A Time-Out Before Every ECT Procedure
It is with great interest that we read the commentary by Watts,1 “A Time-Out Before Every ECT Treatment,” who advocates that this surgical standard be adopted routinely before every ECT treatment to improve safety, reducing the risk of error. In our local health district, the universal protocol for preventing wrong site, wrong procedure, and wrong person is governed by Policy Directive—Clinical Procedure Safety.2 We adopted this procedure in our services many years ago. It is now part of routine clinical practice conducted before every treatment to improve safety and reduce errors in the administration of ECT.
In our service, time-out occurs on 3 occasions: following the patient’s admission to the theater complex, entry into the operating theater, and before treatment is administrated.
The admissions nurse asks the patient, his/her name, allergies, and date of birth and compares the information to the medical record. The nurse then checks that the surgical alert band is attached to his/her limbs (arm and leg), and the correct information is recorded including his/her medical record number. Further inquiry determines whether the patient has complied with nil-by-mouth fasting since midnight except for important medications that must be taken before the treatment, including antihypertensive and antinausea agents. Other questions include whether the patient has voided before the procedure and whether he/she has any adverse events from the previous treatment. This information is then passed onto the treating team. Voluntary patient is then asked whether he/she is aware of the procedure and freely consents to proceed with ECT.
The ECT coordinator completes a second time-out when the patient arrives in the operating theater. The patient is introduced to the treating team. After the setup has occurred, the ECT coordinator checks that all members of the ECT team are present, including the treating psychiatrist, ECT coordinator, anesthetist, and anesthetic nurse. The ECT coordinator checks the medical record, and another member of the team checks the surgical alert band on the patient’s limb. Together they confirm the medical record number, the date of birth, the name of the patient, and whether the patient has any allergies. As noted in the article, we go on to check the anesthetic doses and combinations of agents used, the electrode placement, and stimulant parameters on the device including the dosage and pulse width and ensure that the impedance is within normal limits.
Anesthesia is then commenced with induction and injection of suxamethonium. The time is measured from the administration of the suxamethonium to the treatment delivered, usually between 90 and 120 seconds.
The third time-out occurs immediately before treatment is administered. The treating team recites the following: “Sux away, chocks away, cross check and arm, fire away!” “Sux away” checks the suxamethonium given and absent deep tendon knee reflex. “Chocks away” ensures that bite block has been inserted with adequate support of the chin. “Cross check and arm” ensures that all parameters on the ECT device are set correctly and that the patient does not respond to the command “move the right foot.” This command ensures that the anesthetist has dosed the induction agents adequately by the routine use of the isolated limb technique. We aim to administer the least amount of anesthetic agents to ensure an optimal seizure. Impedance is then routinely checked. “Fire away” refers to the green light that all systems are checked and ready to treatment.
We agree with the author that the use of a cognitive aid or checklist to guide the time-out procedure is recommended. We agree with the author’s conclusion that time-out is a quick, simple, and low-cost intervention that improves the safety of ECT.