Apparently under direction from JCAHO our hospital has instituted a new policy requiring that virtually all procedures in the ED be preceded by "marking" and a "Time-out" Anybody else having to do anything like this?
Here is an excerpt from a letter I recently received explaining the policy
Procedures that definitely require both marking and time out
Urgent/Nonemergent chest tubes
Thoracentesis
Lacerations when there are multiple lacs and only some are to be sutured ones to be sutured should be marked. This is straight from the JCAHO website
Gray areas that MIGHT require both marking and time out awaiting additional confirmation
POSSIBLY joint and fracture reductions such as shoulders/hips/elbows/ankles/fingers/toes - Jackie will discuss this with OR personnel, as there are obvious lesions with visible deformity that declare the site---also these procedures do not involve puncture/incision of skin, or insertion of foreign material into the body. We may HAVE to do this if the organization declares this as a surgical procedure involving laterality, but I am hopeful that the institution-wide interpretation of the policy allows us to exclude these for the reasons stated. We have to have one policy throughout the hospital, I would suppose---ie if a procedure is marked in the OR, the same procedure should be marked when it is done in the ED.
Joint aspiration, if no obvious wound/lesion exists - caveat: We dont aspirate normal looking joints. I have a feeling that JCAHO would not interpret a red/hot joint as an obvious wound or lesion and I havent been able to find any language that directly answers this question. I, for one, am happy interpreting a red/hot joint as obvious, thus excluding this from marking, until instructed to do otherwise.
Abscess incision and drainage (again, I will buy the obvious wound or lesion exception to marking)
Procedures that are EXCLUDED from marking, but REQUIRING time out
Emergent chest tubes
Laceration repair
Joint/fracture reduction (potentiallysee above)
Joint aspiration (see above)
Abscess I&D (see above)
Paracentesis
Teeth - this is the way it is listed in the JCAHO exception. I guess this would include dental blocks, abscess drainage, the rare extraction
Procedures that are EXCLUDED from marking and time out
Central line placement
Fiberoptic scope (duh!)
Anoscopy (double duh)
How this works .
For procedures requiring marking and time out:
1) Once a procedure is deemed to be necessary that falls under the policy to mark, the provider doing the procedure will take an indelible ink pen (which will be provided in the ED) and write yes at the site to be worked on. This is done while discussing the laterality with the patient, and obtaining their confirmation that you are marking the correct side. The yes must be visible once drapes are placed, if applicable. If the patient is incompetent to participate, or if they dont know what side they need the procedure on ---ie the pneumothorax that is relatively asymptomatic except for shortness of breath---the responsibility to mark the correct side falls completely on the practitioner, who must verify and confirm the xray findings at the time of marking.
2) In the event that you will never leave the bedside from the time the decision is made to do the procedure, through the consenting process, and until the completion of the procedure (highly unlikely that this would happen), you dont have to mark.
3) At the time immediately before the procedure is done, a time out will occur involving all members of the team doing the procedure. At this time, an out-loud, verbal confirmation of the five elements are required by the entire team involved---correct patient, correct side/site, correct procedure, correct position, correct xrays .
4) The time that the time out occurred will be documented by the nursing staff on a sticker that has been developed for this purpose.
5) Any member of the team is equally able and empowered to stop the procedure by expressing concern that something is wrong. At that point, the procedure must stop and the site/patient must be verified once again, until all members of the team are comfortable that the right thing is being done at the right place to the right person.
6) Even if the practitioner doing the procedure is the only person in the room with the patient at the time the procedure is done (ie laceration repair), the time out is still appropriate (ie REQUIRED) by JCAHO and must be documented either by filling out the sticker or listing that the time out was done in the dictation Marking must also be dictated, along with the level of participation by the patient/representative.
For procedures requiring time out only:
1) We are supposed to stop and take a breath and verify the five elements before proceeding. The policy does not state that the practitioner doing the procedure must document the exact time of the time out. That occurs in the nursing note when nurses are involved. I would just try to start incorporating into your dictation the statement A time out was taken per protocol immediately before the procedure was begun.
2) Even life threatening and emergent procedures require time out performance and documentation. Time outs should always be out loud when multiple staff members are involved. A silent time out is ok when there is only one practitioner in the room.
Again, there is now no applicable procedure, no matter how emergent, that allows us to be exempt from announcing a time out and verifying the five elements before proceeding. This is for everyones protection.
The nursing staff is to be trained to participate fully in the marking and time out process. They are also being asked to help remind us that this is now policy.
Anytime a staff member reminds a physician/practitioner that marking or time out is mandatory per policy, the practitioner will be expected to respond respectfully and comply with policy to assure patient safety. Likewise, if any team member brings up concern during a procedure, the practitioner must stop and verify the five elements until all team members are satisfied. All team members are responsible for speaking up if they identify a potential problem or concern AS THIS IS THEIR INDIVIDUAL RESPONSIBILITY PER HOSPITAL POLICY.
😱 😱 😱 😱 😱
Here is an excerpt from a letter I recently received explaining the policy
Procedures that definitely require both marking and time out
Urgent/Nonemergent chest tubes
Thoracentesis
Lacerations when there are multiple lacs and only some are to be sutured ones to be sutured should be marked. This is straight from the JCAHO website
Gray areas that MIGHT require both marking and time out awaiting additional confirmation
POSSIBLY joint and fracture reductions such as shoulders/hips/elbows/ankles/fingers/toes - Jackie will discuss this with OR personnel, as there are obvious lesions with visible deformity that declare the site---also these procedures do not involve puncture/incision of skin, or insertion of foreign material into the body. We may HAVE to do this if the organization declares this as a surgical procedure involving laterality, but I am hopeful that the institution-wide interpretation of the policy allows us to exclude these for the reasons stated. We have to have one policy throughout the hospital, I would suppose---ie if a procedure is marked in the OR, the same procedure should be marked when it is done in the ED.
Joint aspiration, if no obvious wound/lesion exists - caveat: We dont aspirate normal looking joints. I have a feeling that JCAHO would not interpret a red/hot joint as an obvious wound or lesion and I havent been able to find any language that directly answers this question. I, for one, am happy interpreting a red/hot joint as obvious, thus excluding this from marking, until instructed to do otherwise.
Abscess incision and drainage (again, I will buy the obvious wound or lesion exception to marking)
Procedures that are EXCLUDED from marking, but REQUIRING time out
Emergent chest tubes
Laceration repair
Joint/fracture reduction (potentiallysee above)
Joint aspiration (see above)
Abscess I&D (see above)
Paracentesis
Teeth - this is the way it is listed in the JCAHO exception. I guess this would include dental blocks, abscess drainage, the rare extraction
Procedures that are EXCLUDED from marking and time out
Central line placement
Fiberoptic scope (duh!)
Anoscopy (double duh)
How this works .
For procedures requiring marking and time out:
1) Once a procedure is deemed to be necessary that falls under the policy to mark, the provider doing the procedure will take an indelible ink pen (which will be provided in the ED) and write yes at the site to be worked on. This is done while discussing the laterality with the patient, and obtaining their confirmation that you are marking the correct side. The yes must be visible once drapes are placed, if applicable. If the patient is incompetent to participate, or if they dont know what side they need the procedure on ---ie the pneumothorax that is relatively asymptomatic except for shortness of breath---the responsibility to mark the correct side falls completely on the practitioner, who must verify and confirm the xray findings at the time of marking.
2) In the event that you will never leave the bedside from the time the decision is made to do the procedure, through the consenting process, and until the completion of the procedure (highly unlikely that this would happen), you dont have to mark.
3) At the time immediately before the procedure is done, a time out will occur involving all members of the team doing the procedure. At this time, an out-loud, verbal confirmation of the five elements are required by the entire team involved---correct patient, correct side/site, correct procedure, correct position, correct xrays .
4) The time that the time out occurred will be documented by the nursing staff on a sticker that has been developed for this purpose.
5) Any member of the team is equally able and empowered to stop the procedure by expressing concern that something is wrong. At that point, the procedure must stop and the site/patient must be verified once again, until all members of the team are comfortable that the right thing is being done at the right place to the right person.
6) Even if the practitioner doing the procedure is the only person in the room with the patient at the time the procedure is done (ie laceration repair), the time out is still appropriate (ie REQUIRED) by JCAHO and must be documented either by filling out the sticker or listing that the time out was done in the dictation Marking must also be dictated, along with the level of participation by the patient/representative.
For procedures requiring time out only:
1) We are supposed to stop and take a breath and verify the five elements before proceeding. The policy does not state that the practitioner doing the procedure must document the exact time of the time out. That occurs in the nursing note when nurses are involved. I would just try to start incorporating into your dictation the statement A time out was taken per protocol immediately before the procedure was begun.
2) Even life threatening and emergent procedures require time out performance and documentation. Time outs should always be out loud when multiple staff members are involved. A silent time out is ok when there is only one practitioner in the room.
Again, there is now no applicable procedure, no matter how emergent, that allows us to be exempt from announcing a time out and verifying the five elements before proceeding. This is for everyones protection.
The nursing staff is to be trained to participate fully in the marking and time out process. They are also being asked to help remind us that this is now policy.
Anytime a staff member reminds a physician/practitioner that marking or time out is mandatory per policy, the practitioner will be expected to respond respectfully and comply with policy to assure patient safety. Likewise, if any team member brings up concern during a procedure, the practitioner must stop and verify the five elements until all team members are satisfied. All team members are responsible for speaking up if they identify a potential problem or concern AS THIS IS THEIR INDIVIDUAL RESPONSIBILITY PER HOSPITAL POLICY.
😱 😱 😱 😱 😱
