The Time Out: Make it Meaningful

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The intraoperative time out can become mundane and routine; in fact, teams sometimes forget it was even done. How many times has it been asked, “Did we do a time out?” The time out is one part of the Universal Protocol developed by The Joint Commission.  An effective time out prevents wrong-site, wrong-procedure, and wrong-person surgery, each of which is considered a never event by the National Quality Forum and The Joint Commission.¹,² It also is a tool that can protect the patient from potential surgical risk that could cause harm like pressure and positioning injuries, hypothermia, and fire. 

The Why Behind the Time Out 

Although the time out is a part of every surgery, there are still sentinel events occurring. Take, for instance, the 97 unintended retentions of a foreign object (eg, sponges) and 85 wrong-patient, wrong-site, and wrong-procedure surgeries reported to The Joint Commission in 2021; these two examples are the third and fourth highest reported events of the year.3 While these numbers seem low in the overall picture, they only reflect a small proportion of the actual events (less than 2%)3 and underscore the need for continued work. Utilizing the time out to recognize and verbalize patient risk is the first step. 

The time out is an avenue for team communication and risk identification. Identifying risks and communicating them during the time out ensures that the team is aligned with the planned patient safety interventions that will take place throughout the procedure. Examples of safety interventions include preplanned ongoing micromovements (intraoperative manual offloading of identified pressure points without disturbing the case) and intentional reassessment of positioning throughout the case⁴ to decrease the risk for pressure injury and temperature management to prevent hypothermia. A strong commitment to the time-out process is needed for these strategies to work.⁵  

An average time out can take anywhere from 30 seconds to two minutes. To the surgical team, this can seem like a lifetime. In a busy surgical setting, the time out is often rushed and lacks team participation. Like the moments before a big race, anticipation and excitement can distract the team. The time out loses its purpose and becomes a meaningless task, resulting in poor patient outcomes. By verbalizing identified patient risk factors and setting expectations for the implementation of an intraoperative nursing intervention plan, the time out becomes meaningful. When the surgical team agrees on the expectations for the plan of care, confusion surrounding the interventions decreases and team alignment is created.  

Making it Meaningful 

If there is a chronic lack of engagement by the surgical team when the time out begins, consider some of the following strategies to create buy-in to help ensure a complete pause takes place during the time out.

  • Create a coalition with the surgical technologist and anesthesia care provider before the time out and involve them early in the planned time-out communication before the patient comes in the room during setup, such as by asking if they would like any other risks identified during the time out.
  • Make the time out more meaningful for the whole unit, such as asking other team members what they have talked about during their other time outs and ending the time out with a question to the team on any other identified risks that were not discussed and planned interventions.
  • Empower the team with knowledge, such as by sharing individual patient risk factors and related possible poor outcomes (which the surgical team rarely sees); for example, pressure injury can increase the risk for readmission and result in an 11.2% higher mortality rate,⁶ and hypothermia can cause increased bleeding, increase the risk of surgical site infection and myocardial complications, and inhibit medication effectiveness.⁷
  • If there is often pushback by the surgical team on the planned intraoperative patient safety interventions identified during the time out, try to overcome it by using the words, “Best practice interventions that will protect this patient in our care will be…"

Conclusion

Whatever the case may be, the time out is the team’s communication platform and should not be taken for granted or marginalized. Set the stage for patient safety by utilizing the time out to strengthen the team; improve communication; verbalize expectations; and, most importantly, improve patient outcomes.

References

  1. Serious reportable events. National Quality Forum. Accessed October 12, 2022. https://www.qualityforum.org/Topics/SREs/Serious_Reportable_Events.aspx 
  2. Sentinel event policy and procedures. The Joint Commission. Accessed October 12, 2022. https://www.jointcommission.org/resources/sentinel-event/sentinel-event-policy-and-procedures/ 
  3. Sentinel event data released for 2021. The Joint Commission. Published March 9, 2022. Accessed November 23, 2022. https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/joint-commission-online/march-9-2022/sentinel-event-data-released-for-2021/#   
  4. Prevention of perioperative pressure injury tool kit. AORN. Accessed August 6, 2021. https://www.aorn.org/guidelines/clinical-resources/tool-kits/prevention-of-perioperative-pressure-injury-tool-kit
  5. Time-outs and their role in improving safety and quality in surgery. The Bulletin. Published June 1, 2017. Accessed October 13, 2022. https://bulletin.facs.org/2017/06/time-outs-and-their-role-in-improving-safety-and-quality-in-surgery/ 
  6. Kimsey DB. A change in focus: shifting from treatment to prevention of perioperative pressure injuries. AORN J. 2019;110(4):379-393.
  7. Nordgren N, Hernborg O, Hamberg Å, Sandström E, Larsson G, Söderström L. The effectiveness of four intervention methods for preventing inadvertent perioperative hypothermia during total knee or total hip arthroplasty. AORN J. 2020;111(3):303-312.

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