Anna Prishchepova, MD
Mercy Hospital Saint Louis
Saint Louis, MO
Disclosure information not submitted.
Steven Trottier, MD, FCCM
Department Chairman
Mercy Hospital St. Louis, United States
Disclosure information not submitted.
Alice Edler, MD, MPH
Educational staff
Mercy Hospital Saint Louis, United States
Disclosure information not submitted.
Kimberly Fowler, BSN, RN
Clinical supervisor
Mercy Hospital Saint Louis, United States
Disclosure information not submitted.
Title: Is There Time for a Time-out? Improving Compliance with the Bedside Pre-procedural Time-out Process
Introduction: Bedside procedures are integral to the work flow of an Intensive Care Unit (ICU). The Joint Commission created the Universal Protocol in an attempt to eliminate wrong procedures through a pre-procedure verification process, site marking, and a “time-out”. Previous literature has demonstrated that improved compliance with procedural time-out process decreases adverse events and enhances patient safety. This project was aimed to improve staff compliance with performing the pre-procedural time-out for the non-emergent bedside procedures in the ICU.
Methods: In order to analyze the reasons for the noncompliance with the time-out process, an anonymous survey was distributed to all providers. The data on number of bedside procedures was collected from the web database where all providers are required to log them. This data was compared to the number of documented time-outs in the electronic medical record (EMR) flowsheets. The percentages of documented time-outs were compared before and after the interventions using one sample t test. These interventions included reminder emails, education on the EMR flowsheets, participation in nursing morning huddles, announcements during scheduled meetings and visual reminders in the common areas.
Results: Baseline survey demonstrated that there were multiple knowledge gaps leading to noncompliance with the time-out process for all provider levels. Consistent with our data, 71% of respondents reported preforming and documenting time-outs less than 50% of the time. The number of documented bedside procedures (intubations excluded) was similar before and after the interventions (368 vs 360, respectively). The number of documented time-outs improved from 46% (170/368) to 67% (241/360), a statistically significant difference (p< 0.001).
Conclusions: Hospital-based interventions used in this project successfully improved staff compliance with performing and documenting the time-out before bedside procedures in the ICU. Through the identification of specific gaps leading to noncompliance and integrating the time-out documentation into the EMR, this project enhanced the quality of bedside procedure process and therefore the quality of patient care.