psn article

JCHAO Calls Time-Out for Plastic Surgeons


The JCAHO Universal Protocol For Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery,  becomes effective July 1, 2004. The adoption of the "time-out" or "huddle" technique, where the surgical team participates in a structured, documented review of the impending procedure, is the Protocol's third step.  In taking a moment for preoperative review, the identity of the patient is confirmed, as is the location on the body of the planned procedure.  If possible, the patient is communicated with.  The presence of all necessary equipment, devices and implements is confirmed. All present and participating parties acknowledge the correctness of the review and express any observations or comments at this time, and then the operation proceeds.  Some institutions have computerized the documentation of this perioperative ritual.


This focus on preventing Wrong-Site surgery can be traced back to the report released by the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry, released in 1998, and the Institute of Medicine's subsequent report, To Err Is Human:Building A Safer Health System, released in 1999. While the accuracy of the statistics contained in these two documents have been called into question,  the concerns they have both reflected and generated cannot be denied.  Medical associations across the country are signing up for or initiating programs to ensure their members take appropriate steps to reduce or eliminate the conditions that encourage errors of all types, including the delivery of improper medications, incomplete or switched documentation and errors in post-operative care.  There is  good reason for this increased attention beyond the desire to practice better medicine;  one website that encourages malpractice lawsuits  states " ..cases of such surgeries are thought to be on the rise in America". Clearly, more than doctors and patients are interested in this issue.     


The Protocols  are a direct result of these studies, and the JCAHO considers some form of time-out mandatory. According to the FAQ to the Protocol," the 'time out', or immediate preoperative pause, must occur in the location where the operation is to be done" and must involve the entire surgical team, including the nurse and anesthesiologist.  As the ASPS has endorsed these protocols, the requirements carry some teeth - members are obligated to perform any invasive surgery in JCAHO-certified facilities and failure to follow the guidelines could carry the risk of loss of facility accreditation. The requirements should come as no shock- ASPS members are assumed to be following the nearly identical National Patient Safety Goal guidelines that the Protocol supercedes. But questions remain as to how common wrong-site surgery is  among plastic surgeons and how they will react to mandatory rules on operating-room behavior.


One Medical Director at an east-coast hospital stated in an on-line memo, "Most surgeons, when first hearing of this requirement, are resistant to the process." Most plastic surgeons, like all surgeons, have adopted their own pre-operating procedures. Adding to the discussion is that fact that the risk of wrong-site surgery is often not seen as a big problem in plastic surgery.



In the opinion of Dr. Jana Cole, Board-certified plastic surgeon and Assistant Professor at the University of Washington School of Medicine, the nature of  plastic surgery itself and the long-developed practices of the specialty have traditionally provided a measure of safety, even before the introduction of the guidelines. "We routinely see our patients before the surgery. Marking is a big part of the surgery itself.", she says, "I wouldn't say that seeing the patient beforehand is unique to plastic surgery, but it's something we strongly emphasize."  The opportunity to discuss the upcoming operation with the patient is another important safely valve. "It's not like the first time we see them that day is when they're asleep in the operating room., as she puts it. Still, she utilizes the formal time-out protocol, including marking the sight and then receiving confirmation by the circulating nurse. "Personally, it does not change our routine at all, as plastic surgeons", she says about the new guidelines, "because we were pretty much following the guidelines they were recommending (already)," adding that the only new requirement is the signing of the operative site by the surgeon.  


 Although the risk run by plastic surgeons of performing the wrong-site surgery that a "time-out" is supposed to help prevent  obviously varies according to specialty, it does exist.  Nineteen percent of plastic surgeons surveyed by Meinburg and Stern in Incidence of Wrong-Site Surgery Among Hand Surgeons, published in the Feb. 1, 2003 Journal of Bone and Joint Surgery, reported that they had prepared at least once to operate on the wrong hand but noticed their error in time. The report states "No significant difference was noted among the specialties" in terms of incidents of wrong-site surgeries.  Caseload was the main factor found to influence incidence, which in turn is tied to a doctor's age and time in practice. The study notes that 'the risk of performing wrong-site surgery may be higher for hand surgeons  than it is for surgeons whose practices focus on paired structures." 


   The most popular cosmetic surgeries- liposuction, breast augmentation and eyelid surgery- either involve paired structures or present fewer risks of misidentification due to the nature of the surgery itself.  "In plastic surgery, we don't do cookie-cutter operations", according to Dr. Jay Pensler, a Chicago plastic surgeon. " If we are putting in breast implants, they are often filled to different volumes.  If I do a rhinoplasty, sometimes the cartilages are asymmetric.  I'll have to take a little more off one side than the other." Multiple-site liposuction is a good example of a procedure that can present a plastic surgeon with problems. "We always mark everything out preoperatively", says Dr. Pensler. "You don't want someone waking up expecting to have their hips, thighs and abdomen done and finding out only the hips and thighs were operated on. " At Northwestern Memorial Hospital,  he  explained, procedures such as preoperative marking and nurses discussing the planned operation with the patient before they are anesthetized have been in place for some time.  Still, he expresses enthusiasm for the new protocols.


    Plastic surgeons run a reduced but real risk of performing wrong-site surgery and can benefit from a preoperative time-out. Flexibility in order to "meet specific patient needs" is built into the Protocol, and, faced with a unique set of challenges,  plastic surgeons have for the most part developed their own techniques tailored to the requirements of the specialty.  That these largely dovetail with the new guidelines should not be a surprise.