Transforming the surgical "time-out" into a comprehensive "preparatory pause"

We propose expansion of the standard "time-out" into a comprehensive "preparatory pause" encompassing five well-documented perioperative risk avoidance strategies: beta-adrenergic blockade, DVT prophylaxis, preoperative antibiotics, normothermia, and euglycemia. Although all members of the surgical team acknowledge the clear benefit of these five prophylactic strategies, published national compliance even in the target patient population is a disappointingly consistent 50%. We have developed and field-tested a "preparatory pause" form that we appended to our "surgical time-out." By politely challenging our surgical team as to the inclusion of these five risk avoidance strategies in 167 consecutive patients, we increased our compliance to more than 90% for each preventive measure. We have not attempted to quantify the physical and psychological benefit of complication avoidance due to the enhanced activation of these five prophylactic strategies. Using published surgical complication prevalence data, with and without these accepted risk avoidance measures, we estimate the number of complications per 100 patients avoided. Utilizing the Medicare payment schedule for each complication, we approximate the purely financial benefit of the "preparatory pause" to be $88,640 per 100 patients, or almost $900 per patient. The now standard surgical "time-out" is designed to avoid the gratifyingly uncommon problem of "wrong patient," "wrong procedure," and "wrong site." Many surgeons negotiate an entire career without stumbling over these disastrous problems. We propose expansion of the "time-out" to include five well-documented perioperative risk avoidance strategies that many of us overlook all too often.