Thursday, January 31, 2013

Layers of Nonsense

Wrong site surgery is never acceptable.  A surgeon ought never to find himself in a situation where he has to inform the family that he just operated on the wrong body part.  It is embarrassing, unprofessional, and an egregious violation of the patient/physician covenant. 

That being said, we have allowed this issue to be defined entirely in terms of "systems management".  And hence the rise of the Time-out and the Checklist.  The ultimate responsibility for identifying the proper surgical site has been diluted.  No longer is it at the sole discretion of the operating surgeon.  Now we have a Team-Based approach involving nurses, anesthesia personnel, mid level providers, and surgeons.   Performance of a group time out (of which I am actually a strong proponent) has quickly become the standard of care at most American hospitals prior to initial incision.

But the bureaucrats have taken a good idea and muddled it up in layers of unnecessary complexity.  The simple time-out has been expanded and diversified.  Now, for a routine elective surgery I am required to see the patient in the holding area for proper marking of the site (as applicable), to sign the H&P, and answer any questions the patient may have.  This is a standard protocol.  I have been doing exactly this same thing since I was a resident.  The next layer of the process occurs when the patient arrives in the OR.  This is called the "sign-in".  At this point we confirm that we have the right patient and are proposing to do the proper procedure.  Once the patient is asleep we then perform the official time out, which involves repeating the same facts already addressed at steps one and two.  Finally, once I have scrubbed in and am ready to commence the case, we have to all participate in the Pause.  In the Pause, I am supposed to repeat the same mindless data as in steps 1,2,and 3.   Then, and only then, am I allowed to take the scalpel and begin.

On the surface, the casual reader may be thinking to herself, "well if it improves patient safety, what's the big deal?  You doctors are so arrogant".  To that I would respond, "then why don't we make even more layers of screenings?  If four steps are better than one, then why shouldn't we be taking 8 or 10 mini-pauses prior to starting these cases?"  Why don't we take a pause before I move on from one step of a gallbladder removal to the next?  Why don't we make checklists for "when it's safe to put a clip on the cystic duct?"  The truth is that once you state the pertinent facts of an case , i.e. patient name, procedure, which side, proper antibiotic, etc, each subsequent oration of said facts devolves ever more obscurely into rote recitation, mumbled and mindless.  The fourth time we state the patient's name and procedure, no one is paying any attention.  Every one's guard is down.  We are fogged by a sense of false security.  We did our time out!  Now it's IMPOSSIBLE something bad could occur! 

No one seems to have considered the concept of the law of diminishing returns.  Repetition is sometimes harmful.  The surgeon may have marked the patient improperly to begin with.  I don't care if the team repeats the mindless mantra 50 times. If the initial evaluation was performed incorrectly, all the time-outs and pauses and huddles in the world will fail to salvage the patient from harm. 
My primary problem with the whole overly complicated, multi-tasked process is that it disperses ultimate responsibility from individuals and focuses too much on broad, systemic solutions.  For wrong site surgery, the ultimate responsibility lies with one person: the operating surgeon.  If he is so lackadaisical and irresponsible to the extent that he needs a team-based, multi-layered algorithmic approach to preventing wrong site surgeries, then he really has no business ever drawing a knife again.

It's about professional duty.  A surgeon who doesn't review his notes, who doesn't re-examine the patient in the holding area and mark the proper side himself, is a surgeon who is on the road to having his privileges permanently revoked.  Exempting surgeons from the consequences of unprofessional, negligent conduct only obscures the root cause of  the problem.        


Frank Drackman said...

I loved the early days of this, when it would turn into Abbot & Mostello...
"OK, its the Left Knee, Right"
"You mean Left?"
"Right, Left"
"The Left Knee?"
and by the time they'd be done the spinal had worn off...


Josh said...

Totally agree. Couldn't have said it better. Another problem: there are now people employed by hospitals whose sole jobs consist of advocating for and monitoring compliance of these types of protocols of questionable benefit. How can you hope to make a successful argument for the futility of a protocol when you are, in effect, showing hostility towards a person's professional identity and their livelihood. I've thought that a few times while watching surgeons argue to a brick wall otherwise known as something like the "OR Quality Initiative Compliance Supervisor Nurse".

Anonymous said...

Back in good old RSA I was asked to sign a register of attendance - and this whilst all the non professional staff were signing same, but with a significant proportion being less than truthful in their noting of times of arrival and departure. I refused to participate in this charade and was hounded by the authorities until I finally opted for retirement. Now, the big news locally is of doctors being fired for unprofessional conduct in not signing a register of attendance - yet it remains the same nefarious and poorly controlled tool of deceit for all the junior staff.

Anonymous said...

Each added pause gets as much attention as an ICU alarm.

Anonymous said...

Though I don't work in the OR, I have trained in these protocols. The question, is what are the statistics since these protocols were devised? Better? I will agree, they are highly irritating to follow, and seem a colossal waste of time. However, after I heard why they were instituted, they became easier to accept.

These were taken from airline safety studies, empowering all in the team to speak up when something is not right. Because they follow similar check lists, airline safety is now topnotch. Notice how you never hear of major crashes these days? In a hospital, the hope is to save the surgeon, much less everyone else dealing with a mistake,like the patient, a whole passel of trouble.