OR to ICCS
Time-Out Audit
addressograph
Date: ______________________
Time patient arrived to ICCS
______________
Time Surgeon arrived
_______________
Time Anesthetist arrived
________________
Time ICCS Attending arrived
________________
Time the time-out was called
______________
Time time-out completed
______________
Were there any interruptions/distractions during process
Time family in to visit
Cardiac Anesthesia Checklist
Checklist used
Yes
Yes
No
_________________________
Anesthetists Name: _____________________________
No
□ Pertinent past medical history, physical exam and co-morbidities, medications
□ Baseline HB, Cr, BP and HR
□ Airway Issues
□ Issues with Induction
□ Oxygenation/ventilation issues
□ Time of last neuromuscular blockade
□ IV and arterial-line placement
□ Pre-CPB TEE findings
□ Technical Considerations/Issues with separation from bypass
□ Post-CPB TEE findings
□ Drugs: allergies, inotropes/vasopressors, last antibiotic, analgesics, last paralytic
□ Fluids/blood products administered
□ Desired hemodynamic goals/filling pressures
□ Desired period of sedation (if required)
□ Other issues relevant to ICU care
Comments:
______________________________________________________________________________
______________________________________________________________________________
October 24, 2013
Cardiac Surgeon Checklist
___________________
Checklist used
Yes
Surgeon Name:----------------------------------------No
□ Patient Demographics (age, gender, etc)
□ Indication of surgery
□ Pertinent past medical history
□ Surgical Plan/Surgery Completed (i.e. fully revascularized, adequacy of repair)
□ Deviations for surgical plan/intraoperative complication
□ Issues with separation from bypass
□ CPB and X-clamp times
□ Bleeding/coagulation Issues
□ Need for protamine
□ Systolic/MAP blood pressure limit
□ Pacer wires
□ Chest tube placement
□ Restart Plavix (y/n)
□ Family discussion (y/n)
□ Other issues relevant to ICU care
□ Patient is enrolled in a study? Which Study
Comments:
______________________________________________________________________________
______________________________________________________________________________
ICCS/Anesthesia Attending Checklist
Checklist used
Yes
No
Attending Name:
_________________
□ Sedation goals and planned titration (default: RASS 0 - -2 unless indicated)
□ Desired period of sedation (if required)
□ Analgesia (amount and frequency)
□ Oxygenation/Ventilation plan (default: non-physician protocol driven extubation)
□ Desired hemodynamic goals/filling pressures
□ IV fluids (maintenance)
□ IV fluids boluses (amount and frequency)
□ Inotrope/vasopressor wean (if applicable)
□ Pacer settings
□ Protamine (y/n)
□ Delirium Risk
□ Other issues relevant to ICU care
Comments:
______________________________________________________________________________
______________________________________________________________________________
ICCS Nurse
□ Goals repeated
October 24, 2013
Nurse: ______________________________