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The Resus “Time Out!”

“Time Outs” have been used in the operating theatre for many years. They are designed as an error reduction method, whereby everyone in the theatre stops what they are doing whilst a checklist is run through, ensuring that the correct procedure is being carried out, on the correct patient, by the correct people with the correct equipment.

Checklists like this have been shown to reduce error rates in surgical cases, so I’ve wondered for a while if a resus time out could be implemented for a similar purpose.  Obviously stopping during CPR to do a checklist is not feasible, but at certain times during a resus it may be possible to at least pause, do a stocktake, run through a brief checklist to ensure critical steps have not been overlooked, and to communicate the forward plan to the team.

Checklists are making their way into critical care medicine, for example there are now different intubation checklists available to assist with planning for, and executing intubation. You can see examples of these here, here, here and here.

Cliff Reid talked about the Resus Room Safety Officer in a recent post on Resus.me, which is more of a real-time, dynamic concept, whereby a nominated staff member, separate to the team leader, oversees the resus with a checklist that ensures critical elements are not missed. I wonder if a “time out” approach may be utilized to stop, focus everyone’s attention, ensuring that critical steps have not been missed and to ensure that the group is aware of the current status of the patient and the forward plan.  A downside of a time-out is that there may not be an appropriate time for everyone to stop and listen, and getting everyone’s attention could be hard, however they manage to stop surgeons in their tracks in theatre with time-outs, and once established in the culture of your resus room, it may not be as hard.

Here’s a very basic example of a resus time-out checklist, designed to ensure the really critical steps are covered. It doesn’t go into specifics, but acts more as a prompt, which allows staff to use their experience to make specific choices about how they like to do things.

Resus Time Out Checklist

It only takes 1-2 minutes to run through this list, and it could be done at set times, such as post intubation, upon return of spontaneous circulation, or prior to transfer to ICU, Theatre or Radiology.

This is a simplified form of resuscitation decision support.  Computerised decision support algorithms have been implemented at major trauma centers such as the Alfred Hospital in Melbourne, which uses software created by the Trauma Reception and Resuscitation project,  This system was designed based on data showing that most errors in trauma resus were simple errors of omission, rather than active mistakes made by clinicans.  Obviously the infrastructure required to implement this sort if system is out of reach of most public hospitals in Australia, but a more simple, human operated checklist system may still help reduce error in resus.

What do you think about resus time outs? Do you think it’s feasible, or would it just add more confusion to an already busy environment? Feel free to comment on, make suggestions, add or delete items from the checklist, it’s a version 1.0 draft that I’d like your comments on.

9 Responses to The Resus “Time Out!”

  1. Michael Eddie February 13, 2013 at 12:13 pm #

    Another great article! Many of the aircrew checklists are designed to be challenge / response… Could this checklist be rewritten in this format?

    • Andy Buck February 13, 2013 at 5:01 pm #

      Absolutely could be rewritten, was wondering about optimal checklist format while I was writing it, will look into it & update.

  2. Tim Leeuwenburg February 13, 2013 at 10:34 pm #

    Like it

    Challenge-response is the way to go – otherwise key steps are skipped over

    Example recently – Weingart has put up an intubation checklist on emcrit.org. It includes a lot of detail, but to my mind is more like a ‘mind map’ aide memoire than a true challenge-response checklist

    Ideally the reading of checklist can be delegated to least expienced, whilst the more experienced ‘do their thing’

    So need to be ale to flatten communication with challenge-response and avoid checklists which rely heavily on jargon

  3. Reuben Griscti February 18, 2013 at 12:20 am #

    Excellent idea! Alternatively the intubating assistant (eg ODP, Outreach Nurse, Senior ED Nurse) could go through the list instead of doctors if the latter are busy – I guess it is up to the Leader to allocate roles.

    A few other suggestions if I may:

    Wave-form capnography or alternative : reinforcing NAP4 findings
    Confirmation of ET tube length at incisors
    Consideration of Tranexamic Acid – we’re not always as good as we could & should be at remembering/administering anti-fibrinolytic therapy in uncontrollable haemorrhage

  4. Andy Buck February 18, 2013 at 8:31 am #

    Thanks Reuben. Yes, the checklist could be administered by an RN or other non-doctor person. I like the additional suggestions too and will try and incorporate them into version 2.0!

  5. will sargent March 21, 2013 at 10:01 pm #

    About to introduce an RSI checklist. I used this in SIM sessions the other day. In fact, the nurse educator introduced the idea , and then as the scribe in the scenario, we paused, and he just read through the airway registry checklist. Flowed really well.


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