Ads Are Often Called Heuristics Art Infusions Animatics Creative Mnemonics

When a patient has an acute event in the perioperative setting, health care practitioners aim to manage the situation according to best practices and to minimize morbidity equally well as mortality. Yet during the stress of a critical event, the vast majority of clinicians do not implement all known best practices optimally.¹ Sometimes, vital steps are never performed. How can this fact exist changed then that clinicians perform better and patients benefit? Emergency transmission implementation and use are two of import elements inside the larger context of team training, such as crisis resources direction (CRM)² (Fig. one), the Veterans Affairs (VA) Medical Team Training,³ or TeamSTEPPS™.⁴

Figure 1:

Key points of crisis resource management (CRM). At left, back cover of emergency manuals. At correct, inside back embrace. Integration of these concepts, which are frequently discussed in simulation courses, into clinical arenas is expected to raise awareness of nontechnical contributions to critical events. © 2008 Diagrams: S. Goldhaber-Fiebert, K. McCowan, Yard. Harrison, R. Fanning, S. Howard, D. Gaba.

When and Why to Use Emergency Manuals

In that location is a common misconception that emergency manuals are not relevant in the direction of time-sensitive astute events. Certainly, it can be harmful to consult a volume or computerized device at the wrong time (e.thou., when a pulseless patient needs breast compressions, or other acute concrete actions, with insufficient clinicians present). Notwithstanding, with appropriate use, emergency manuals tin be a helpful resource for important direction priorities during many disquisitional events, in improver to providing an attainable resource for more mutual needs of "Pre" crisis educational activity and "Post" event debriefing. (Fig. ii and further explanation in the "Iv Elements of Implementation: Use" subsection) In other high-stakes industries, such as aviation and nuclear power, emergency manuals accept proved to be helpful tools, are integrated into training, and are expected to exist used.

Figure 2:

Clinical uses of emergency manuals. The double arrows from "Pre" and "Post" to "During" emphasize that both content and format familiarity are increased when emergency manuals are utilized for educational review. During a crunch, specific categories of events may be appropriate for emergency transmission consultation in detail ways. © 2012 Diagram: S. Goldhaber-Fiebert.

A recent aviation example of the effective employ of an emergency manual during a time-sensitive disquisitional event occurred on January xv, 2009. After a bird strike caused the failure of both engines on U.S. Airways Flying 1549 before long after take-off, the pilot, Captain Chesley "Sully" Sullenberger III, start officer Jeff Skiles, and crew, were able to perform a safe emergency landing in New York's Hudson River. The pilot took control of flying the plane and communicated with air traffic control, while the first officer read from the "dual engine failure" section of the emergency manual to ensure that they completed the recommended "management" actions.^a This event unfolded chop-chop, with many lives at stake including their own, the crew had <iv minutes between the bird strikes and their safe h2o landing. Aviation studies of like incidents underscore that well-designed and attainable emergency manuals, combined with recurrent training, can exist used effectively even in the midst of time-sensitive crises.^b,^c

Although patients and their diseases differ from airplanes, there is growing simulation-based testify that clinicians under stress, and therefore the patients in their care, can be well served by the like utilize of emergency manuals in one case they are integrated into practice settings, training, and culture. There is a challenge to appropriately implement emergency manuals in a mode that positively affects patient care, while avoiding distraction from concurrent necessary deportment.

At that place is a finite set of critical events for each clinical domain. Each event has pregnant data on best practices for management, although these are ultimately modified by the particular patient'southward comorbidities and individual case details. For each disquisitional perioperative outcome, common management errors accept been repeatedly observed during simulated and real clinical intendance. In health care, there is a responsibleness to improve this situation by recognizing the challenges that clinicians face, and then creating and appropriately implementing tools that can help. Although our examples come from the perioperative setting, emergency manuals are equally pertinent for acute events in emergency departments, labor and delivery wards, medical or pediatric wards, and intensive intendance units.

Terminology

For consistency, nosotros utilize the term emergency manual throughout this article, referring to a packet of cognitive aids relevant for a particular context such equally perioperative care or aviation. In aviation, these are often referred to as emergency sections of flight manuals or as quick-reference handbooks. In health care, emergency manuals, or their components, have been referred to by various names, each with their pros and cons.

Cognitive assist is a term used in many high-stakes industries as well as in much of the medical literature, emphasizing that the information is provided to cue practitioners at the fourth dimension it is needed. Cognitive aids are tools to help people remember to deed on important information that they often already know simply may either be inert or nondeployable. The term recognizes that humans are not optimized to remember rarely used information. All the same, individual practitioners unfamiliar with the term may feel it insults their capabilities, implying that they have a cognitive impairment. For this reason, we adopted the more than neutral "emergency manual" equally the primary title for such a bundle, in parallel with like terms in aviation.

The term "crisis checklists" is an extension from the successful work of Gawande et al. in implementing the Earth Health Arrangement surgical safety checklist, emerging from their more recent piece of work in medical crises.^{5 , 6} In the lay public and the medical community, there is positive momentum for the role of checklists in health care. Past its component words, "cheque list" implies a linear flow to check off items, without subsequent afterthought that may exist needed in some medical situations, eastward.one thousand., difficult airway management. A checklist also does non automatically include other considerations, such as signs or differential diagnoses that are not explicit actions. This inherent issue is frequently dealt with past including carve up boxes for the additional considerations that do not fit within the linear catamenia of the master checklist. Finally, asking for the checklist during a crisis may create defoliation with other routine checklists such as the surgical safety checklist described in a higher place.

While the implications of terminology are relevant and naming the emergency manuals is important for their integration in the clinical arena, the iv-element implementation process described in the main part of this commodity is ultimately the nearly important aspect in ensuring their optimal use.

Cognitive Psychology and Human Factors

In health care, we can learn significantly from the extensive relevant literatures in the fields of cognitive psychology and human factors. Klein's recognition-primed decision making model emphasizes the positive part of intuition in the grade of pattern matching.^vii Experts rapidly recognize a familiar pattern that matches the current situation "well enough," which is frequently followed by analyzing the fit using mental simulation, and so making adjustments as necessary. This intuitive procedure allows professionals in diverse fields, ranging from fire chiefs to acute care clinicians, to usually correctly make difficult decisions in less than platonic circumstances, including fourth dimension pressure, loftier stakes, and incomplete information.^{8 , 9}

In concert with the recognition-primed decision making model, anesthesiologists often must act efficiently and intuitively. These responses involve rapidly recognizing diagnostic patterns and managing the offset minutes of a crunch. When patients require firsthand actions, information technology is sometimes distracting for a clinician to consult a cognitive aid.

In contrast, Tversky and Kahneman¹⁰ wrote extensively about the systematic, albeit rare, biases that follow naturally from the heuristic mental shortcuts that allow united states of america to perform efficiently. Heuristics are simple and necessary techniques that help people to efficiently determine acceptable responses to difficult questions. Clinicians, similar all dynamic conclusion makers, use many heuristics equally approximation strategies during ambiguous, time-sensitive situations.¹¹ Through cognizance of the mutual resulting biases, also known equally cognitive errors, practitioners can help to protect patients from poor outcomes.

Cognitive errors that are specifically applicative to anesthesiologists and the perioperative setting accept been recently reviewed.¹² Emergency manuals may help avert preventable patient harm, as office of a toolbox to combat cerebral errors.¹³ For case, tunneling of attention causes clinicians to fixate on what the private or team perceives (rightly or wrongly) equally the greatest risk, potentially resulting in a loss of situational awareness.^{14 , xv}

Klein¹⁶ and Kahneman,¹⁷ while emerging from competing psychological schools of thought, both have applicable models for decision making in clinical care, and each has written an informative book for nonpsychologist lay audiences. Their recent collaboration confirmed that the works of Kahneman and Klein^eighteen are not contradictory, but rather by and large emphasize different aspects of the aforementioned phenomena. Applied to wellness care, our intuitive expertise, while necessary and frequently helpful, every bit in efficiently responding to astute status changes, tin exist misleading and if unchecked can lead to a worsening patient status. Management gaps, caused past well-described cognitive biases and errors, are a cardinal reason why emergency manuals can be useful to anesthesiologists and other clinicians during refractory or rare critical events.

Experts provide extensive pattern recognition and applicable mental models that they accept adult from prior experiences, and then they are often appropriately consulted for management advice.¹⁹ However, no doctor is expert at managing all aspects of all critical events. For case, during a pulseless electrical activity (PEA) cardiac arrest, important diagnostic causes can exist missed even when multiple clinicians trained in Advanced Cardiovascular Life Support (ACLS) are present. It is non expert plenty to treat and exclude 90% of the "H'south and T's" (Hypovolemia, Hypoxia, Hydrogen ion–acidosis, Hyperkalemia/Hypokalemia, Hypothermia, Hypoglycemia and other metabolic disorders AND Tablets [drug overdose, accidents], Tamponade [cardiac], Tension pneumothorax, Thrombosis-coronary, Thrombosis-pulmonary [embolism], Trauma) a common mnemonic for diagnostic causes in PEA, because of reliance on retention alone.²⁰ Fifty-fifty when all H's and T's are verbalized at a PEA cardiac arrest, often some are neither excluded nor actively pursued. Normally, when teams miss crucial steps in the management of false or existent disquisitional events, information technology is not because they have never heard of the appropriate intervention. Ideally, the H's and T's of PEA should be organized in order of priority for the particular medical context, e.k., operating room (OR) versus medical ward, and should be read aloud with explicit follow-up actions to either exclude or care for. By providing information that is not hands retrievable from retention, emergency manuals tin can be helpful in allowing u.s. to focus our express bachelor attention on higher level cognitive tasks.

During crises, avoidable performance gaps occur, which is oft pointed out by participants themselves during debriefing.^{2 , 21} The common culprits in operation gaps, as well noesis, are a combination of crisis management team challenges (advice, leadership, etc.) and a failure to implement knowledge nether stress.^22–24

This latter failure to accordingly execute actions may exist because of nondeployable knowledge, systematic cognitive errors, or several common memory bug.^ten,^d,^east,

Stressful situations have been shown to negatively touch multiple aspects of human memory, including retrieval of inert knowledge, working retentivity for calculations, and prospective retention for future tasks.^d Here, nosotros ascertain each briefly, with application to anesthesiology and clinical medicine. Inert noesis is familiar merely sometimes not accessible or active, similar the imperfect ability to retrieve the full details of all H's and T's for PEA cardiac abort. Working retention is used to make calculations, such every bit for drug dosages. These calculations crave active attention, which is a limited resource during periods of stress and distraction, when mental tasks may as well take longer and be more prone to mistake. Prospective memory fault is a formal term for getting distracted despite knowing what to exercise, sometimes described equally "forgetting to call up," such every bit listening to breath sounds on manual mode, getting interrupted by a question, and then forgetting to switch on the ventilator over again.

Practitioners are starting to recognize the danger to patients of relying entirely on their own memories and the potential advantages of accessible cognitive aids or checklists.^{25 , 26} In both observational and controlled trials, perioperative teams that consult an emergency manual for simulated critical events perform vital actions more oftentimes, more than efficiently, and more accurately than those who exercise non.^{5 , 27 , 28}

These simulation-based medical studies can be understood in the context of the described psychology research, further emphasizing a part for emergency manuals. However, the mere presence of cerebral aids does non ensure that they will be used^{29 , xxx} or used appropriately,³¹ which all underscores the importance of systematic implementation and appropriate grooming.³²

Implementation Science

Traditionally, translational scientific discipline describes the progression from bench studies to clinical trials. McGaghie et al. discuss a parallel concept to describe translational research for medical educational activity and simulation.^{33 , 34} This type of enquiry can be divided into 3 categories: T1 is change in clinician actions achieved in an educational laboratory or imitation setting; T2 is transfer of these results to improved patient intendance practices by providers in a clinical setting; and T3 is improved patient or public health outcomes, such as lower morbidity or bloodshed. Implementation science integrates methods from many fields, including human factors, behavioral and cognitive psychology, business organisation, teaching, and aviation. Within wellness care, implementation science can help patients receive the full benefits of known data in preventive, diagnostic, or handling realms. In the case of emergency manuals, the goal is to provide easily attainable information, combined with training, to assistance clinicians effectively prevent, diagnose, and care for critical events. To date, research has been mainly within the T1 category, although there are now more opportunities to motility to T2.

Why Now?

The fourth dimension is ripe for implementation of emergency manuals containing best practices for perioperative critical events. At that place is increased interest in the utilise of related resources among both physicians and the public. Gawande'due south 2010 volume, The Checklist Manifesto ³⁵ addresses tools for preventing errors, with examples including preoperative checklists for safer surgery. In October 2011, Dr. Gawande was the keynote speaker at the Fall meeting of the American Society of Anesthesiologists. Many anesthesiologists who were in omnipresence work in settings that take implemented versions of the World Health Organization'due south surgical prophylactic checklist, which Dr. Gawande's team helped to develop, implement, and inquiry.^six While some practitioners initially complained about the change, most institutions take now achieved significant cultural credence. The benefits of this program include: a check for all practitioners of mundane items that adhere to all-time practices such as preincision antibiotics, increased information sharing in response to open-ended questions well-nigh patient or example-specific concerns, and increased team communication during surgical cases after introductions of all team members. The latter teamwork aspect is less quantifiable merely increasingly recognized as vital to patient outcomes. In 2013, a simulation-based trial from Harvard in the New England Journal of Medicine reported that teams missed half dozen% vs 23% of disquisitional actions during a diversity of OR events when crisis checklists were accessible versus not.³⁶

Although it is e'er preferable to preclude complications from occurring, the early diagnosis and constructive direction of complications that practice arise tin significantly subtract patient morbidity and bloodshed.³⁷ Practitioners and health intendance systems seem increasingly ready to admit this reality, with numerous requests for copies of constructive emergency manuals, cognitive aids, or checklists from both Stanford- and Harvard-affiliated^f simulation centers.

Methodology and History of Stanford Feel

In the implementation framework beneath, we integrate the relevant published literature with explicit citations, forth with our local feel. This section provides an overview of that feel and its evolution. Stanford's simulation-based Anesthesia Crisis Resource Management course has been taught for more than than 20 years.ⁱⁱ Approximately 90% of these courses are attended by residents, although nosotros are conducting an increasing number of courses for experienced practitioners, e.yard., during the Maintenance of Certification in Anesthesiology course. The courses have iv participants each, on boilerplate, for a total of 60 to 75 residents per year. Maintenance of Certification in Anesthesiology courses are run similarly, with approximately 5 courses per twelvemonth.

For more than a decade, specific cognitive aids or full emergency manuals have been available for participants to use during these courses. Many different versions have been developed, with iterative simulation testing and progressive adaptations for usability, but the initial versions were developed in 1988 in work that led to the offset extensive "catalog of disquisitional events" for anesthesiologists.^xiv In 2003, an updated subset of these critical events was deployed nationally within binders for ORs at all VA hospitals.

In 2009, we piloted adding a cursory immersive module nearly the first of resident simulation courses to communicate the value of cognitive help employ and to increase familiarity with the emergency manual format. Over fourth dimension, our residency program integrated emergency manual use into several other simulation courses, including the new resident orientation, which served to farther reinforce the familiarity and perceived utility of emergency manuals. Commencement in 2010, Stanford anesthesia residents in their Clinical Base year were shown how cognitive aids could be used in acute care situations during a program called Kickoff (Successful Transition to Anesthesia Residency Training).¹⁰⁰⁰ During residency grooming, the utilise of such tools is further encouraged by nigh faculty within the associated institutions.

Equally of 2012, accessible emergency manuals have been integrated into anesthetizing and other perioperative locations. OR staff grooming, including in situ simulation, began in 2012 with a goal of introducing all OR squad members to emergency transmission use and demonstrating how this fits into CRM strategies. CRM concepts are displayed on the back cover of the emergency manuals for reference, including for event debriefings (Fig. i). Pertinent examples from diverse phases of our implementation process are interwoven with relevant published literature throughout the framework presented hither.

FOUR-ELEMENT IMPLEMENTATION STRATEGY

In i of the get-go medical studies of the use of cognitive aids, anesthesia resident teams were observed during scenarios of faux cancerous hyperthermia, with a readily bachelor cognitive aid provided.²⁷ Many of the teams in this study did non use cognitive aids at all, or did so only sparingly. Teams that consulted a cognitive assistance performed more of the critical actions, and did and then more than chop-chop, than teams that worked solely from memory. The nonusers seemed to share with the users the same inherent human vulnerability of incomplete memory under pressure, but either did not realize the problem or were not aware that assistance was easily bachelor.

This written report spurred the question of how to help the nonusers to achieve the better success rates of the cognitive assist users. As with other significant improvements in wellness care, such as decreasing central-line infection rates³⁸ or early handling of sepsis,³⁹ multiple important elements are probable required rather than a single "magic bullet." We suggest a iv-element approach that integrates recommendations from the medical literature with examples from our experience. The elements are: create, familiarize, use, and integrate (Fig. iii). The elements are presented in judge social club of execution, although they have multiple, overlapping interconnections that tin can influence one some other, and some contain >1 subelement.

Effigy 3:

Four vital elements for implementing emergency manuals. © 2012 Diagram: S. Goldhaber-Fiebert and S. Howard.

We describe each element in detail below, giving relevant examples from both the nascent medical literature on the utilize of cognitive aids and from our experiences with iterative testing in simulation courses at our institution over the last decade.

Create

Elements and Attributes

To be of maximum apply, emergency manuals must focus on both medical content and blueprint. How the data is presented plays a vital role, every bit emphasized past an extensive review article that summarizes 5 considerations for creating effective checklists: context, content, structure, images, and usability.⁴⁰ A cognitive aid cannot replicate a comprehensive article, merely must present the important, current, evidence-based practices and recommendations. Moreover, a set of cognitive aids for a specific context, such as perioperative, should be in a format that is (1) sufficiently complete to encourage consultation without being overwhelming, (2) relevant for the intended clinical environment, and (3) organized in a way that is easy to find whatever specific cognitive aid during a crisis. Such a design facilitates optimal usability during a disquisitional upshot. Expertise in both the content and usability aspects is important for cosmos. Various helpful sets of cerebral aids or checklists, specific for anesthesia and perioperative medicine, have been published in contempo years inside explanatory articles or standing alone.^{5 , 41},^h,⁴²,ⁱ,⁴³ These resource have significant commonalities and all are intended to supplement, merely not to supervene upon, more in-depth educational activity and clinical judgment. Given many requests from practitioners at other institutions for an emergency transmission formatted for clinical usability, the Stanford Anesthesia Cognitive Help Group^j has made publicly available a no-price downloadable document, with a Creative Eatables license, which is hosted at http://emergencymanual.stanford.edu.

The emergency manuals that have been integrated into all perioperative areas at our institution address critical events that are mostly rare, just with high potential for bloodshed. As well included are some mutual perturbations, such as hypotension and hypoxemia, which may be refractory to initial treatment. The events are organized alphabetically, except that ACLS events are grouped separately in a front section. Simulation testing showed that placing the table of contents on the front end embrace allows for piece of cake reference (Fig. 4). Each event besides has a sidebar proper noun and number at the unbound edge, for like shooting fish in a barrel access (Fig. 5a).

Figure iv:

Forepart cover prominently displays tabular array of contents for easy reference. The most recent pdf of this emergency manual, by Stanford Anesthesia Cognitive Aid Group^j, is available for free download at http://emergencymanual.stanford.edu.

Effigy 5:

Examples of improvements from iterative simulation testing of 2012 Stanford Emergency Manual using the malignant hyperthermia (MH) cognitive aid, which now includes: (a) distinct sidebars with proper name and number of critical event listed on each folio's unbound edge; (b) emphasized importance of dantrolene, forth with readily accessible developed dose calculation and preparation. The calculation showing number of vials for a 70-kg developed has increased the efficient delivery of recommended initial dose of dantrolene in faux MH cases; (c) large arrows to decrease confusion nearly where to starting time reading on 2-folio cognitive aids. MH cognitive aid was developed past Stanford Anesthesia Cerebral Assist Group^j forth with Dr. Henry Rosenberg. This cognitive aid was adjusted from a prior version, originally published as function of Ref. 42ⁱ.

Simulation Testing

Consequent with the cognitive psychology literature described above, nosotros observed during many simulated scenarios and debriefings that having the right information nowadays in an accessible emergency manual does not guarantee that stressed anesthesiologists can easily find or utilize that data. Equally for the development of other checklists,⁴⁰ we constitute that it is vital to iteratively examination prototypes during simulated emergencies to develop constructive manuals. What appears clear to the developers of emergency manuals may be easily missed or misunderstood by the user during stressful crunch situations.

Iterative testing at our institution, during faux scenarios, has also shown the importance of appropriately emphasizing vital steps. For example, in the cognitive assist for malignant hyperthermia, treating with dantrolene was originally listed as 1 of many actions. When dantrolene was bolded and a 70-kg adult dose calculated, explicitly showing the number of vials required, practitioners accordingly focused more resources on preparing this disquisitional medication more rapidly, and in debriefings stated that their cognitive load of calculating dose details was decreased (Fig. 5b). In addition, two-page cognitive aids were initially labeled "continued from prior page" on the top of the 2nd page. Nevertheless, during imitation crises, multiple teams of trainees and of board-certified anesthesiologists mistakenly started reading from the 2d page, missing of import data on the starting time page. This effect was effectively addressed past adding large arrows (Fig. 5c), indicating that the material is connected from the prior page. The iterative testing process proved essential in allowing changes to be made to improve accessibility and usability.

Familiarize

Familiarity Is Crucial

The following example, executed during a series of simulation courses, illustrates this concept. A set of large-format ACLS cognitive aids was attached to the code cart, at chest peak and partially blocking the defibrillator monitor. Equally expected, each team moved the aids to see the defibrillator screen, and none felt they hindered their use of the defibrillator. Interestingly, even though all teams touched the ACLS instructions, many did not consult them, fifty-fifty when they were leaving out essential elements of cardiac abort management. During debriefing, the teams were asked why they had not used the provided cognitive aids. The vast majority answered "Where were they? We never saw them." The participants were perceptually blind⁴⁴ to the presence of these large, colorful resource. The video recordings showed the clinicians moving the cognitive aids, simply their brains probable viewed them to be extraneous during a stressful event because they were unfamiliar.

Grooming

An important goal of the training and familiarization described here is to enable clinicians to become practiced in using emergency manuals without neglecting firsthand patient care, like the crew that safely landed their plane in the Hudson River, while simultaneously consulting the engine failure section of their emergency transmission. In a study of 50 anesthesia residents managing simulated cardiac arrests, McEvoy et al.⁴⁵ showed that the residents performed better after they were trained in the use of ACLS cerebral aids. However, merely giving them an unfamiliar bill of fare to use failed to ameliorate performance, despite the fact that the card contained all the correct information for managing the specific critical event. They also establish that half dozen months later on the residents' operation, without a cognitive aid, had returned to baseline, echoing many studies showing rapid decay of ACLS training. The use of the familiar card at 6 months improved their operation to levels similar to those seen direct later on preparation, showing promise to increase effectiveness of intermittent trainings.

The findings of 2 national VA studies that examined awareness and use of cognitive aids,^{46 , 47} indicated that even if we could create a useful emergency manual (Element 1), our efforts would exist unsuccessful in affecting clinical direction until nosotros were able to: (1) increase awareness of the existence of emergency manuals; (two) convince practitioners that emergency manuals tin better their performance; and (3) familiarize practitioners with the manuals' specific formats. Anecdotally, at our institution's simulation courses there has been an upwards trend in emergency manual apply over the past decade of increased resident exposure, as well as a notable deviation betwixt courses when a brief immersive introduction to emergency manuals was provided or not.

Our experience concurs with a contempo editorial³² which stated that if emergency manuals are to be useful during critical events in ORs, and then broad integration into simulation trainings for clinicians will assist significantly. They should exist office of a simulation class'south prebriefing about expectations and resources, they must be hands accessible during each simulated scenario, and, when appropriate, they should be consulted during debriefings for review. Given the importance of familiarity, practitioners should exist trained during simulations to use the same emergency manuals that they volition use clinically. Emergency manuals should also be integrated into clinical grooming in an experiential way, increasing sensation of their existence and familiarity with their use.

Employ

Accessibility Is As well Crucial

Several years ago, we made a ring-jump set up of pocket cards for all first-year anesthesia residents, with larger versions for simulation training. These cards contained both ACLS events every bit well equally perturbations such as hypoxemia and hypotension. Text was combined with effective blueprint elements, such as rhythm strips, icons, and employ of color. Anecdotally, the start-year residents commented that they found them helpful for clinical events, for simulation courses, and for review. However, we found that 3 factors express the clinical employ of pocket cards: (one) Size: Any minor card is inherently limited by bachelor space, and is therefore more than difficult to read during a crisis; (2) Set: Because of size and weight limitations, pocket cards cannot include as large a ready of potentially relevant critical events; and (three) Location: Depending on clinicians to always carry their pocket cards with them will lead to organization failures because the cards will non always be available when needed.

These observations led us to create the large-format, durable, emergency manuals that nosotros currently use for each OR and perioperative location. Because they are located primarily in situ in ORs, simply similar emergency medications or devices, they are readily available and accessible for clinical utilise.

Specific Location

After surveying local anesthesiologists and observing pilot clinical utilize in the ORs, we decided to hang the spiral-leap, laminated book from a hook on the computer arm that connects the anesthesia automobile with the anesthesia workstation (Fig. 6). Although the most ideal specific location will differ per institution, emergency manuals should be given a consistent place in each OR that is both visible and easily accessible during a critical upshot, without blocking daily workflow. There is a balance also between valid concerns for security and unlimited mobility during an issue. Initially, nosotros addressed this result by giving a personal re-create to interested anesthesia residents and faculty and by printing them in bulk to keep costs downward and to provide for occasional replacement. A pocket-size just constant rate of loss led us to readdress this issue, and we decided to attach them by not only a hook but also by a 6-ft long metal chain to allow for flexibility with security. Although we provide electronic access to the aforementioned data on our internal website, simulation testing has made it clear that physical copies are currently much more than useful during a crunch.

Figure half-dozen:

Location of 2012 Stanford emergency manual: hanging from the computer arm near anesthesia machine. Placement should balance the need for accessibility and consistent location, without interfering with routine piece of work catamenia.

Importantly, having an emergency transmission accessible is not an culling to learning and teaching the material in depth. As the format becomes more than familiar, emergency manuals volition become more useful and can exist integrated into educational exercises as noted in the grooming section above.

Suggested Perioperative Use of Emergency Manuals

In that location are iii distinct types of utilise in the clinical environment, all of which can facilitate one another by increasing familiarity with both content and format: precrisis education, postcrisis debriefing, and during-crisis consultation (Fig. 2).

Precrisis educational "what if" exercises tin can exist conducted with teams, trainees, and for self-review. They can be related to the current patient's history and surgery, highlighting potential complications and how to ideally forbid them, and verbally practicing appropriate responses should these complications occur. This practice has the dual benefit of providing memorable learning for a trainee and improving patient management if the event occurs.

Postcrisis debriefing can assist change current or futurity patient management.⁴⁸ Once the patient is stabilized, a cognitive help can exist a resource to guide immediate debriefing, reinforcing learning for future events and potentially helping the current patient if some further actions are indicated. Ideally the entire clinical team should participate in this word, however there are many barriers to the review of clinical management afterwards a disquisitional event or nearly miss. Having emergency manuals accessible in the OR environs, and preparation all team members in their use, should help make debriefings of events more common and useful. For example, after stabilization from massive hemorrhage, either the anesthesia practitioners or, if practical, the entire OR squad can review what went well and any elements that could exist improved in the time to come. This debriefing should include both medical and technical elements, as well as CRM concepts and applicable systems issues (Fig. 1).

During-crisis utilize of emergency manuals can accept the most straight touch on on patient management, just is too the near challenging to implement effectively. For many events, initial life-sustaining interventions must be learned every bit reflex actions, such as the early response to astute hypotension or immediate chest compressions for cardiac abort. Still, emergency manuals can exist useful if the condition is rare, such every bit malignant hyperthermia requiring dantrolene; refractory, such every bit hypotension unresponsive to usual management; or when sufficient people are present to designate a reader role,³⁰ such as during a PEA cardiac abort. The combination of simulation training, precrisis educational uses, and postcrisis debriefings will make emergency manuals more familiar and, therefore, more than likely to be used effectively and efficiently during critical events.

Specified Roles

Prior studies found that it is hard for an event leader to perform all monitoring and communication duties while simultaneously reading from a cognitive aid.^{27 , 29} Brunt et al.³⁰ formally examined the additional function of a cerebral aid reader to help the leader during fake critical events. In 31 simulated crises, they found that before the introduction of a reader, fewer than a 3rd of teams consulted the available cognitive help and no teams completed all necessary steps for malignant hyperthermia or obstetric cardiac abort events. Later on a medical educatee, who was trained equally a reader offered scripted aid, functioning of missing steps greatly improved and all teams appreciated the help. There is still significant need to written report such a reader role in the clinical environment, including determining who might be the ideal individuals to role as team readers, given staffing and other patient care needs, appropriate training, and potential cultural issues. With multiple copies accessible and familiar, an extra bachelor anesthesia technician or nurse could also await ahead during an unstable result to anticipate and gather needed equipment.

Integrate

An accepting culture is vital for successful implementation of emergency manuals and interacts with all of the other elements. Practitioner feedback and involvement in the other 3 elements (create, familiarize, and utilize) ensures more than successful implementation both by integrating helpful suggestions and by increasing stakeholder buy-in.

The provision of constructive training sessions on the use of well-designed and accessible emergency manuals helps to positively influence practitioner attitudes. As the manuals become more familiar and as clinicians become convinced of their potential value through grooming as well as seeing them used successfully, they will become more likely to use the emergency manuals themselves.^{46 , 47}

System Examples

Later the VA'south National Center for Patient Safe developed and distributed cerebral aids to all VA ORs, 6 months later it was found that seven% of anesthesia providers had used them during an emergency.⁴⁷ Well-nigh emergency users had attended a local formal familiarization session and all felt that the cerebral aids were helpful during patient direction. About half of all responding providers had actively used the cognitive aids in the OR for educational purposes. No formal sessions were provided nationally, so grooming was left to local discretion. Both nonusers every bit well as those unaware of the cognitive aids were much less likely to have attended a grooming session than the user groups.

Our recent feel has been promising. Even when the scientific data are clear, affecting system changes in the practice of medicine is as difficult as changing personal habits such as diet and practise. Chip and Dan Heath provide helpful suggestions in their book Switch: How to Change Things When Alter Is Hard,⁴⁹ and we incorporated many of their suggested techniques when nosotros adult the implementation framework described here. Awareness of the manuals and excitement about their potential benefits have grown at our institutions. We included stakeholders from all relevant disciplines: anesthesia practitioners, surgeons, nursing staff, anesthesia technicians, surgical technicians, and hospital leadership. Presentations and interactive discussions during committee meetings served to both brainwash these stakeholders most emergency manuals, as well as to solicit and integrate their important feedback for successful implementation. Anesthesiologists, surgeons, and nurses started asking when emergency manuals would be fabricated available in every OR.

In 2012, we launched a system-wide Stanford initiative to have emergency manuals attainable in anesthetizing and perioperative locations of all affiliated hospitals. Training sessions have begun for relevant OR clinicians to increase awareness and familiarity. Immersive simulation-based techniques are being used to familiarize clinicians with the format of the emergency manuals, so that relevant medical information can be hands accessed (Fig. 7). Practitioners are as well being introduced to the primal points of CRM (Fig. one) and encouraged to include these concepts as part of debriefing sessions after critical events.

Effigy 7:

Use of emergency manual during a false cancerous hyperthermia critical result, to efficiently guide team in key management steps. © 2012: Photo by David Gaba.

Culture change is occurring. Departmental and hospital leaders now want all team members to be trained in their utilise. Since implementation, practitioners accept mentioned that the accessible and familiar emergency manuals were particularly helpful during specific critical events every bit well as for educational purposes.

CONCLUSIONS: APPLYING THE 4 ELEMENTS OF EMERGENCY Manual IMPLEMENTATION

Health intendance systems and health care practitioners have a challenge to improve the management of many critical events. Nosotros believe that the 4-element framework for the implementation of emergency manuals (create, familiarize, utilise, and integrate) volition help extend the benefits seen in simulation studies to improving patient care. We presented relevant examples from the literature and from the feel at our institution. Yet, further research is needed to evaluate all of the details of such a framework besides equally to determine the potential for broad generalizability. Our observations from many years of instruction simulation courses for multiple institutions, specialties, and levels of feel have reinforced the thought that emergency manuals address an unmet need and resonate almost universally with practicing clinicians. Many studies described in this article have shown that cerebral aids can help to change clinicians' deportment, at to the lowest degree in simulated (T1) settings. Since implementing emergency manuals at our institution, we have already gotten reports of several constructive uses during critical events, in add-on to before and after. In studying the elements of this framework in the futurity, the nearly meaningful questions may be whether the complete package is effective in irresolute practitioner actions in clinical settings (T2) and ultimately in affecting patient outcomes (T3). In the concurrently, the costs of not implementing emergency manuals are high besides, as observed in countless simulated and clinical scenarios where teams do not optimally utilise known best practices. We now have tools to change this, assuasive widespread implementation of emergency manuals and research on effectiveness.

DISCLOSURES

Name: Sara North. Goldhaber-Fiebert, Physician.

Contribution: Sara Northward. Goldhaber-Fiebert contributed to the ideas, concepts, and preparation of this manuscript.

Attestation: Sara N. Goldhaber-Fiebert approved the last manuscript.

Name: Steven M. Howard, Medico.

Contribution: Steven K. Howard contributed to the ideas, concepts, and preparation of this manuscript.

Attestation: Steven K. Howard canonical the final manuscript.

This manuscript was handled by: Sorin J. Brull, MD, FCARCSI.

ACKNOWLEDGMENTS

For their involvement in the Stanford emergency manual development or implementation projects, we are particularly grateful to: Kyle Harrison, Larry Chu, David Gaba, Ruth Fanning, Becky Wong, Diane Alejandro, Ron Pearl, Bryan Bohman, Randy Cook, Amir Rubin, Rina Horiuchi, and Flake Heath. We very much appreciate the numerous anesthesia residents, anesthesia faculty, surgeons, nurses, anesthesia technicians, and hospital leaders at Stanford and VA Palo Alto who accept provided feedback, excitement, and leadership throughout evolution and early on implementation. Finally, to David Gaba specifically, for his foresightful vision, encouragement, and tools to make healthcare safer, even when alter seems slow or hard at times.

FOOTNOTES

a Loss of thrust in both engines afterwards encountering a flock of birds and subsequent ditching on the Hudson River, U.S. Airways Flight 1549 Airbus A320-214, N106US Weehawken, New Jersey, January 15, 2009, Aircraft Accident Report NTSB/AAR-10 /03. Washington DC: National Transportation Safety Board, 2009. Available at: http://www.ntsb.gov/doclib/reports/2010/AAR1003.pdf. Accessed March 15, 2013.
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b Burian BK. Emergency and aberrant checklist blueprint factors influencing flight coiffure response: a example written report. Air Line Pilots Association Air Safe Week Forum. Washington, DC, 2004.
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c Burian BK. Design guidance for emergency and abnormal checklists in aviation. In: Proceedings of the Human Factors and Ergonomics Order 50th Annual Coming together. San Francisco, CA: SAGE Publications, 2006:106–10.
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d Staal MA. Stress, cognition, and human performance: a literature review and conceptual framework. NASA technical memorandum. Ames Inquiry Center, 2004.
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e Bourne LE, Yaroush RA. Stress and cognition: A cognitive psychological perspective. NASA grant NAG2-1561, 2003.
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f Personal communication, William Drupe, Harvard School of Public Health, 2013.
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m START program data. Bachelor at: start.stanford.edu. Accessed March 15, 2013. LF Chu, LK Ngai, CA Young, RG Pearl, A Macario, TK Harrison. Preparing interns for anesthesiology residency training: development and cess of the Successful Transition to Anesthesia Residency Grooming e-learning curriculum. J Grad Med Educ (in printing 2013).
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h For Reference 41, in the aforementioned journal issue there are 24 published "sub-algorithms" for specific critical events, each with explanatory text and a helpful figure.
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i For Reference 42, this appendix consists of cognitive aids for 21 dissever critical events. The offset 3 authors collaborated on all events. Authors iv through half dozen contributed on 1-2 critical events each.
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j Stanford Anesthesia Cognitive Assist Group core contributors in random order: Steven Howard, Larry Chu, Sara Goldhaber-Fiebert, David Gaba, Kyle Harrison.
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