Improving Wake-Up Times for Spine Surgery Using New OR Team Checklist Protocol and Communication

Introduction: Prolonged post-anesthesia wake-up times present a threat to patient safety. Shorter wake-up times allow for intraoperative physical exams and potential to re-operate quickly in case of detected neurologic deficits, which may allow for a better neurologic outcome. Furthermore, shorter wake-ups may reduce length of hospital stay, lowering healthcare costs. Methods: We studied how a standardized spine deformity surgery checklist and new OR team communication impacted post-anesthesia wake-up times after scoliosis surgery. We used a Kruskal-Wallis one-way ANOVA to compare 17 wake-up times recorded prior to using the new surgery checklist and teamwork protocol to 468 wake-up times recorded over three years after implementation of the new protocol. We used a Pearson correlation coefficient to analyze how wake-up times varied based on surgical duration with the new protocol. Results: After one year of the new protocol, wake-up times reduced from an average of 16.6 minutes to an average of 7.6 minutes. Wake-up times further declined to an average of 6.0 minutes by years two and three of the new protocol, with significant reductions in these years (p=0.024 and p=0.030, respectively). Improvements to the protocol were made over time in response to outliers. Nearly 75% of wake-up times were less than five minutes with the new protocol. Wake-up times recorded using the new protocol showed a significant weak positive correlation with surgical duration (r=0.092, p=0.047). Conclusion: The standardized surgery checklist and new team communication promotes significantly shorter post-anesthesia wake-up times, irrespective of surgical duration. While using a comprehensive surgery checklist may take a few more minutes up front, that time is saved at the end with shorter wake-up time, creating net time savings while improving safety. Key steps to promoting a shorter intraoperative wake-up include: 1) using a bispectral index monitor (BIS) with a goal in the 50s, 2) standardized target anesthetic dosing parameters, 3) eliminated anesthetic drug variability, 4) every-thirty-minute timeouts to monitor patient status, and 5) sub-three-minute pre-surgery wake-up time goals verbalized to the OR team.