September 2019 HSC Section 1 Congenital and Pediatric Problems

Volume 44, No. 9, September 2018

final

recommendations, surgical population.

tailored

to

the

specific

needs

of

our

patient

identity

check,

final

procedure

confirmation,

of

site marking

in

field,

and

confirmation

of

visualization

administration

( Figure

1 ).

antibiotic

interdepartmental

electronic meetings,

correspondence,

Following

APPROACH This project

perioperative education,

leadership

and

periopera-

several

tive

team

the

enhanced pediatric Universal Pro-

was

conducted

at

Lucile

Packard

Children’s

tocol ment

was was

initiated. increased employees

Stakeholder

engagement

and

agree- both

Stanford,

a

freestanding,

311-bed

academic hospital

chil-

Hospital

through

active

championing

by

dren’s

hospital

in Northern California. The

has

7

who

are

members anesthesia,

of

the

periopera- perioperative

frontline

rooms

(ORs)

and

12

non-OR

settings,

such

as

operating

tive

QI

team

and

surgical,

and

rooms and providers

interventional

suites. The

ambulatory procedure

leaders.

To

increase

visibility

of

this

novel

compo-

nurse nent,

and

surgical

include

academic

faculty,

anesthesia

residents,

nurse

practitioners,

and

physician

assis-

large

posters were

displayed

in

each OR

and

in

each com- four

fellows,

chart

along

with

the

consent.

In-person

patient’s pliance weeks.

tants.

As

a

quaternary

care

trauma ICUs,

center

with

neonatal,

audits

were

performed

by

OR

nurses

over

and

cardiovascular

the surgical population from complex neonates

pediatric,

includes a diverse group of patients,

ambulatory

procedures

on

healthy Review quality

children.

The

Stan-

to

ford

University

Institutional

Board

approved

a

OUTCOMES Convenience

of

consent

for

this

improvement

(QI)

waiver project. The

audits of 60

safety

stop

and

time-out

compo-

perioperative

QI

team,

consisting

of physicians, accreditation

nents

of

the

enhanced Universal

Protocol were

completed

four weeks. Of

those

completed, 96.7%

(58/60) demon-

in

and

an

nurses, pharmacists, quality managers,

regulatory

compliance

specialist,

used

an

A3

project

strated

compliance perioperative

with

the

new

policy.

Verbal

feedback

and plan

9 Current

to

guide development of

a new process.

state

members

involved

was

unanimously

from

positive.

revealed

that had

the

time-out was

performed

after

the

analysis

the

subsequent

Joint Commission

accreditation

During

completed

all

induction

procedures

anesthesiologists

prior

to

P&D. This was

intentionally

done

to

ensure

the

enhanced

pediatric Universal

Protocol with

in-

and that the

survey, clusion

of

the

safety

stop

was

highlighted

by

The

Joint

the

correct

patient

and

surgical

site were

prepared

by of

as

a

leading practice.

Commission

circulating RNs. Unlike

an

adult,

the

operative field

pediatric

patient

is

relatively

smaller,

increasing

the

pos- body

a

10 Also,

sibility

of wrong-site

preparation.

due

to

the

KEY INSIGHTS QI methodology was

relative

to

the OR

table,

a

child’s

limbs

are

often

not

size

beyond

the

table

on

arm

boards,

which

further

used

to

optimize

the Universal

Pro-

extended reduces

11 Although

visual

cues

and

worsens

access

to

the

name

band with- could

tocol

for

pediatric

patients

at

our

institution.

P&D. Multiple

surgeons

were

concerned

that site

that

simply moving

the

time-out

from solu- P&D bod- table.

after

initially we believed

out

a

safety

check

prior

to

P&D,

the

wrong

to

P&D

to

just

prior

to

incision surgeons’

would

be

a

prior tion,

inadvertently

prepared,

which

could

lead

to

a

wrong-

further

analysis

revealed

concerns

of

be

site

or

wrong-patient

surgery

despite

a

time-out

prior

to

wrong being

site

or

wrong

patient

due

to

their

small

the ies

After

problem

analysis,

we

decided Protocol,

to

imple-

obscured

by

draping

on

a

typical

OR

incision.

ment safety

a

novel

adjunct

to

the Universal

called

the

the

Joint Commission

report

that wrong-site, wrong-

Given

stop .

procedure, wrong-patient ond most commonly

surgeries

continue

to

be

the

sec-

safety

stop would

occur

just

prior

to

patient P&D,

reported

sentinel event, developing an

The

the

time-out would be performed

just prior

to incision, circulating

to mitigate

the

risk of

these events was an

and

enhanced protocol

12 By

with WHO

recommendations.

The

for

the

development

of

the

safety

stop.

using

aligning OR nurse

impetus

initiated

the

safety

stop after

the anesthesiologists

team

approach

to

the

development

of

the

safety

stop, we

a

completed

all

induction

procedures.

This

time

point

the new process. The

had

achieved near perfect compliance with

in

the

chart

as

“anesthesia

ready.” Participants

audits

that were noncompliant were

associated with

an

was denoted

two OR with

the

safety

stop

included

all

personnel

in

the OR,

who

RN who

had

been

recently

hired

and was

unfamiliar

in

were

a

surgical

attending

or

fellow,

anesthesiol-

our

novel

process, which

reinforced

the

need

to

em-

typically

ogist,

circulating

RN,

and

surgical

scrub

technician.

Key

phasize

this

component

of

the Universal

Protocol

during

of

the

safety

stop

included

introduction

of

all

components personnel by

orientation.

name, readily

the

arm

band

patient

identifier

check

to

the Universal Protocol

that

are

applica- 7,8 Lee

Modifications

was

available

prior

to

P&D),

procedure expected

ble

for

the

pediatric

population

have

been

reported. performed

(which

against written administration,

consent,

site marking,

an

extended induction

surgical

time-out

prior con-

verification antibiotic

described

anticipated

postoperative

desti-

anesthesia

(in

addition incision)

to

the

time-out

to

nation,

and

fire

risk

( Figure

1 ).

The

time-out

included

a

ducted

immediately

before

and

showed

that

the

2