Preop Regional JCAHO guideline

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pencan

pencan

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Does anyone do blocks prior to the surgeon marking the site for surgery? According to the joint commission guidelines it appears that as long as some sort of "timeout" is completed by the licensed provider doing the procedure the site marking by the surgeon would not be required. Any experience in dealing with this? We have a OR nurse manager that swears you cannot do any procedure until the surgeon marks the site.

Thanks
 
pencan said:
Does anyone do blocks prior to the surgeon marking the site for surgery? According to the joint commission guidelines it appears that as long as some sort of "timeout" is completed by the licensed provider doing the procedure the site marking by the surgeon would not be required. Any experience in dealing with this? We have a OR nurse manager that swears you cannot do any procedure until the surgeon marks the site.

Thanks
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I think that anesthetizing the correct side is the responsibility of the anesthesiologist while operating on the correct side is the responsibility of the surgeon.
I do my blocks sometimes an hour before the surgeon gets to the hospital.
But if JACHO says I should wait and the nurses agree then who am I to disagree?
They make the rules and I just give anesthesia.
 
Planktonmd said:
I think that anesthetizing the correct side is the responsibility of the anesthesiologist while operating on the correct side is the responsibility of the surgeon.
I do my blocks sometimes an hour before the surgeon gets to the hospital.
Click to expand...

I would agree with this.

But if JACHO says I should wait and the nurses agree then who am I to disagree?
They make the rules and I just give anesthesia.
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I sincerely hope you are speaking tongue-in-cheek. 😉

-copro
 
For my first blocks of the day I wait until the surgeon is in the holding area. Catastrophies happen, albeit very rarely (car accidents, they are operating on an emergency at another facility, they forgot their own schedule, etc.) I have everything ready, I've already surveyed my site with the ultrasound and I am ready to go. Once the surgeon is working in a room I think it is reasonable to mark the site of the block, do a timeout with another person present, and go ahead. Our nurses are on board with this.
 
2ndyear said:
For my first blocks of the day I wait until the surgeon is in the holding area. Catastrophies happen, albeit very rarely (car accidents, they are operating on an emergency at another facility, they forgot their own schedule, etc.) I have everything ready, I've already surveyed my site with the ultrasound and I am ready to go. Once the surgeon is working in a room I think it is reasonable to mark the site of the block, do a timeout with another person present, and go ahead. Our nurses are on board with this.
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Generally my experience too, at least in residency. Still trying to feel out the "system" here, as I just started my new job on Tuesday (notice that I'm already home and posting, though. 😉 ) and I haven't done any blocks yet.

Plankton, this is a huge problem in medicine right now. I agree with you. We are more and more serving the system, and not necessarily the patient in the process. How we remedy this, I don't know. But, I am amazed at how local policies often supercedea what JCAHO and other oversight organizations often actually mandate.

For example, my new institution requires that you wear contact isolation precautions anytime you are within three feet of the patient. That's right: gloves, gown, and a face mask. So far, this hasn't really been enforced from what I can tell, but it certainly doesn't jibe with what the CDC says on the subject. And, I think JCAHO policy isn't even this stringent (could be wrong).

Should this be a big deal to us? Does this really cut down on transmission of resistant organisms? I dunno. I tend not to think so. But, there are nurses who will jump all over you if you violate this. And, how much cost does this actually add to the patient's care with minimal return? Whatever the answer is, I'm starting to think I need to invest in companies who make nitrile gloves and yellow gowns.

-copro
 
I often do my blocks prior to the surgeon seeing/marking the patient. As long as all the information (posting, consent, schedule etc) agree with what the patient says is the surgical site, I think it is fine. Before sedating the patient and doing the block, I always confirm one last time the correct side. When following the rules to a "t" we do a "time-out".
 
My attendings who’ve been in town for awhile just text or call the surgeon to get a go-ahead so we don’t have to wait.
 
At our hospital we always wait for the surgeon to see the patient and mark the site before blocking. In the vast ocean of stupid policies that JCAHO espouses, this seems to be one of the less idiotic ones. IMO it makes sense to have the surgeon talk to the patient and make sure they both agree to move forward before I stick a needle in the patient. Sometimes it has been months since the surgeon has last seen the patient in their office, and something may have changed?

Additionally, in terms of "efficiency", blocking a patient takes all of 2 minutes - rarely is that the rate limiting step in getting a patient back to the room.
 
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Urzuz said:
At our hospital we always wait for the surgeon to see the patient and mark the site before blocking. In the vast ocean of stupid policies that JCAHO espouses, this seems to be one of the less idiotic ones. IMO it makes sense to have the surgeon talk to the patient and make sure they both agree to move forward before I stick a needle in the patient. Sometimes it has been months since the surgeon has last seen the patient in their office, and something may have changed?

Additionally, in terms of "efficiency", blocking a patient takes all of 2 minutes - rarely is that the rate limiting step in getting a patient back to the room.
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Tell that to the surgeons at my institution.
 
MirrorTodd said:
Tell that to the surgeons at my institution.
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Do your partners (or you) take forever to perform blocks? Most of my partners are good but there are a few that literally take 15 minutes to do something like an adductor canal block…
 
Urzuz said:
Do your partners (or you) take forever to perform blocks? Most of my partners are good but there are a few that literally take 15 minutes to do something like an adductor canal block…
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Academic, so residents are doing the blocks under supervision. I am not slow with the needle, so (not to sound too cocky), but MY blocks wouldn't be slow. lol
 
MirrorTodd said:
Academic, so residents are doing the blocks under supervision. I am not slow with the needle, so (not to sound too cocky), but MY blocks wouldn't be slow. lol
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That just makes the desire for fast turnovers all the more rich, since they probably allow the med student or first year resident to take 2 hours to close a 3 cm wound.
 
Our blocks are done asap. Sometimes before or after I see them. If we got multiple rooms going, doesn't matter.

If it's a hip fx, and I'm coming in for the case. That block better be done before I get there and not waste another 20mins. By the time your get a nurse, meds, us machines.. It's 20mins.
 
ChiDO said:
Our blocks are done asap. Sometimes before or after I see them. If we got multiple rooms going, doesn't matter.

If it's a hip fx, and I'm coming in for the case. That block better be done before I get there and not waste another 20mins. By the time your get a nurse, meds, us machines.. It's 20mins.
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:slap::slap::slap:
 
ChiDO said:
Our blocks are done asap. Sometimes before or after I see them. If we got multiple rooms going, doesn't matter.

If it's a hip fx, and I'm coming in for the case. That block better be done before I get there and not waste another 20mins. By the time your get a nurse, meds, us machines.. It's 20mins.
Click to expand...

I feel like 20 mins is nothing compared to 20 hours of decreased pain for your patient. Although a fem block should really take 2.
 
ChiDO said:
Our blocks are done asap. Sometimes before or after I see them. If we got multiple rooms going, doesn't matter.

If it's a hip fx, and I'm coming in for the case. That block better be done before I get there and not waste another 20mins. By the time your get a nurse, meds, us machines.. It's 20mins.
Click to expand...

Our surgeons see them and mark them and we have everything ready in our preop area (ultrasound, monitors, etc). I block them after a surgeon sees them. Not a single surgeon has ever made a peep about this policy since it just makes sense. The smart ones who really want to be efficient will consent and mark the patient before (sometimes in the morning for an afternoon case) so that we can do everything before they physically arrive in the perioperative area.

By your logic, if we are blocking them before you are even physically in the hospital, we should just intubate them as well before you see them. During blocks patients usually get some degree of sedation, so it's not like they are consentable anymore...so why **** around? Let's just block them, intubate them, position them...hell if I can bill as a surgical assistant I will even start your exposure for you.
 
Urzuz said:
Our surgeons see them and mark them and we have everything ready in our preop area (ultrasound, monitors, etc). I block them after a surgeon sees them. Not a single surgeon has ever made a peep about this policy since it just makes sense. The smart ones who really want to be efficient will consent and mark the patient before (sometimes in the morning for an afternoon case) so that we can do everything before they physically arrive in the perioperative area.

By your logic, if we are blocking them before you are even physically in the hospital, we should just intubate them as well before you see them. During blocks patients usually get some degree of sedation, so it's not like they are consentable anymore...so why **** around? Let's just block them, intubate them, position them...hell if I can bill as a surgical assistant I will even start your exposure for you.
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Acorns are not oak trees ….

By that logic a preop nurse couldn’t place a peripheral IV before the surgeon came ajd say the patient.
 
Urzuz said:
Our surgeons see them and mark them and we have everything ready in our preop area (ultrasound, monitors, etc). I block them after a surgeon sees them. Not a single surgeon has ever made a peep about this policy since it just makes sense. The smart ones who really want to be efficient will consent and mark the patient before (sometimes in the morning for an afternoon case) so that we can do everything before they physically arrive in the perioperative area.

By your logic, if we are blocking them before you are even physically in the hospital, we should just intubate them as well before you see them. During blocks patients usually get some degree of sedation, so it's not like they are consentable anymore...so why **** around? Let's just block them, intubate them, position them...hell if I can bill as a surgical assistant I will even start your exposure for you.
Click to expand...

Why not? You know the patient saw the surgeon in clinic way before you ever entered the picture. I've seen the procedure change maybe once and minimally at that.
 
dipriMAN said:
Acorns are not oak trees ….

By that logic a preop nurse couldn’t place a peripheral IV before the surgeon came ajd say the patient.
Click to expand...

I would argue that the harm / negative optics caused by putting an IV in a patient whose surgery gets cancelled/changed is far less than the harm of a patient ending up with a numb extremity or limb whose surgery gets cancelled/changed. The risk associated with each procedure is far different.

Also, there is the huge component of you sedating a patient before the surgeon has even consented them...you don't see an issue with having the surgeon come by and consent them after having just received midazolam and/or fentanyl?

GassYous said:
Why not? You know the patient saw the surgeon in clinic way before you ever entered the picture. I've seen the procedure change maybe once and minimally at that.
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That's exactly it, they saw them God knows how long ago (or in that poster's example above, for a hip fracture, he's probably never seen them). They should see them again, have all their questions answered, etc before undergoing a procedure associated with the surgery (ie: a block).

It's not terribly uncommon to have procedures change (not change the limb that they're operating on, but how much/little they are doing), and if that discussion is taking place, I would want the patient to be completely awake without any sedation in them. And though not as common, I see cases just outright cancel as well (patient has second thoughts after talking to surgeon, extremity has a pimple on it that the surgeon doesn't want to incise through, etc etc). Just the other day one of our orthopedic surgeons cancelled one of his total hips that he had in the middle of his lineup...
 
Urzuz said:
I would argue that the harm / negative optics caused by putting an IV in a patient whose surgery gets cancelled/changed is far less than the harm of a patient ending up with a numb extremity or limb whose surgery gets cancelled/changed. The risk associated with each procedure is far different.

Also, there is the huge component of you sedating a patient before the surgeon has even consented them...you don't see an issue with having the surgeon come by and consent them after having just received midazolam and/or fentanyl?



That's exactly it, they saw them God knows how long ago (or in that poster's example above, for a hip fracture, he's probably never seen them). They should see them again, have all their questions answered, etc before undergoing a procedure associated with the surgery (ie: a block).

It's not terribly uncommon to have procedures change (not change the limb that they're operating on, but how much/little they are doing), and if that discussion is taking place, I would want the patient to be completely awake without any sedation in them. And though not as common, I see cases just outright cancel as well (patient has second thoughts after talking to surgeon, extremity has a pimple on it that the surgeon doesn't want to incise through, etc etc). Just the other day one of our orthopedic surgeons cancelled one of his total hips that he had in the middle of his lineup...
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Our joint guys can be pretty neurotic too. I’ve seen them cancel for a little blemish near the incision.
 
Eh I've heard of more limbs getting jacked by infiltrated ivs than by a block. I'd rather have some sensory deficit or even motor weakness over an amputated limb.
 
ChiDO said:
Our blocks are done asap. Sometimes before or after I see them. If we got multiple rooms going, doesn't matter.

If it's a hip fx, and I'm coming in for the case. That block better be done before I get there and not waste another 20mins. By the time your get a nurse, meds, us machines.. It's 20mins.
Click to expand...

Right, because your time being called in is so much more valuable than ours? 🙄

Give me a break. It may take 20 minutes where you are but with a proper set up, it takes less than 5 minutes. And that includes talking with the patient and family.
 
Urzuz said:
I would argue that the harm / negative optics caused by putting an IV in a patient whose surgery gets cancelled/changed is far less than the harm of a patient ending up with a numb extremity or limb whose surgery gets cancelled/changed. The risk associated with each procedure is far different.

Also, there is the huge component of you sedating a patient before the surgeon has even consented them...you don't see an issue with having the surgeon come by and consent them after having just received midazolam and/or fentanyl?



That's exactly it, they saw them God knows how long ago (or in that poster's example above, for a hip fracture, he's probably never seen them). They should see them again, have all their questions answered, etc before undergoing a procedure associated with the surgery (ie: a block).

It's not terribly uncommon to have procedures change (not change the limb that they're operating on, but how much/little they are doing), and if that discussion is taking place, I would want the patient to be completely awake without any sedation in them. And though not as common, I see cases just outright cancel as well (patient has second thoughts after talking to surgeon, extremity has a pimple on it that the surgeon doesn't want to incise through, etc etc). Just the other day one of our orthopedic surgeons cancelled one of his total hips that he had in the middle of his lineup...
Click to expand...
I’d be willing to bet you’ve consented many patients for anesthesia who are “not consentable” by your logic…. Kidney stone in the ER pumped full of dilaudid and Benadryl, hip fx on a pca all night. Not to mention patients who take Xanax for anxiety at home. We consent these patients all the time. Many of these policies are dumb and we pick and choose the patients to which they apply.
With that said, at our hospital we do wait until the surgeon has marked the patient before we block, I do it to be left alone by clip boards and it doesn’t impact our throughput at all.
 
Volatile said:
I’d be willing to bet you’ve consented many patients for anesthesia who are “not consentable” by your logic…. Kidney stone in the ER pumped full of dilaudid and Benadryl, hip fx on a pca all night. Not to mention patients who take Xanax for anxiety at home. We consent these patients all the time.
Click to expand...

Right...and how are you using that as justification for giving a patient a sedative before they've talked to the surgeon about the surgery they're about to undergo? Especially, as you're saying, if it has zero effect on throughput? It's like you're saying if you can't do something properly 100% of the time, then **** it, you may as well do it 0% of the time.
 
Urzuz said:
Right...and how are you using that as justification for giving a patient a sedative before they've talked to the surgeon about the surgery they're about to undergo? Especially, as you're saying, if it has zero effect on throughput? It's like you're saying if you can't do something properly 100% of the time, then **** it, you may as well do it 0% of the time.
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Lol don’t think you’re tracking. I DO wait until they’re signed before I block. I’m simply saying, I’ve heard multiple people, mainly nurses with clip boards, say we shouldn’t consent patients who have received sedation. And my point is we do it all the time.
 
ChiDO said:
Our blocks are done asap. Sometimes before or after I see them. If we got multiple rooms going, doesn't matter.

If it's a hip fx, and I'm coming in for the case. That block better be done before I get there and not waste another 20mins. By the time your get a nurse, meds, us machines.. It's 20mins.
Click to expand...
Hope you're not sitting in the chair at home, dead for 12 hours while they have your patient asleep on the table, all because "he's always here". Seen it happen.

No surgeon, no block, no induction, Period.
 
jwk said:
Hope you're not sitting in the chair at home, dead for 12 hours while they have your patient asleep on the table, all because "he's always here". Seen it happen.

No surgeon, no block, no induction, Period.
Click to expand...

It’s amazing how people will compromise common sense safety measures just to potentially save five minutes and appease surgeons.
 
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jwk said:
Hope you're not sitting in the chair at home, dead for 12 hours while they have your patient asleep on the table, all because "he's always here". Seen it happen.

No surgeon, no block, no induction, Period.
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I would like to hear a more detailed story about this if you don't mind.
 
abolt18 said:
I would like to hear a more detailed story about this if you don't mind.
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Not quite as dramatic, but I did see a patient put to sleep for a “reliable” surgeon who was in another state for a conference. Somebody screwed up and didn’t notify the patient that their surgery date was rescheduled.
 
dr doze said:
Not quite as dramatic, but I did see a patient put to sleep for a “reliable” surgeon who was in another state for a conference. Somebody screwed up and didn’t notify the patient that their surgery date was rescheduled.
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Oh yeah I've had a patient scheduled for a case when the surgeon was on vacation in a different country. They only had consents done and iv placed before the mistake was discovered.
 
dr doze said:
Not quite as dramatic, but I did see a patient put to sleep for a “reliable” surgeon who was in another state for a conference. Somebody screwed up and didn’t notify the patient that their surgery date was rescheduled.
Click to expand...

I’ve had this happen as well.
 
ChiDO said:
That block better be done before I get there and not waste another 20mins.
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Boy are you gonna be upset when I tell you to get bent. We used to cater to d bag surgeons at my place all the time too, until we had blocked one shoulder guy's first three patients and he got t-boned on his way into the hospital and was unable to operate for the next month.

I promise, we wait on you guys WAY more than you wait on us.
 
Mehd School said:
Boy are you gonna be upset when I tell you to get bent. We used to cater to d bag surgeons at my place all the time too, until we had blocked one shoulder guy's first three patients and he got t-boned on his way into the hospital and was unable to operate for the next month.

I promise, we wait on you guys WAY more than you wait on us.
Click to expand...
I will second this, I would not block a patient until surgeon is confirmed present, and ideally consented the patient. I want to be 100% sure surgery is happening before blocking, and would want this myself if I were the patient.
 
dipriMAN said:
I will second this, I would not block a patient until surgeon is confirmed present, and ideally consented the patient. I want to be 100% sure surgery is happening before blocking, and would want this myself if I were the patient.
Click to expand...
Blocking the pt without the surgeon present in the hospital just seems straight up foolish to save what 5-10 minutes...maaaaayyyyybe the rare 20 minute difficult anatomy block? Just as others have said, we're waiting for the surgeon FAR more often than they are waiting for us.
 
MirrorTodd said:
Blocking the pt without the surgeon present in the hospital just seems straight up foolish to save what 5-10 minutes...maaaaayyyyybe the rare 20 minute difficult anatomy block? Just as others have said, we're waiting for the surgeon FAR more often than they are waiting for us.
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Perhaps but it isn't always cut and dry.

Let's say you know the surgeon is on the way and the room is ready to go. What if you know you will be tied up (perhaps for a while) when the surgeon gets there and you won't be able to block the patient? Are you just going to make everyone wait or are you going to ask one of your partners to do it (who may or not be able to help)?
 
Arch Guillotti said:
Perhaps but it isn't always cut and dry.

Let's say you know the surgeon is on the way and the room is ready to go. What if you know you will be tied up (perhaps for a while) when the surgeon gets there and you won't be able to block the patient? Are you just going to make everyone wait or are you going to ask one of your partners to do it (who may or not be able to help)?
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Yes I think there should be exceptions, these types of cases you describe I would be ok blocking a patient. Just want to avoid the situation where the surgeon is nowhere near the hosptial and I block a patient without even confirming he or she is on their way.
 
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