Univeral Protocol
Created to decrease the incidence of wrong site, wrong procedure, wrong patient surgery
What is the Universal Protocol?
Must be visible after prepping and draping?
What is the site marking?
Minimum required elements of a procedural Time Out
What are:
correct patient, correct site, correct procedure
Additional information included in WHO checklist: allergies, radiographs, blood or special equipment, sterilization indicators, antibiotic time, fire risk, beta blockers, warming modalities, SCDs?
Approved patient identifiers at University Health
What is name and date of birth or FIN (account number)
Pause
What everyone should do during the time out
Per the Joint Commission, the Universal Protocol is a ____ prior to the start of surgery or any invasive procedure?
What is a requirement?
Alternative site marking form
What to use if a patient refuses to have their surgical site marked?
(Provider must document refusal and place UH Alternative site marking form in patient chart when a refusal occurs) #90119
Personnel required to participate in the Time Out
Who is: surgeon, anesthesia, surgical techs, RN circulators, any ancillary staff that are in the room and involved in the procedure
A patient must be determined to have _____ in order to participate in the informed consent process.
What is capacity?
(Capacity is procedure, time, and situation specific and requires that the patient express a basic understanding of medical condition, proposed treatment/procedure, and risks/benefits of accepting/refusing treatment, state decision)
Situation where, in competent medical judgement, the proposed surgery, procedure, or medical treatment, are immediately and imminently necessary and any delay occasioned by an attempt to obtain consent would reasonably jeopardize the life, health, or limb of the person affected, or would reasonably result in disfigurement or impairment of faculties.
What is an emergency condition?
Components of the Universal Protocol.
What are:
Pre-procedure verification (sign in)
Site marking
Time-out
Debrief (sign out)-UH required
Surgeon or licensed independent practitioner
Who is approved to mark the site prior to surgery?
(Site marking may be delegated to a resident, APRN, or PA familiar with the patient and who will be present for the procedure.)
In addition to, "correct patient, procedure, and site", UH requires the Time Out to include? (minimum 3)
What are
allergies, imaging displayed, sterilization indicators, critical elements of the case, Beta Blocker, SCDs in place, warming needs addressed
H&P < 30 days or updated note
Anesthesia notes with plan of care
Signed, witnessed, dated, & legible surgical consent
What paperwork must be completed prior to transporting a patient to the operating room?
Tonsillectomy
Dental Extractions
Emergencies
What are procedures that do not require site marking prior to incision?
Does the patient have a difficult airway/aspiration risk?
Risk of > 500mL blood loss (7mL/kg in children)>
What are the 2 questions in the anesthesia safety checklist at University Heath?
UH approved method of marking the surgical site
What is the surgeon or licensed independent practitioner's initials?
Situation requiring a second time out to be performed in the OR.
What is a dual procedure involving two separate surgeons and/or teams?
(Block prior to procedure and procedures involving repositioned during surgery)
Location where you will find the Alternative Site Marking Form and University Health policy for Universal Protocol/Time Out.
What is Policy Medical?
(direct link for alternative site marking is in Universal Protocol and Time Out Policy)
What is site marking?
Elements of sign in or pre-procedure phase of Universal Protocol confirmed with patient (minimum 3) prior to the procedure
What are identity (dual identifiers), surgical procedure, surgical site, consent, allergies, anesthesia safety check completed,
If a patient arrives in an immobilization device or cast, it is not necessary to mark the site.
What is false?
You must perform a second time out
What must be done if the surgeon leaves the room before making incision after the Time Out is completed?
First step of any patient interaction
What is patient identification?
(confirmation of patient and date of birth (or FIN) -dual identifiers: both verbally and using the patient's armband)
What year did this facility officially become TMC Lakewood?