Neurosurgery is the third most vulnerable specialty to wrong-site/level surgery, behind orthopedic and general surgery. Research shows that operating room time-outs and surgical checklists improve safety outcomes, but most of that data comes from general surgery. What about neurosurgical time-outs?

In one study, researchers surveyed neurosurgical faculty, fellows, and residents across five hospitals and found that despite operating room time-outs becoming standard practice, there’s considerable variability in who leads time-out and when the time-out happens during neurosurgery.  While the World Health Organization’s guidelines allow for variation, nearly half of the study’s respondents still see the need for surgical checklists specifically tailored for neurosurgery.

Study of Operating Room Time-Out Reveals Wide Variation

Results from the survey were published in Neurosurgery with the intention of presenting current practices of neurosurgical time-outs, identifying variations among hospitals, uncovering neurosurgeon attitudes, and looking for areas for improvement.

A 15-item survey was emailed to all 51 clinical neurosurgery faculty, fellows and residents affiliated with a single, large, academic neurosurgery training program in the southwestern U.S. The hospitals included were a cancer center, children’s hospital, county hospital, private/university hospital and a veteran’s affairs hospital. The survey had a 72.5% response rate, and 78.3% of the respondents were male and 45.9% were attendings or fellows.

Most respondents believe time-outs make neurosurgery safer (97.2%) and that the process reduces the risk of wrong-side or wrong-level neurosurgery (94.6%). All of the hospitals required time-out before incision, but there was no consensus regarding the precise timing, either in policy or in practice.

Here are the results from the survey:

    • Who is most likely to lead time-out in neurosurgery?

At four hospitals, it was attending surgeons—at one, resident or fellow surgeons. Most respondents believe attending surgeons are responsible for ensuring a standardized process, followed by O.R. coordinators, hospital administrators and surgical accrediting bodies.

    • When should time-outs occur?
      • After the patient gets into the room, before anesthetizing (62.2%)
      • After positioning, before draping and prepping (13.5%)
      • After anesthetizing, before positioning (10.8%)
      • After prepping and draping, before incision (8.1%)
      • After positioning and prepping, before draping (5.4%)
    • When do neurosurgical time-outs actually occur? Here were the most frequent answers:
      • At Hospital 1, “after prepping and draping, before incision”
      • At Hospitals 2 and 4, “after the patient gets into the room, before anesthetizing”
      • At Hospital 3, a three-way tie between “after the patient gets into the room, before anesthetizing,” “after positioning, before prepping and draping” and “after prepping and draping, before incision”
      • At Hospital 5, “after anesthetizing, before positioning”
    • What are the barriers to implementing standardized time-outs?
      • Pragmatic challenges to efficient workflow (54.1%)
      • Individual beliefs and attitudes (54.1%)
      • Confusion about how to properly use the checklist (21.6%)
      • Others: diversity of operations and procedures, length and rigidity of time-out
      • No barriers to implementation (13.5%)

The respondents also noted what items they would like to see on a neuro-specific surgical checklist as part of time-outs. Responses included:

    • Positioning
    • Neuromonitoring
    • Systolic blood pressure parameters
    • Neurosurgery-specific drugs
    • Intracranial pressure parameters
    • Awake vs. asleep surgeries

How Neuro Checklists Can Reduce Surgical Errors

Given the high cost of medical malpractice claims, implementing customized time-outs in neurosurgery could help reduce surgical errors. Each year, 20% of practicing neurosurgeons in the U.S. are faced with medical malpractice litigation and the average payout is $439,146, the highest of all specialties. The majority of claims stem from spinal surgery, but payouts resulting from cranial surgery are generally higher.

Checklists are routinely used during surgical time-outs. Some hospitals have already modified these checklists so they’re tailored for various specialties. Clinicians at Children’s Hospital in Boston modified their surgical safety checklist for pediatrics and reported improvements in teamwork and communication.

At the University of Florida, clinicians implemented a best practice protocol, including a specialized checklist, for the placement external ventricular drains. Results of the multi-year study showed a quarterly decline in infections, ultimately dropping to 0%, compared to a 9.2% infection rate for the two quarters before implementation.

After the UCLA Health System customized its checklist for neurosurgery, they reported no wrong-side or wrong-level surgical errors in the operating room during the 18 months following implementation whereas in the three years prior to implementing a neuro-specific checklist, they had when one wrong-sided burr hole in an emergency case and one wrong-sided lumbar spine surgery. UCLA’s customization was to add two neurosurgery-specific items to the standardized checklist: the review of critical imaging and use of lasers, even if not used in all procedures.

The study authors note some potential neurosurgical-specific customizations to the time-out:

    • Conducting it prior to draping the patient’s head to help identify the correct level (versus immediately before incision as recommend by the Joint Commission’s universal protocol)
    • Considering blood pressure goals, medications for neuromonitoring, anticipated events including burst suppression and need to obtain and interpret localizing x-rays, among others.
    • Considerations for awake craniotomies re: communication in the OR and interactions with the patient in a headframe.

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