Memorial Healthcare Rolls Out New Protocol to Eliminate Wrong-Site Nerve Blocks

Hospital Boosts Customer Satisfaction Scores and Surgeon Confidence with Two Simple Steps

By Megan Headley

Wrong-site nerve blocks are considered never events. Evidence indicates that this is not actually the case. A 2015 article in Current Opinion in Anesthesiology puts its best guess of the frequency of wrong-site blocks as 7.5 per 10,000 procedures. A 2018 review of publications reporting on at least 10,000 blocks found a rate of 0.52 to 5.07 wrong-site nerve blocks per 10,000 blocks, unilateral blocks, or “at-risk” procedures.

Adam Blomberg, MD, Memorial Healthcare System’s chief of anesthesiology, and regional medical director at Envision Physician Services and national education director for Envision’s anesthesiology division, sees several reasons why, if protocols remain unchanged, wrong-site and wrong-side nerve blocks are likely to continue:

1. Nerve block frequency is increasing. Anesthesiologists are moving away from opioid-based anesthetics and more toward multimodal anesthetics, as evidence shows that regional anesthetics help people wake up quicker, have less nausea and vomiting, they are more easily able to get back to their normal routine
2. The efficiency push is increasing in both the operating room and pre-operating space. In the past, healthcare workers might have had a few hours with the patient prior to the operation; now that window is shrinking. With patient satisfaction metrics in play, hospitals are looking to ensure that patients are spending less time sitting in a stretcher before their surgery.

These two trends are driving a trend in the wrong direction, toward more wrong-side/wrong-site blocks nationwide, Blomberg says. And, as he put it, “We wanted to get ahead of the game.”

Memorial Healthcare System, the fifth largest public health system in the country, administers approximately 73,000 anesthetics a year. Envision, Memorial’s contracted anesthesiology service, wanted to ensure that wrong-site blocks remained a “never event.”

Envision approached Memorial with the idea of holding a Kaizen (the Lean rapid improvement process) to look at how to prevent wrong-side events. Four anesthesiologists, two RNs, and two Kaizen mediators participated in two days of brainstorming and ultimately took to the system’s Quality & Patient Safety Committee two ideas that were reviewed as part of a six- to nine-month process. The new protocols first implemented at Memorial Regional Hospital South in Hollywood, Florida, were:

1. Visual confirmation of laterality– Patient wears colored wrist bands on the operative side for easily visible, easy to confirm, rapid identification of right or left surgery.
2. “Patient-led” timeouts– Patient reads script to lead consistent, thorough, standardized timeout (a short meeting before a procedure to verify important information), which eliminates confirmation bias amongst the clinical team and improves patient satisfaction.

Slowing Down

“When you walk into a room you really don’t know just by looking at the patient on which side they’re having a procedure,” points out David Sacks, MD, Memorial Regional Hospital Chief of Anesthesiology. Sacks participated in the Kaizen and helped champion the protocol’s rollout. As he adds, “Of course, you read the chart and ask the patient and find out, but we wanted to create a visual confirmation.”

The bright green band on the patient’s arm provides immediate insight that increases the anesthesiologist’s and surgeon’s confidence. “You can see it from anywhere in the room, it creates a redundancy and it’s yet another confirmation that we’re on the correct side,” Sacks says.

Before the nerve block procedure is performed, the attending nurse asks the patient to put the wristband on the same side on which they’re having the surgery, phrasing that avoids confirmation bias.

But it’s the patient-led script that really slows the team down. While The Joint Commission made timeouts part of its Universal Protocol for eliminating wrong-site surgeries back in 2003, there have been mixed reviews on the effectiveness of the timeout. That concern was felt at Memorial as well.

“We felt that timeouts in the holding area can be rushed. We wanted to create a process where we would take our time and go to a timeout very respectfully,” Sacks says. “We thought that if the patient led the timeout, that would slow things down. There’s always respect for the patient, and this heightened respect for the process.”

As Blomberg points out, “Most nerve blocks are done on elective operations. The majority of patients are awake, alert, able to communicate, and they know what side they’re having done. If a patient is having a left knee operation, they know they’re having a left knee operation.”

In the timeout, the team explains to the patient that they’re going to verify some information and asks the patient to participate. The patient then takes the script and reads eight steps aloud to the team, verifying their personal information as well as surgery type and location out loud, following the same processes of the universal timeout process. The entire process takes about 45 seconds, Sacks says.

The script is available in various languages, but in the event the patient can’t verify the information, the team proceeds with the timeout in the third person.

Alleviating Fears

Memorial Regional Hospital South has never had a wrong-site event, yet the staff there was quickly struck by the effectiveness of the armband solution, to the point that, surgeons are requesting armbands for additional procedures whether or not a regional an aesthetic is used, Sacks shares.

After piloting the protocols at Memorial South for approximately two years, Memorial Healthcare System is now rolling these protocols out as a systemwide policy and Envision Physician Services will roll them out nationally in the next year. So far close to 100 patients have participated, and not one has declined a chance to participate. Blomberg explains that the confidence in this system comes largely from patient satisfaction and the confidence of the anesthesiologists.

“The patients really appreciate this procedure,” Sacks says. As Sacks explains it, the script eliminates an often-present fear for patients that the anesthesiologist will make a mistake. Consider a recent Reader’s Digest article, “34 Ways to Survive Your Next Trip to the Hospital.” Wrong-side surgeries are well documented, and anesthesia risks are a relatively common discussion in the media. Patients coming to the hospital for these procedures are often holding onto concerns that this patient-led process helps alleviate.

“If I told you how many patients in my career have come in who write ‘Make sure you do the correct side’ or write the word ‘No’ on the wrong side…,” Sacks recalls. “They’re nervous, they’ve heard of this, there are some well documented cases of surgeries done on the wrong side. And blocks [on the wrong side] happen much more frequently than surgeries on the wrong side.”

Taking the time to involve the patient is a simple way to boost customer satisfaction in procedures, while also standardizing the required timeout protocol. “It’s a very simple effective solution to a problem. Patients will have a lot of satisfaction with it, and I think the anesthesiologists will feel more confident,” Sacks says. “It’s a win-win.”

About the Author

Megan Headley is a freelance writer and owner of ClearStory Publications. She has covered healthcare safety and operations for numerous publications. Megan can be reached at megan@clearstorypublications.com.