August 31, 2014

JCAHO Mandates Time-Out for Emergency Tracheostomy

Due to confusion from readers, please note that this is a work of satirical fiction.

Washington DC August 31, 2014 - Effective September 1, 2014, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has mandated that time-outs must be performed prior to emergency tracheostomy due to any reason, no exceptions. Due to numerous incidences of "never" events and lack of consistent acquisition of consent prior to emergency tracheostomy to treat catastrophic airway loss, this rule has been implemented to ensure the highest level of safety for patients in critical need of airway.

As with any surgical procedure, full informed signed consent by the patient must be present in the chart. If the patient is unable to provide informed consent (since unable to breath), consent must be obtained from next-of-kin or someone who has power-of-attorney (POA). If next-of-kin or POA is not available, than an ethics committee must be convened with attorney representation and POA assigned by judge as quickly as possible.

Once consent obtained, the neck needs to be marked and initialed by the surgeon so the surgeon does not get confused where the tracheostomy is to be performed. Surgeon must also specify side of tracheostomy (right or left or both) to be performed. Site confirmation and side needs to be confirmed independently by anesthesiology, circulating nurse, and independent third party. Most importantly, the patient should also confirm surgical site and side in a clear loud voice. If patient lacks vocal clarity, he should write on a piece of paper confirming surgical site and side.

Relevant imaging needs to be present and confirmed. Duration of surgery needs to be determined to the nearest 10 seconds given how important obtaining airway is as quickly as possible. If this accuracy level of surgical duration cannot be provided, the surgeon needs to provide surgical duration of last 30 emergency tracheostomies time range, average duration, and standard deviation. If documented surgical duration is not within an average of 5 minutes, another surgeon must be found who can provide such documentation given airway loss may occur with death if not able to be accomplished quickly. If no surgeon is available that meets this highest standard level of care, a committee must be convened to allow a special exemption. This committee shall include director of nursing, director of surgical services, chairperson of anesthesiology, chairperson of the surgery department, and elected designated layperson.

Once a surgeon has been selected, the surgeon must provide an estimate blood loss (EBL) to the nearest 1cc. The surgeon must provide documentation certifying this estimate based on past history and if unable to provide one, another surgeon must be selected who can provide such certified EBL. If EBL is anticipated to be higher than 50 cc, T&S must be obtained prior to incision.

Detailed patient positioning must be declared including exact angle of head relative to neck to nearest 1 degree, where right/left arms should be placed, where legs should be positioned, height of bed from ground to nearest 1.5mm, etc.

DVT prophylaxis must be stated whether SCD will be used or whether lovenox or other medical form of DVT prophylaxis will be administered. Some form of DVT prophylaxis must be utilized and if not,  another informed signed patient consent must be obtained making patient aware of the risks/benefits of DVT prophylaxis.

Time-outs will occur in the presence of the surgeon, circulating nurse, scrub technician, anesthesiology, floor nurse, ICU nurse, and elected independent layperson.

Every individual will clearly state their name and role. Government issued photo IDs will be displayed to every individual for confirmation with verbal acknowledgement.

Finally, before incision is made, the surgeon will clearly explain to everybody the critical steps of the procedure. Anesthesiology will do the same as well as other staff members present.

Any concerns raised during the time-out process can be raised by anybody and must be thoroughly and comprehensively addressed before proceeding. If there is a dispute over any concerns, an ad hoc committee will immediately be convened involving three uninvolved registered nurses who will listen and decide on course of action after all parties state their case.

When these new regulations were told to practicing surgeons, many voiced their pessimism that patient safety is not being served by adding such onerous steps to an already stressful and time-limited situation. "If a patient is not able to breath, is turning blue, is not intubatable, and is at death's door due to lack of oxygen, I fail to see how making time-out mandatory prior to a life-saving tracheostomy is in the patient's best interest," stated a well-respected surgeon who spoke only on condition of anonymity. "By the time time-out is done, the patient may already be dead!"

However, according to JCAHO spokesperson Aimee Adams, BSN, MS, MPH, etc, etc, etc, time-outs have raised the level of safety for patients suffering from a critical airway loss to a new level of safety. "It is our duty to ensure that everything that can be done is done to ensure patient safety is carried out to as high a level as possible before anything invasive is done to a patient, especially when at their most vulnerable."

If you have not already figured this out, this blog article is a work of satirical fiction. However, time-outs DO happen in reality and can be carried out in ludicrous situations. 

Here's a few mandatory (for real) time-out rules that make no sense:
- Why does the anesthesiologist have to declare whether beta-blockers (an adult blood pressure medication) are being administered in a 3 year old undergoing ear tubes for chronic ear infections???
- Why does an ophthalmologist have to declare patient positioning? It's always going to be supine! (Same goes with ENT cases.)
- Why does an ophthalmologist have to declare estimated blood loss for any eye surgery? It's always going to be miniscule.
- In a tiny community hospital, why does everybody have to declare their name and role?

etc, etc, etc

Fauquier blog
Fauquier ENT

Dr. Christopher Chang is a private practice otolaryngology, head & neck surgeon specializing in the treatment of problems related to the ear, nose, and throat. Located in Warrenton, VA about 45 minutes west of Washington DC, he also provides inhalant allergy testing/treatment, hearing tests, and dispenses hearing aids.

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