Preop Area Checklist (8)
Flight Brief: Initial OR Visit (22)
Visit OR and greet staff, getting all names (incl guests) on the white board
Any guests or new team members today? (Special welcome and additional training)
Set room temp 69F/21C
Review surgical plan with staff and positioning
Welcome & Remind Anesthesia/CRNA: TXA; Sufenta instead of Remi; Avoid Ketamine
Fluid Warmer in Room
Both lightboxes in room
Lateral X-Ray holder and lead shield in room
Confirm Cell saver ordered and machine in room.
Confirm Imaging ordered including Large Field C-Arm Flouro
Instrument layout photograph available for new staff
Specials for Today. All equipment available?
Give Circulator Saline: Betadine concentration 3:1
Check Jackson Table Pin Position, and test up/down/tberg/locking
Thigh foam pad and 3 pillows at foot to keep knee caps free
Stool under table for X-Ray
Put on under-body warmer on Jackson Table; Connect and turn on warmers x2
Sutures for the Field: VLock 3-0 x2, Quill or StrataFix #2 double-ended
Bone Graft ordered
Dural repair supplies in room: 6-0 Proline, Duraseal, Surgicel
Diamond and metal cutting bur available in room
Prep table setup: Sterile 4×4’s, Alcohol, Chloroprep x2, Sterile Pen, Integuseal
Answer any questions that they have from OR team. Thank You for Help.
Before Turning (11)
In OR Time (Wheels in)
Tape up all preop imaging on the wall, and/or pull up digitally on monitor
Put Warm Blankets On Patient Immediately
Double-Check Jackson Table pad positions for patient size
Foley placed with good urine flow
Pneumatic boots applied (non-pediatric) and turned on
Evoked Potential Wire Placement Done
Endo-Tracheal tube taped securely & tube depth (cm) – confirmed 2 team memb.
Bite block x2 between molars, w test jaw close, confirmed 2 team memb. double-check
Stretcher / Jackson Table heights set correctly and tables locked
Ensure all lines, foley, wires are free, foley threaded through under-warmer
NM Tech: Identify Needle Locations for Staff Safety and wrists/hands wrapped w towel
Positioning (19)
Patient gently turned to prone position with my help, arms positioned
Face carefully positioned in Prone View with eyes protected and visible w/o pressure (2 team memb cross-check)
ET Tube and bite blocks secure and proper depth, tight connections (2 team member cross-check)
Lips and Ears without pressure (2 team memb cross-check)
Chest roll is away from the brachial plexus and airway (2 team memb)
Neck in neutral position (2 team memb)
For women, adjust breasts to minimize pressure on nipples
New warm blankets on entire patient
Turn on warmers, on high
Elbows and shoulders at 90 degrees, no pressure ulnar nerve
Arm boards out of way for surgeon, all connectors tight.
Pneumatic boots on, plugged in and turned on.
Add additional foam under iliac wings if needed for thin patients
Pelvis level, thighs on pads, knees no pressure, legs on pillows w knees flexed, strap on.
Under Patient: Abdomen hanging free without pressure
Under Patient: Genitals free of pressure, not lying on foley valve
Under Patient: Tape/Velcro up Foley and NM wires to be out of way of C-Arm
Reverse Trendelenberg approx 4 degrees – eye/airway protection (Lenke eye/airway)
Check that all IV AND Arterial connectors all double-checked tight
Prep and Drape (15)
Set Tracker/Timers for OR Time, Surgical Time, q30m anesth & leg check, 90m family call, 2h glove change
If needed, Shoulders/Buttock taped to prevent creasing.
Upper and Lower Warm blankets applied
4×4 sterile sponge alcohol wipe down entire back, avoiding pooling for fire risk avoidance (SRS 2017)
Surgical lights lined up over the surgical field, “kissing”, high enough to avoid head bump
Stick-on plastic “1010” drapes at least 3 inches from expected incision ends, 5+ inches each side
Tape top 1010 up to blankets to prevent contamination
Chlorohexadine Dry x3min and no “pooling” on field or on sheets below (fire risk)
Skin incision and cross-hatches marked sterile marker
Large Sticky Drape, Splits, and edges sealed with sticky drapes.
Red banner or Tape across main OR door (infection prev)
Confirm patient stretcher location outside door with room label (emergent flip)
Family phone number and name on white board
Trip Hazard Removal and Check: Tape down or remove all wires/tubes on floor.
Set Bovie 50coag, 70cut, Bip 70, TPS STRYKER NEURO Pi DRILL ACCELERATION & ORQUE 100%
Pre-Incision Timeout (33)
SURGEON: welcome & Team introductions name and role, names on white board
SURGEON: Briefing Begins: Patient/Family Intro &Surgical Plan, EBL
SURGEON: Reviews Preop Imaging: confirmed patient ID, levels, transitional anatomy?
Circ RN: Patient name, DOB confirmed with Anesthesia
Circ RN: Surgery consent read aloud
Circ RN: Allergies / Latex Allergies
Circ RN: Positioning confirm legs/feet ok and strap on legs
ANESTH: Antibiotic given within 1 hour skin incision
ANESTH: Positioning confirm OK eyes, nose, mouth, bite block, ears, neck, arms/shoulders
ANESTH: warm all fluids, keep warmers on high until patient 37c
ANESTH: minimize fresh gas flow to move bellows (1 liter) — optimize body temp
ANESTH: TXA given and drip started (50mg/kg, 5mg/kg/hr); run until PACU
ANESTH: MAP in 70’s exposure, 80’s during rod insertion
ANESTH: Verbally Report Eyes,ET Tube & Hands OK; EBL,MAP,PPV,TEMP,UO q30.
Circ RN: IF ARMS TUCKED, Verbal “Hands OK” q30m
Circ RN: Verbal “Legs OK” q30m
Timers set for q30 min Anesth & foot/leg checks, 90m fam call, 2h glove changes
ASSISTANT: spinal “RED ZONE” education L1 and above.
NEUROMONITORING: being performed and baseline readings
Neuromonitoring Change Emergency Protocol review – Circ Nurse will run. copies posted & available
Fire Safety Review: no alcohol/CHG pooling. Prep dry. Emergency checklist available.
Safety zone & sharps awareness – pass blunt end first to table
Keep light handles 4in/10cm above highest head (infection prev)
Confirm floor clear of trip hazards, all cables/tubes taped down.
Verify bed location and label in case of emergency flip needed
Make sure everyone is double gloved
Minimize trips going in and out of room unless necessary.
Sit down immediately if light-headed and notify staff. (falls prevention)
Keep talking / music to minimum to maximize communication, minimize distraction.
Use verbal “readbacks” to ensure communication completed accurately.
Any other team concerns?
Encourage all team members to speak up if there is concern or question
All team members agree with completed timeout and reply with “Aye”
Intraoperative (17)
Skin incised lightly. Surgical start time:
Circulating nurse calls family for first phone call, marked on board
Penfield 4 over transverse process for level confirmation, skin marked
Take off the sucker-tip to avoid Betadine in cell saver (Dan Woodfin)
Incision covered with green towel and sponge placed in wound
Help XRay Tech align C-arm or X-Ray to decrease XRay exposure
AP/Lat Flouroscopy/X-Ray: confirm Penfield position above sacrum, confirmed 3 team members
Facet joint and lamina marked with bur adjacent to Penfield 4
Marked Level written on white board
Hemostasis check completed left side (every 10 cm during exposure each side)
Vancomycin powder 1gm rubbed into muscle left side (Lenke Oct 2016)
Hemostasis check completed right side
Vancomycin powder 1gm rubbed into muscle right side
Exposure complete time:
Screw Implant insertion begin time
Pedicle screw placement safety subroutine (repeat)
Each step called out verbally as completed to NM and checklist team members
Finishing screws and confirming imaging (5)
All pedicle screws left side completed
All pedicle screws right side completed
Bilateral iliac wing screws completed, if needed
Dilute Betadine solution and sponge in wound, Sterile towel cover w marks
Flouroscopic/X-Ray confirmation screw position
Final Rods and Locking Checklist (5)
Rods inserted bilaterally with multiple persuaders, compression and distraction.
Time Spine implants completed:
Ensure there is adequate rod sticking out each end, no muscle entrapment.
Dilute Betadine placed in wound, Incision Covered and Marked
X-rays: good coronal/sagittal balance, rod lengths.
Prior to closure checklist (6)
Screw caps double checked by surgeon and assistant with verbal check each cap. (Vitale M-2016 Pt Safety Conf)
Valsalva maneuver done to confirm no spinal fluid leak.
Irrigate wound copiously with saline
Complete posterolateral decortication, and place bone graft mixed w 2g Vancomycin.
Meticulous hemostasis confirmed by careful wound inspection top to bottom bilat
Blood Loss/Added
Drain placement if needed.
Closure (11)
Note Closure Begin Time:
Fascia closure at distal and proximal ends first, then middle.
Great care to ensure drain not sutured in, deep and superficial
Push down on wound to test for water-tight closure
Running #1 Vicryl or #2 Quill on fascia to further water-seal fascia
Confirm body weight, then Inject 0.5% Marcaine with epi up to 30cc if wt>=60kg
Incision Closed Time. (Surgery End)
Dermabond and Steri-Strips applied and allowed to dry on incision
Confirm Evoked potential and emg monitoring was normal throughout surgery
Remove ALL non-disposables from drapes (bipolar, clips, cables, etc)
Pre-turn check for all lines/foley. Loosen Foley from table.
Turn to supine (11)
Turn supine onto bed gently.
Inspect face, arms, hands, chest, pelvis and lower extremity for skin/pressure/swelling.
Patient opens eyes
Extubated Time
Tongue check: no laceration
All neuromonitoring needles removed and accounted for. (ELI Nov 2017)
Patient moved bilateral lower extremities.
Extubated and moving lower extremities (wakeup done)
Time Patient Leaves Room (Wheels Out):
Complete Operative Note with merged eChecklist Log, pasting into Hosp EHR.
Ask for family to be put into consult room
Checkout / Debriefing (7)
What went well in the surgery?
Complications?
Any equipment problems? (blank = no)
Any preventable trips in/out of OR room?
Anything we could have done to make safer/more efficient? (ELI’s – Error/Event, Learn Improve) (blank=no)
Suggested changes to checklists?
Thank everyone for their help, recognizing them for things done well.
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