multidisciplinary team lends itself to the staff’s increase awareness of potential problems and adverse conditions, which contributes to improved patient outcomes. Taylor (2010) surveyed operating room staff and found a perceived improvement in communication, teamwork, respect and patient safety related to the use of the timeout. Improved patient outcome following the implementation of the surgical checklist has been clearly demonstrated within Veterans Affairs (Neily et al 2010) as well as in the Netherlands (deVries et al 2010) and Iran (Askarian et al 2011).
In the Netherlands study by deVries, it was found that most postoperative complications declined and that this decline could be credited to improved communication. An interesting outcome was that rates of bleeding and anastomotic leaks also declined as well as technical problems which occur primarily at the surgeons hands. The findings of this study suggest that the indirect effects of implementing checklists may be much more important than their specific content. (Birkmeyer 2010) Improved communication leads to respect for each team member and trust in each other.
To maintain a high degree of efficacy all staff members should be provided with continuous education and evaluation of their performance. All members should therefore be informed and have access to the data that shows the benefits of using the surgical checklist. This will prevent the staff from becoming complacent. However, complacency is not the only obstacle preventing the success of the surgical checklist, poor or even non compliance is of greater concern. There are a number of reasons for this. A checklist implies that mistakes can and do happen.
In a study which investigated medical professionals’ attitude to the safety systems 30% of nurses and doctors stated that they ‘did not make errors’. (Sexton 2000; p745-9) A great number of medical personnel have this misconception that they do not make mistakes or they feel that admitting to mistakes, no matter how minor, will lead to their colleagues loosing respect for them and some fear being punished as the medical profession as a whole has a low tolerance for errors. These feelings can cause staff members not to report minor incidences; unfortunately many minor incidences can lead to major problems.
The hierarchy system that exists in the theatre environment also leads to poor compliance with regards to the surgical timeout. Although nursing in theory is now deemed to be a profession that works alongside doctors, not for them or subservient to them, in practise this is not always the case. When there is resistance from the surgeon or anaesthetist toward the checklist this resistance is expressed verbally in an active ridiculing manner, or non-verbally by just ignoring the process (Valen, Waehle et al 2012, p 4).
When this type of attitude is displayed the theatre nurses’ main objective becomes self-preservation and the maintenance of peace, which makes the nurse rush the checklist and omitted points that may cause the surgeon or anaesthetist to become more displeased. If the surgeon and anaesthetist are supportive of the checklist, it is more likely that it will be done correctly. (Mahajan 2011, p161-8) One often finds that staff feel that doing the surgical checklist will cause delays in patient turnover, they also feel that the current system is working for them and their team so why fix what is not broken.
The 2010 report by Patient Safety First showed that while most trusts reported that the checklist led to improved safety and teamwork the most common challenges to its implementation were negative clinician attitudes. (Allard, 2011, p711-17) In the operating theatre setting there are three professions involved, namely, nursing, surgery and anaesthesia and all three are working towards a common result and yet each profession is accustomed to doing this to achieve individual goals.
All three are faced with staff shortages, educational duties and economic pressures. (Lingard et al 2006, p 471-83) These pressures lead to the inconsistent use of the checklist. When the checklist process is started all staff are meant to stop what they are doing, thereby giving their full attention to the checklist. However, this is not always the case as team members may be reluctant to alter their work routine and feel that what they are doing is more important, or that if people of the team knew what they were doing the checklist would not be necessary. Amalberti et al 2005, p756-64) If there is no clear decision made as to who is responsible for the completion of the surgical checklist, points may not be addressed or in the rush the checklist may just be ticked so that it is complete when it is audited. Vats et al( 2010, p340) discovered that there was confusion over who’s responsibility it was to do the sign-out checks which were frequently missed due to it being at the most time pressured part of the process and also found some checklists to be incomplete, hurried, dismissed or completed without key members participation.
As can be seen from the above observations there are a number of factors that lead to poor compliance and this presents a challenge in finding ways to remedy this. It is hard for junior or more timid members of the team to implement the checklist if the more senior or assertive members are not compliant. Paull et al (2009, p 675-78) states that leadership support was deemed the strongest single predictor of successful checklist implementation among sixty four Veterans Health Administration Facilities.
When studying the implementation efforts of five hospitals Conley et al (2011, p873 – 79) found that having the department chiefs as members of the implementation team and actively promoting the checklist was a big factor in its success. The senior staff need to lead by example and should be seen actively supporting and participating in this process, which in turn will ensure compliance by the rest of the staff. A team approach is recommended, with the team being made up of respected members of physicians, anaesthetists and nurses.
Having all disciplines represented in these teams is important as they are likely to positively influence their peers. (Reinertsen et al. 2007) This team approach removes the need for a nurse to approach a doctor or anaesthetist, which would prove difficult and they would more inclined to ignore the advice given. To ensure the surgical checklist is adopted completely by the multidisciplinary team, it should be first introduced on a small scale, to one team or theatre.
This allows for more comprehensive training in the correct way to complete the surgical checklist (Taylor 2010), Positive feedback will filter from the team doing the checklist to the teams not involved, so when they have to start using the check list they will have a positive attitude towards it. This is when changes should be made to the list which will customize it to the institution. The success of the surgical checklist will filter to the other surgical teams, thereby causing wider acceptance and compliance. Langley 2009) Modifying the original WHO checklist will ensure equal participation from all team members and, therefore, creates a checklist that is inherently “team led”. A feeling of ownership will be cultivated. The WHO published a comprehensive implementation manual (WHO, 2008) to accompany the introduction of the WHO checklist that encouraged modification to fit with local practice, cautioning against making the checklist overly complex. The Multidisciplinary team members need to receive comprehensive training with regards to how the surgical checklist is to be presented to the other staff members.
They need to have clear guidelines as to who will take ownership of the checklist, in many cases it is the circulating nurse. The checklist should ideally not be recited from memory; it should be read from the list. All activity should stop when the checklist is being presented. To maintain the interest and compliance of all staff, regular feedback should be given, namely real-time feedback. As Ursprung et al (2005) cited in their discussion on improving safety, providing real-time feedback is critical for early detection and remediation of problems that may arise.
Data should be collected on a regular basis and be correlated, as to provide solid evidence that will provide proof of the goals the staff have achieved and evidence of what still needs to be addressed. Thereby, maintaining their interest in the checklists importance. The surgical checklist when approached in the proper manner is a simple tool that has the potential to improve patient outcomes expediential. Various studies by A. B Haynes (2009), J. Neily (2010), C.
Hayes (2009) just to name a few have shown marked improvement with regards to patient complications and mortality rates. To prevent poor compliance by members there are a number of strategies that can be adopted. Senior members should be seen to actively participate in the checklist process so that the rest of the staff will take ownership of their checklists. To assure the success of the checklist, a small team should be formed comprising of respected members of the three disciplines involved, this will allow for peer interaction.
Introducing the checklist on a small scale allows for more comprehensive education and positive feedback to the members not involved. The culture in theatre needs to change, the theory that doctors and nurses are both professionals in their own rights and neither are boss over the other, needs to be put into practise. The multidisciplinary team in theatre needs to become a team, forget their individual agendas and make the positive outcome for their patients their priority.
The surgical checklist will help, as it creates the opportunity for open communication between the multidisciplinary team, which leads to greater respect and trust between the members. With the ever increasing number of surgeries performed each year, the need for quicker turnover times will become greater, therefore without the surgical checklist, surgical complications and mortality rates will increase. It is the opinion of the writer based on the evidence gathered, that the implementation of a comprehensive surgical checklist, should be mandatory for every medical facility in the world.

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