November 7, 2016

In the heat of a perioperative crisis, the most diligent and highly trained anesthesiologist or certified registered nurse anesthetist can miss a crucial step.  Even with years of experience monitoring patients and managing emergencies, anesthesia providers are not above making critical errors in stressful situations.  Key details can be overlooked as memory and employable knowledge shrink under pressure.

Awareness of these human limitations and insight into strategies for overcoming them are driving the development and growing use of emergency manuals as cognitive aids for anesthesiologists, CRNAs and other clinicians in perioperative settings. 

The idea is taking hold within anesthesiology as an outgrowth of the World Health Organization’s development of the Surgical Safety Checklist and the powerful arguments in support of checklists put forth by Atul Gawande, MD, in The Checklist Manifesto.  Many of you already use checklists and emergency manuals in your practices, while some of you still may be exploring opportunities to incorporate these tools into your work. 

Cognitive aids, including emergency manuals, don’t replace clinical judgment, but enable clinicians to extend their abilities as expert practitioners, says Sara Goldhaber-Fiebert, MD, of Stanford University, who spoke at ANESTHESIOLOGY^® 2016.  The emergency manual, which Dr. Goldhaber-Fiebert defines as a context-relevant set of tools, including checklists, for critical events, can help transform a chaotic and confusing crisis situation, such as malignant hyperthermia, into one that is calm, organized, collaborative and significantly less likely to result in a life-threatening omission.  That difference can reduce complications and save lives.

Comparable checklist-based documents and other cognitive tools have been used widely for decades in such high-reliability industries as aviation and nuclear energy for training and practice, so their appearance in healthcare is a natural, albeit overdue, occurrence, Dr. Goldhaber-Fiebert contends.  It was almost 100 years ago that Dr. W. Wayne Babcock advocated for emergency protocols to be rehearsed and “posted on the walls of every operating room.” 

Research and Resources

A growing body of evidence indicates that emergency manuals work.  A simulation-based trial of surgical-crisis checklists published in the New England Journal of Medicine in 2013, for example, showed a significant and substantial value in the use of carefully designed checklists in the operating room. 

The study used a crossover design in which each of 17 teams was given four scenarios with and four scenarios without access to crisis checklists.  Teams consisted of anesthesia staff (attending physicians, residents and CRNAs), operating room nurses and surgical technologists.  Teams were exposed to a series of simulated intraoperative crises, including air embolism, anaphylaxis, asystolic cardiac arrest, hemorrhage followed by ventricular fibrillation, malignant hyperthermia, unexplained hypotension and hypoxemia followed by unstable bradycardia, and unstable tachycardia.  Each team was randomly assigned to manage half the scenarios with the checklists available and the remaining scenarios by memory alone.  The use of checklists yielded a 75 percent reduction in “failure to adhere to critical steps.”

The time has come to take this evidence into clinical practice and learn how to implement emergency manuals effectively, Dr. Goldhaber-Fiebert argues. 

Several organizations have developed tools that are available for download free of charge, including the Emergency Manuals Implementation Collaborative, the Society for Pediatric Anesthesia (see figure below), Ariadne Labs and the Cognitive Aids in Medicine Group at Stanford University.  The more than 70,000 downloads of these tools combined during the past three years reveal that interest among clinicians and healthcare organizations is high, Dr. Goldhaber-Fiebert says.

A checklist on difficult airway management after induction from a set of checklists developed by the Society for Pediatric Anesthesia Quality and Safety Committee.  The full manual and a mobile app are available for download free of charge.

The Road to Reliable Use

Still, moving from a download to improvements in the accuracy and efficiency of responses to crises in the OR and saving patients presents a variety of interesting hurdles.  Foremost among these is getting operating room staff to actually use the emergency manual when a crisis occurs.  As in other areas of healthcare, interest in implementing a tool to increase safety and creating an environment that convinces clinicians to predictably access it are two different things. 

To boost their chances of success in this regard, Dr. Goldhaber-Fiebert encourages clinicians to build on existing tools such as those mentioned above, because a great deal of careful work has gone into their design.  However, she also stresses the importance of customizing emergency manuals to suit local needs and cultures.  It’s going to be a problem if OR staff don’t recognize “epinephrine” because the drug is commonly referred to as “adrenaline,” for example. 

A multidisciplinary committee of anesthesiologists, CRNAs, surgical nurses, surgeons, technicians and pharmacists to customize the manual can build a sense of ownership among OR staff.  Customization by committee takes more time and energy, but pays off in the quality of the finished product and the staff’s investment in it.

Dr. Goldhaber-Fiebert advises including, at the very least, a list of local emergency phone numbers in a customized manual.  This aspect of customization also requires time and effort, but the act of compiling a local list involves clinicians in opening and touching the manual, and those touches create familiarity of use and awareness that the manual is useful on a daily basis.

One of the first simulation-based studies done by the Stanford group involved the use of a poster for managing malignant hyperthermia.  While the residents were using the contents of the malignant hyperthermia cart, many were not taking advantage of the cognitive aid, even though the residents who did use it performed better.  The group tried to address the problem by hanging the tool on the defibrillator so residents would have to touch it to reach the defibrillator controls.  The approach did not work.  About half of the residents said they didn’t “see” that the cognitive aid was there.

This early experience taught Dr. Goldhaber-Fiebert and her colleagues about the role of “inattentional blindness”—a psychological lack of attention in which an individual fails to recognize an unexpected stimulus that is in plain sight—as well as the need to pre-train and pre-expose residents in introductions that gave them the opportunity to look through the manual and familiarize themselves with it, and chances to use the checklists to get a visceral feel for why they are helpful. 

Dr. Goldhabert-Fiebert stresses that emergency manuals are designed to assist experts, not replace them, and should not be used when immediate action is required, as a replacement for appropriate training, as a replacement for clinical judgment or instead of calling for appropriate help. 

The emergency manual should be in a consistent location where it is easy to see and reach.  Some hospitals produce pocket copies of the manuals for use during transport of patients to the ICU. 

Every crew in the OR also needs a reader—someone who assists the team leader by reading the contents of the checklist during the crisis event.  Although the ideal characteristics of the reader are still being studied, this person should be someone who is comfortable reading aloud and who does not stumble over the words.  The reader could be an extra anesthesiologist, an extra nurse who is not otherwise occupied in the OR, a competent medical student who is familiar with the resource or the surgeon. 

A supportive culture conducive to the use of emergency manuals also plays a key role in implementation.  In high-reliability fields such as aviation, the use of comparable tools is not only supported, it’s expected.  In healthcare, this entails obtaining “buy in” from staff that they will not be thought of as incompetent for using a checklist during a crisis.  Dr. Goldhaber-Fiebert advocates using emergency manuals at the medical student level all the way through training so that people become comfortable using the manuals as a tool to enable their teamwork and improve their care, not as a replacement for clinical judgment or as a sign of clinical incompetence.  

New Findings

A 2015 study published by Dr. Goldhaber-Fiebert and her colleagues in the Joint Commission Journal of Quality and Patient Safety concludes that hospitals should not only provide emergency manuals in accessible locations in operating rooms, but should also incorporate training to increase familiarity, cultural acceptance and planned clinical use among clinicians.  Nine 50-minute simulation-based in situ training sessions included why and how to use emergency manuals, education in the format, simulated scenarios of critical events and debriefings.  A retrospective pre-post survey revealed significant increases in awareness of, familiarity with and willingness to use the emergency manuals for educational review, as well as intention to use the tools during critical events.  Dr. Goldhaber-Fiebert attributes part of the shift in attitudes among staff following the training sessions to informal word-of-mouth spreading, which can be at least as important as formal activity in innovation and culture change.

Another study published in the September issue of Anesthesia & Analgesia reported that 15 months following the clinical implementation of emergency manuals, 45 percent of Stanford anesthesiology residents had used an emergency manual at least once during an actual critical event.  “Although these reports all come from a pilot study at a single institution, they serve as an early proof of concept for feasibility of clinical EM implementation and use,”  Dr. Goldhaber-Fiebert and her colleagues conclude.  “Larger, mixed-method studies will be needed to better understand emerging facilitators and barriers and to determine generalizability.”

Dr. Goldhaber-Fiebert encourages clinicians to share their experiences and clinical uses of emergency manuals and other cognitive aids with the Emergency Manuals Implementation Collaborative to support learning about their effectiveness. 

It’s one more way in which anesthesiology is taking the lead in safety. 

With best wishes,

Tony Mira
President and CEO