1. Universal Protocol Guide for Anesthesia Nerve Blocks
Mount Auburn Hospital
Department of Quality and Safety
Instructions:
To proceed through this tutorial mouse click on the blue forward > or back < navigation buttons.

2. Goals of this guide
This guide is designed to help all care providers (anesthesiologists, CRNA’s, and RN’s) who perform nerve blocks at Mount Auburn Hospital:
Understand the rationale behind the universal protocol
Correctly perform all of its elements

3. Contents Case example What is the universal protocol? Background
The impact of errors
What does the universal protocol include?
What procedures fall under the protocol
Pre-procedure verification
Site marking
The “time out”
Barriers
Take home points

4. How well do you know the universal protocol?
Please take this brief quiz
The answers will be discussed within this module
Disclaimer: The case described is a composite based upon cases in the public domain

5. Bob Jones’ knee replacement
Bob Jones is an 80 year old retired engineer with bilateral knee osteoarthritis. His right knee is more severely damaged and symptomatic. He meets with Dr. Smith, his orthopedic surgeon, and they agree upon the need for surgery.

6. Bob Jones’ knee replacement: In the holding room
The nurse in the holding room greets Mr. Jones and initiates the pre-operative verification checklist. Dr. Smith’s history and physical indicate that he plans to do a left knee replacement. The nurse checks with Mr. Jones who is fairly certain that he had agreed with Dr. Smith on a right knee replacement. The patient signed an informed consent for a right knee replacement.

7. Which of the following actions should now be initiated?
The nurse should assume the history and physical are incorrect and allow the patient to proceed into the OR
The nurse should notify Dr. Smith of the discrepancies
Dr. Smith should review his notes and the films, and re-confirm the decision with the patient
Dr. Smith should insert a correction into the H & P with his signature, date and time
b, c, and d

8. Which of the following actions should now be initiated?
The nurse should assume the history and physical are incorrect and allow the patient to proceed into the OR
The nurse should notify Dr. Smith of the discrepancies
Dr. Smith should review his notes and the films, and re-confirm the decision with the patient
Dr. Smith should insert a correction into the H & P with his signature, date and time
b, c, and d

9. Bob Jones knee replacement: In the holding room
Dr. Smith reviews his notes and the films, and re-confirms with Mr. Jones the plan for right knee replacement. He marks his initials on the patient’s right mid-tibia with an arrow pointing upward toward the right knee. He then marks “No” on the left knee.

10. Which of the following actions should now be initiated?
No action need be taken
The markings on the right tibia and left knee should be scrubbed off
Dr. Smith should re-mark the right knee, “Yes”
Dr. Smith should re-mark his initials directly at the incision site on the right side only
b and d

11. Which of the following actions should now be initiated?
No action need be taken
The markings on the right tibia and left knee should be scrubbed off
Dr. Smith should re-mark the right knee, “Yes”
Dr. Smith should re-mark his initials directly at the incision site on the right side only
b and d

12. Bob Jones’ Knee Replacement: Holding Room, cont’d
The anesthesiologist verifies that Dr. Smith has correctly marked the surgical site, and proceeds to site mark for the nerve block. Where should the site mark for the nerve block be placed? a) at the surgical site, directly above the surgeon’s initials b) anywhere on the operative extremity c) at the nerve block site, so that the mark is visible after prepping and draping

13. Bob Jones’ Knee Replacement: Holding Room, cont’d
The anesthesiologist verifies that Dr. Smith has correctly marked the surgical site, and proceeds to site mark for the nerve block. Where should the site mark for the nerve block be placed? a) at the surgical site, directly above the surgeon’s initials b) anywhere on the operative extremity c) at the nerve block site, so that the mark is visible after prepping and draping

14. Bob Jones knee replacement: In the operating room
Mr. Jones is brought into the OR. The OR is set up for a left knee replacement. The circulator nurse verifies the patient’s identification with the anesthesiologist after which Mr. Jones is given general anesthesia. His blood pressure drops moderately below his baseline.

15. Bob Jones knee replacement: In the operating room
Dr. Smith enters the OR and begins to prep and drape the left knee. His favorite music is playing on the radio. The scrub technician is not yet in the room. The circulating nurse is at the computer with her back to the patient. She initiates the “time out” stating the patient’s name, planned procedure, site, position and equipment present. Dr. Smith makes his incision in the left knee.
When Mr. Jones’ BP stabilizes, the anesthesiologist looks up and questions which knee is being replaced.

16. Which elements of the “time out” were performed incorrectly?
The “time out” was not initiated by the surgeon
The entire team was not present
The stated procedure was not cross-checked with the informed consent
The site marking was not visualized and verbally confirmed by the team
a, b, c, and d
b, c, and d

17. Which elements of the “time out” were performed incorrectly?
The “time out” was not initiated by the surgeon
The entire team was not present
The stated procedure was not cross-checked with the informed consent
The site marking was not visualized and verbally confirmed by the team
a, b, c, and d
b, c, and d

18. What is the universal protocol?
Guidelines to assure that the correct surgery and invasive procedures are done on the correct person, on the correct side and site
These guidelines apply to invasive procedures anywhere in the hospital

19. Background
The universal protocol was developed by the Joint Commission on Accreditation of Healthcare Organizations (TJC) in 2003 in collaboration with numerous professional organizations
Effective July 1, 2004, compliance with the protocol has been required of all TJC
accredited institutions

20. Background
126 wrong-site surgery cases were reported to The Joint Commission in Root cause analyses found the following:
By specialty:
Orthopedic/podiatric: 41% of cases
General surgery: %
Neurosurgery: %
Urologic surgery: %
The rest were dental/oral maxillofacial, cardiovascular-thoracic, ear-nose-throat, and ophthalmologic surgery
Wrong body part or site:
76% of cases
Wrong patient:
13% of cases
Wrong procedure:
11% of cases

21. Background
Factors contributing to increased risk for wrong-site surgery/procedures:
Emergency procedure
Unusual physical characteristics (morbid obesity, physical deformity)
Unusual time pressures to begin or complete procedure
Unusual equipment or set-up in the OR
Multiple surgeons involved in the case
Multiple procedures being performed during a single surgical visit

22. Background
CRICO experience: analysis of 40 cases of wrong-site surgery
Data from malpractice claims and surgical loss observations
38% (15 cases) wrong vertebral level or
wrong-side laminectomy of the spine
62% (25 cases) non-spine
12 wrong side
12 wrong site – no laterality, 8 involving multiple structures, 4 involving multiple lesions
1 wrong patient
Kwaan MR, et al. Arch Surg.2005;141:

23. What does the universal protocol include?
The protocol includes 3 steps:
Pre-procedure verification to confirm correct
Patient
Procedure
Site/side
Site marking
“Time out” immediately before beginning the procedure

24. What procedures fall under the universal protocol guidelines?
Any invasive procedure that involves puncture or incision of the skin, insertion of an instrument, or foreign materials
Not included under the protocol are routine procedures such as venipuncture, placement of simple IV’s, NG tubes, and Foley catheters

25. Pre-procedure verification
What: A process to ensure that the correct patient is undergoing the correct procedure, including procedure site (and side, if applicable)
When: This step begins with the decision to do the procedure and continues through all settings and interventions in the pre-op preparation of the patient, up to and including the “time out.”

26. Pre-Procedure Verification Components-Patient Identification
Assuring correct patient identification includes:
Any two of the following unique patient identifiers:
Name, date of birth, medical record number, or account number.
Patient stating name and date of birth, when possible.
Active confirmation of two identifiers to the patient’s name band.
Verification of the patient name and unique identifier to the surgical consent (if available) or OR schedule (if surgical consent is not available)

27. Pre-procedure verification components-Documentation Review
Comparison of all relevant documents and studies to ensure that
Surgical consent, Anesthesia consent, OR schedule all available
Have been reviewed
Are consistent with each other
Are consistent with the patient’s and team’s understanding of the intended procedure and site

28. Site marking essentials for Anesthesia
Mark all cases involving:
Right or left laterality
Multiple levels (neuraxial or pain procedures involving multiple spinal levels)
The person performing the procedure should do the site marking
The mark must be:
Unambiguous (initials only)
On the exact anesthesia block site only, after verification of correct surgical site marking
Visible after patient is prepped and draped

29. Site marking essentials
When?
Before the patient is sedated to the point at which s/he cannot be meaningfully involved
Patient involvement
The marking should occur with patient involvement
If the patient is unable to participate, whoever has authority to provide informed consent should participate

30. Site marking examples (1)
Left wrist ganglion
PIP joint

31. Site marking examples (2)
Left hernia
Right shoulder

32. Site marking examples (3)
Right elbow
Right hip

33. Site marking examples (4)
L4 laminectomy
Left eye surgery

34. Anesthesia Nerve Block Marking Example
Anesthesiologist’s initials (RW)
At exact block site
After verification of surgical site marking
Visible after prep/draping

35. Site marking examples: Correct or incorrect?
Left 4th distal interphalangeal joint

36. Site marking examples: Correct or incorrect?
Left 4th distal interphalangeal joint
Incorrect
Correct

37. The “time out” What: A pause to verify that
Patient identification has been confirmed
Surgeon’s articulation, prior to surgical incision, that procedure, site and side agree with informed consent
Anesthesiologist’s articulation, prior to nerve block, that block procedure, site, and side agree with informed consent
Both surgeon’s and anesthesiologist’s site markings are clearly visible
Necessary equipment to perform procedure is at bedside
When: Immediately before starting the procedure or nerve block
Where: In the location where the procedure or nerve block is to be done

38. The “time out”
Who:
The “time out” must involve the entire team that will be present during the nerve block procedure or at surgical incision
At Mount Auburn Hospital, the surgeon initiates the OR “time out”
Additional team members may participate in the procedure but must also participate in the entire process, beginning with the “time out.”
Unanimous agreement among the team that all questions or concerns are resolved is required in order for the case to begin

39. The “time out” The “time out” is a conversation, not a checklist
It is a time when each person who has responsibility for the outcomes of a procedure takes a moment to reflect on whether every aspect of the protocol has been followed, and the chance of error minimized
The “time out” is the team’s final fail-safe prior to the nerve block or surgical procedure

40. Video: The “time out” at Mount Auburn
Video Instructions: Turn computer speaker and volume ON and mouse click on the embedded video below to play.
If you are outside the hospital or cannot play the embedded video click on the link to the video stream below or from the Physician Education webpage.
Click Here for Video Stream of the "Time Out" at Mount Auburn

41. Barriers It won’t happen to me One more external regulation
It could and has happened to competent, vigilant practitioners
One more external regulation
Maybe so, but it might protect you and the patient
Someone else’s responsibility to initiate
It’s yours and everyone’s
“I must be mistaken, it’s probably ok”
If you’re uneasy, speak up

42. Pre-Procedure Verification Take homes
Pre-procedure verification ensures that the correct patient is receiving the correct procedure on the correct site and side.
The purpose of pre-procedure verification is to ensure that all relevant documents and studies
Are available
Have been reviewed
Are consistent with each other
Are consistent with the patient’s and team’s understanding of the intended procedure and site

43. Pre-Procedure Verification Take homes
If inconsistencies are noted during the pre-procedure verification process, the procedure site and side should be
Verified by the surgeon and patient
The verified site/side should be correctly and consistently documented, and
Correctly communicated to the staff setting up the OR room, implants, and equipment

44. Site Marking Take homes
The nerve block site should be marked
With the anesthesiologist’s initials only
By the person performing the procedure
With the patient’s (or surrogate’s) involvement
Directly over the nerve block site, following verification of correct surgical site marking
Visible after draping
Do not:
Use “Yes” or “No”
Mark the non-operative site

45. Time Out Take homes The “time out”
Is initiated by the anesthesiologist for nerve block and surgeon for surgical procedure
Must take place with the entire team present immediately before the planned procedure
Includes verification that
Patient identification has been confirmed
Anesthesiologist’s and surgeon’s articulation that procedure, site and laterality agree with both informed consents and OR schedule
Both surgeon’s and anesthesiologist’s site markings are clearly visible
Correct equipment/implants is/are immediately available

46. Verification of Training
Please complete the brief online verification of training using the link on the Physician Education page or click here:
Universal Protocol Online Quiz

47. Credits Teaching module: Videographer: Technical Support:
Created by Susan Abookire, MD, Yvonne Cheung, MD, Beth Lown, MD and G. Tracey Phillips, RN.
Videographer:
Gary Goldsmith, MD
Time Out players:
Rowland Wu, MD
Leslie Schneiderhan, RN, CNS
Nancy Masoian, RN
Technical Support:
Al Ghilardi, Orthopedic First Assistant
Special Thanks To:
J. Michael Haering, MD
Mary Jo Sharkey, RN

48. Questions?
Contact the Mount Auburn Hospital Department of Quality and Safety
Extension: 5073
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