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“Actually, providers found it cumbersome to switch between an electronic consent document and a manual time-out process. They wanted both processes to be electronic,” notes Wrana. Using an automated informed-consent AICA, iMedConsent application

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from Dialog Medical, VABHS staff built an electronic time-out checklist based on Universal Protocol guide- lines and integrated it with the institution’s electronic health record. “As it happened, the GI service already was testing use of portable laptop carts to complete the informed consent electronically,” Wrana states. “Those carts were easily confi gured with the new checklist and the elec- tronic signature pads required to support an automated time-out process. The new system therefore centered on GI services at VABHS.” Staff at PVAMC also saw a benefi t in performing both consent and time-out electronically – especially in the clinic setting, where minutes often separate a patient’s authorization to undergo a procedure and its accomplish- ment, according to Janet Pouliot, clinical application coordinator for PVAMC. PVAMC subsequently adopted the VABHS electronic mechanism across several outpa- tient sub-specialty clinics, using either rolling laptop carts or desktop terminals with electronic signature pads. The electronic time-out requires both providers and patients to provide verbal confi rmation. In addition, to enhance compliance with the entire time-out concept, the electronic checklist has been constructed so that providers must progress sequentially.

Strict information process

“They cannot skip any elements, as may be possible with a paper-based process,” explains Elise Chapman, charge nurse for PVAMC Specialty Clinics. “All infor- mation must be completed before the next step in the process will be displayed on-screen. Should providers need to edit responses, a drop-down box provides the opportunity to do so, as long as the checklist has not yet been signed.”

The combination of these two factors now results in a process that requires: all key members of the procedure team to agree on the procedure to be performed, as well as the site and the patient’s identity; and the patient to provide full name and Social Security number, as well as a description of the expected procedure and proce- dure site.

The names of the provider and a staff witness are typed into the time-out document, and the signatures of both are collected via an electronic signature pad. Thus, staff knows who was involved in the process, even when the signatures themselves are not legible.

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Once the checklist is completed, it is automatically ap- pended to the patient’s record. The information is avail- able immediately, without risk of being lost or misplaced. In 2009, 5,735 time-out procedures were documented electronically at PVAMC using the AICA. As with any IT process, one of the largest drawbacks to automating the time-out process involves the availability of necessary computer hardware at the point of service. Rolling laptop carts or desktop terminals with signature pads are required, Wrana points out.

The electronic process also takes a few extra minutes to complete. Providers must bring up the checklist on the computer and check off each element, in contrast to completing a handwritten time-out checklist. From a compliance standpoint, however, providers recognize the value of ensuring that an entirely legible document exists to prove that all aspects of the time-out were appropriately completed – and even agreed upon by the patient, says Pouliot. They also appreciate that both informed-consent and time-out documentation are standardized, readily available, and easily tracked in the patient record, she says.

As with any IT process, one of the largest drawbacks to automating the time-out process involves the availability of necessary computer hardware at the point of service.

Obtaining buy-in for the electronic time-out was a team effort at both VABHS and PVAMC. Implementa- tion was facilitated by both organizations working closely with providers to create, test and implement the elec- tronic informed-consent process before the electronic time-out process, which utilizes a similar procedure. Asking for provider input, identifying “super users” and clinical trainers, and gaining support from service chiefs and the chief of staff all were essential components of the earlier implementation. PVAMC fi rst tested the electronic time-out in a few surgical specialty clinics before gradually rolling out fur- ther over the course of about a year. VABHS plans to take the process outside of GI services later this year. By adopting an electronic approach to the time-out process, VABHS and PVAMC now ensure that every step in the time-out is completed; all key providers acknowledge their participation via the capture of their digitized signatures; and comprehensive documentation of the completed time-out is stored in the electronic health record. As a result, the risk of a wrong-site/ wrong-procedure/wrong-patient surgery is signifi cantly decreased.

HMT

HEALTH MANAGEMENT TECHNOLOGY

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