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"Time out" immediately before starting the procedure General Information Sheet JCAHO Requirements: A time out should be conducted in the room before the procedure/incision for any procedure where instruments will be inserted in to a body orifice or the integrity of the skin will be compromised. Pre-Procedure Time-Out Patient safety during invasive procedures is of utmost importance in the medical center. This includes pre-procedure protocols to help ensure that all members of a procedural team, including the patient if applicable and able, are in agreement as to what is to occur. This is known as a “Time-Out” and should be performed prior to the start of any invasive or consent-necessary procedure. This should be viewed as an integral final safety stop before a procedure is to begin. Invasive Procedure- any procedure requiring insertion of an instrument or device into the body through the skin or a body orifice for diagnosis or treatment. • All of these procedures should also require a written consent from the patient or surrogate Time-Out Protocol • All members of the team present during the procedure should participate and verbally acknowledge each component • Patient identity should be confirmed using a minimum of two identifiers • Procedure to be performed confirmed • Patient positioning verified • Procedure location, including correct side • Applicable pre-procedure medications, equipment, imaging set and confirmed • Time-out should be documented • If patient needs to be repositioned, procedure altered, or any other factor that leads in anyway to a gap in the planned procedure, a new Time-out should be performed • Protocol may be abbreviated or by-passed in emergent situations providing appropriate documentation of such Review the Checklist on the Following page. The checklist will be used for all appropriate procedures during training sessions and assessments. Procedural Skills Instruction Time-Out Checklist ASSESSORS: PLEASE DO NOT LEAVE ANY ITEM UNRATED All steps must be verbalized for all applicable procedures. Please rate the examinee on the following items: 1. Written consent from patient or surrogate obtained. 2. All team members participated in time out. (Must verbalize if specific procedure may involve more than one caregiver.) 3. Patient identity confirmed w/minimum of two identifiers. 4. Procedure to be performed confirmed. 5. Patient positioning verified. 6. Procedure location, including correct side (or side being di bpre-procedure li d i imedications, h l f equipment, i ) 7. Applicable imaging set and confirmed. 8. Time Out documented 9. If any change in plan – time-out is performed again. 10. If protocol is abbreviated or by-passed for an emergent i i i d i i id d ___Done __Not Done ___Done __Not Done ___Done __Not Done ___Done __Not Done ___Done __Not Done ___Done __Not Done ___Done __Not Done ___Done __Not Done ___Done __Not Done ___Done __Not Done ___N/A ___N/A ___N/A ___N/A Procedural Skills Instruction Arterial Blood Gas (ABG) Checklist ASSESSORS: PLEASE DO NOT LEAVE ANY ITEM UNRATED Please rate the examinee on the following items: 1. Washed hands. 2. Check that all necessary equipment is available and ready to use. 3. Perform “Time Out” immediately before beginning procedure 4. Put on examination gloves. ___Done __Not Done ___Done __Not Done __Correct Technique __Incorrect Technique ___Done __Not Done __Not Done 5. Identified location of radial artery (palpated pulse lateral to flexor i diand li demonstrate d Th the b steps inbthe Allen d i test” l i ) “Describe __Correct Technique __Incorrect Technique 6. Hold patient’s hand up and have patient clench and unclench hand l i the radial d i and bl ulnar d f arteries h hwhile d patient is 7. Compress clenching the d hand and have patient relax the arm and hand to 8. hLower alleviate i pressure hi h on the ulnar i (M for brisk b li ) 9. Release artery and lobserve return of l h potential d (M b li ) 10. “Describe results” Participant answer need not be verbatim but must be complete: “Positive Test: Color returns to hand in 14 seconds or less and procedure can be done; Negative Test: Color returns to hand in 15 seconds or greater and procedure must be aborted. Assess the other hand.” 11. Prepared area with alcohol wipe to simulate CHG (chlorhexidine gluconate) or idophor. Must state that solution stays on site for 2 minutes until dry before puncturing the skin. 12. Using a Heparinized syringe, removed residual air from syringe. F di b d A h dl i __Correct Technique __Correct Technique __Correct Technique __Correct Technique __Incorrect Technique __Incorrect Technique __Incorrect Technique __Incorrect Technique __Correct Response __Not Done __Not Done __Not Done __Not Done __Not Done __Incorrect Response __Correct Technique __Incorrect Technique __Not Done __Correct Technique __Incorrect Technique __Not Done 13. Palpated artery with index finger. of non-dominant hand __Correct proximal Technique (“ b adduct ”) l arm dand dorsiflex the wrist approximately 30o. 14. Slightly Inserted needle at a 60° angle to the skin and advanced to the __Correct artery with bevel side up. (This must be done proximal to Technique model) *Prompt participant to verbalize proper positioning. 15. Assessed for flashback of blood into the syringe, then allowed syringe to fill. (about 1 cc - assessor should tell examinee __Correct that a Technique smaller amount is sufficient for the purpose of the exam. Assessor may prompt for aspiration.) 16. Placed 2x2 gauze pad over puncture site and withdrew needle __Correct and Technique i N dl f d i i d 17. Upon SI’s question, “How long should pressure be applied ___Correct to puncture site?” Answered, “At least five minutes” or “Five Response Minutes.” 18. Slowly inverts the syringe 10 times, and then roll between __Correct palms Technique 19. In thei patient’s presence, labels the specimen and places in a __Correct biohazard bag. (NO ICE) Technique 20. Ask: “What must you do once the procedure is ___Correct completed?” Answer: “Document in the patient chart including location of Response puncture site, results of Allen test, and any complications”.” 21. Patient comfort was a priority. ___Yes __Incorrect Technique __Not Done __Incorrect Technique __Not Done __Incorrect Technique __Not Done __Incorrect Technique __Not Done ___Incorrect Response __Incorrect Technique __Incorrect Technique __Not Done __Not Done ___Incorrect Response ___No Procedural Skills Instruction Basic Airway #1: Bag-Valve-Mask Ventilation ASSESSORS: PLEASE DO NOT LEAVE ANY ITEM UNRATED Please rate the examinee on the following items: 1. Assessor Prompt: “What equipment should be set out and checked for the procedure?” Correct Response: “Oxygen, ambu bag, Oral & Nasal Airways, Suction, stethoscope.” 2. Washed Hands 3. Put on Gloves 4. Chooses appropriate sized mask and attaches to ambu bag.. 5. Checks patients’ mouth for foreign material and/or small or illfitting dental devices. (Good-fitting full dentures may be left in place to get a better seal.) 6. Oral or Nasal airways properly measured (Tip of lip to angle of jaw/Tip of nare to angle of jaw) and inserted. (If oral, curve up towards hard palate first, then rotated at soft palate - or used tongue blade; if nasal, lubricated generously and initially inserted with bevel tip toward the septum.) Ask: “When is a(n) oral/nasal airway used.” Answer: Indicates gag reflex uses nasal vs. no gag reflex uses oral. **Oral and Nasal Airways can be done in conjunction with BVM or as a separate task.** 7. Attaches Oxygen with tubing and adjusts regulator to at least 15 liters. 8. Head-tilt, Chin-lift performed. 9. Hand positioned– one-handed technique to fit and seal the bag against the face. (Proper hand placement: Thumb & Index finger on body of mask, 3rd & 4th digits on jawbone, 5th digit at the angle of the jaw. Little or NO pressure to the sub-mandibular soft tissue.) 10. Hand positioned– two-handed technique to fit and seal the bag against the face. Assessor should squeeze the bag for the participant. (Proper hand placements: Thumbs & Index fingers on body of mask, 3rd & 4th digits on jawbone, 5th digit at the angle of the jaw. Little or NO pressure to the sub-mandibular soft tissue.) 11. Assessor prompt “What needs to be checked now?” Correct Response: “Auscultation of chest.(By a second person)” __Correct Response __Incorrect Response __Done __Not Done __Done __Not Done __Correct Technique __Incorrect Technique __Not Done __Correct Technique __Incorrect Technique __Not Done __Correct Technique __Incorrect Technique __Not Done __Correct Technique __Correct Technique __Incorrect Technique __Incorrect Technique __Correct Technique __Incorrect Technique __Not Done __Correct Technique __Incorrect Technique __Not Done __Correct Response __Not Done __Not Done __Incorrect Response 12. Ask: “What must you do once the procedure is completed?” Answer: “Document in the patient chart.” __Correct Response __Incorrect Response Procedural Skills Instruction Basic Airway #2: Oxygen Delivery (NC, Simple Mask, NRB) Checklist ASSESSORS: PLEASE DO NOT LEAVE ANY ITEM UNRATED All Items MUST be done in the correct order per the checklist. Participant MUST verbalize full range of oxygen liter flow for each device. NASAL CANNULA 1. Connect end of tubing to Oxygen regulator (flowmeter). 2. Turn on Oxygen from 2 to 6 liters. (states range) 3. Place nasal cannula on patient w/prongs correctly placed in nares and tubing gently looped over ears. 4. Patient comfort was a priority. ___Not Done ___Not Done ___Done ___Done ___Correct Technique ___Incorrect Technique ___Yes ___Not Done ___No SIMPLE MASK 1. Connect end of tubing to Oxygen Regulator (flowmeter) 2. Turn on Oxygen from 6 to 12 liters. (states range) 3. Place mask over patients’ face and gently place l i comfort was d ah priority. b k f h h d 4. Patient ___Done ___Done ___Correct ___Incorrect Technique Technique ___Yes ___Not Done ___Not Done ___Not Done ___No NON-REBREATHER MASK 1. Connect end of tubing to Oxygen Regulator (flowmeter) 2. Turn on Oxygen to 12 -15 liters. (states range) ___Done ___Done ___Not Done ___Not Done 3. Place thumb over vent until reservoir bag is full. 4. Place mask over patients’ face and gently place l i comfort was d ah priority. b k f h h d 5. Patient ___Correct ___Incorrect Technique Technique ___Correct ___Incorrect Technique Technique ___Yes ___Not Done ___Not Done ___No Procedural Skills Instruction IV Insertion Checklist ASSESSORS: PLEASE DO NOT LEAVE ANY ITEM UNRATED Please rate the examinee on the following items: 1. Checked that all necessary equipment is available and prepared to use. 2. Washed hands 3. Perform “Time Out” immediately before beginning procedure 4. Put on gloves 5. Cleaned insertion point. Must use at least 3 wipes, as shown on the training video, for credit. 6. Applied tourniquet (may be done prior to cleaning if necessary to locate appropriate site.) 7. Inserted needle superficially with bevel side up; if blow-out occurred, removed needle and starts procedure over in a different vein with a clean needle 8. Removed tourniquet to release pressure in vein. 9. Using one finger to put pressure at the end of the catheter to stop blood flow, removed the needle. (If using needleless device, retracted needle first.) 10. Disposed of needle in Sharps container without recapping. 11. Attached IV tubing to hub of catheter and opened IV line to ensure proper flow of fluids. 12. Thoroughly secured cannula and tubing with tagaderm & tape. At least two pieces of tape must be used with the tagaderm for credit. 13. Labeled work with the minimum of initials, date, and size of needle. For credit, information must be recorded on piece of tape or on the tagaderm before it is placed on patients’ hand. 14. Used proper removal technique: removed tape, applied 2x2 gauze pad with pressure at removal point, disposed of cannula and attached one band-aid. Note: All steps required for credit; if any are missing or incorrect, item is to be marked “incorrect technique” 15. Placed biohazard materials in proper containers. ___Done __Not Done ___Done __Not Done __Correct Technique __Incorrect Technique ___Done __Correct Technique __Not Done __Incorrect Technique ___Done __Correct Technique __Not Done __Not Done __Not Done __Incorrect Technique ___Done __Not Done __Not Done __Correct Technique __Incorrect Technique __Not Done __Correct Technique __Incorrect Technique __Not Done __Done __Not Done __Correct Technique __Incorrect Technique __Not Done __Correct Technique __Incorrect Technique __Not Done __Correct Technique __Incorrect Technique __Not Done __Done __Not Done 16. Patient comfort was a priority 17. Ask: “What must you do once the procedure is completed?” Answer: “Document in the patient chart.” ___Yes ___No ___Correct Response ___Incorrect Response Procedural Skills Instruction Lumbar Puncture Checklist ASSESSORS: PLEASE DO NOT LEAVE ANY ITEM UNRATED Instruct the Examinee: You are permitted to re-adjust by retracting the needle to the subcutaneous tissue. If no fluid is present on the second attempt or if the needle is completely removed while trying to readjust the angle, you must begin process over at a new insertion site starting with sterilization. Please rate the examinee on the following items: 1. Wash Hands. 2. Checked that all necessary equipment is available and ready to use. 3. Perform “Time Out” immediately before beginning procedure 4. Put on Mask. 5. Identified correct puncture site (midline at L4-L5-S1. L4 is at the level of the iliac crest). 6. Open LP kit carefully to maintain sterility. 7. Open sterile glove package. 8. Put on sterile gloves maintaining sterile environment. 9. Prepped “skin” over proposed puncture site. ___Done ___Not Done ___Done ___Not Done ___Correct ___Incorrect Technique Technique ___Not Done ___Done ___Not Done ___Done ___Not Done ___Correct Technique ___Correct Technique ___Correct Technique ___Correct Technique ___Incorrect Technique ___Incorrect Technique ___Incorrect Technique ___Incorrect Technique ___Not Done ___Not Done ___Not Done ___Not Done 10. Place sterile drapes around site maintaining sterile environment. ___Correct ___Incorrect Technique Technique ___Not Done 11. Properly administered a local anesthetic. Must anesthetize four different tissue levels using smaller needle for initial levels and larger needle for deeper levels. ___Correct ___Incorrect Technique Technique ___Not Done 12. Verified proper fit of the stylette in the spinal needle. 13. Inserted the spinal needle with stylette into the puncture site w/bevel toward the iliac crest and at the proper angle. (10 degrees toward the umbilicus). 14. Advanced the needle into the subarachnoid space; if ___Done ___Not Done ___Correct ___Incorrect Technique Technique ___Not Done ___Correct ___Incorrect ___Not Done bony resistance was felt, backed needle out to the subcutaneous tissue, changed angle and re-advanced the needle. Ask: If boney tissue is felt, what would you do? Response should be as stated above. Technique Technique 15. Tested for presence of spinal fluid. Note: Credit given even if no fluid present. Ask: “How much fluid is collected?” Answer: “3 – 4 ml” 16. If no fluid seen, examinee states they would back needle out to the subcutaneous tissue, changed angle and re-advanced the needle. 17. Stylette placed into needle. Placed gauze over puncture site and removed needle. (Must use gauze every time needle is removed for credit and stylette MUST be reinserted into needle before removal.) 18. Disposed of needle assembly in Sharps container 19. Disposed of soiled or bloodied gauze into biohazard container. 20. When asked “What would you now advise the patient to do?” Correctly answered, “To stay supine/laying down flat for at least several hours.” 21. Ask: “What must you do once the procedure is completed?” Answer: “Document in the patient chart.” 22. Patient comfort was a priority. 23. Maintained sterility appropriately throughout the procedure. ___Correct ___Incorrect Technique Technique ___Not Done ___Correct ___Incorrect Technique Technique ___Not Done ___Correct ___Incorrect Technique Technique ___Not Done ___Done ___Not Done ___Done ___Not Done ___Correct Response ___Incorrect Response ____Correct Response ____Incorrect Response ___Yes ___No ____Done ___Not Done