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Gonzalez M, Brook K, Arriaga A, Hayes R, Nozari A, Ortega R. In Response. Anesth Analg 2024; 139:e4-e5. [PMID: 38885402 DOI: 10.1213/ane.0000000000007028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2024]
Affiliation(s)
| | | | | | | | - Ala Nozari
- Boston Medical Center, Boston, Massachusetts
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Clebone Ruskin A, Ahmed F, O'Connor M, Tung A. Why don't clinicians use checklists? Int Anesthesiol Clin 2024; 62:1-8. [PMID: 38410912 DOI: 10.1097/aia.0000000000000438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Affiliation(s)
- Anna Clebone Ruskin
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois
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Claeys A, Van Den Eynde R, Rex S. The use of cognitive aids in the operating room: a systematic review. ACTA ANAESTHESIOLOGICA BELGICA 2022. [DOI: 10.56126/73.3.18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Background: Cognitive aids (CAs) are clinical tools guiding clinical decision-making during critical events in the operating room. They may counteract the adverse effects of stress on the non-technical skills of the attending clinician(s). Although most clinicians acknowledge the importance of CAs, their uptake in clinical practice seems to be lagging behind. This situation has led us to investigate which features of CAs may enhance their uptake. Therefore, in this systematic review we explored the optimums regarding the 1) timing to consult the CA, 2) person consulting the CA, 3) location of the CA in the operating room, 4) CA design (paper vs. electronic), 5) CA lay-out, 6) reader of the CA and 7) if the use of CAs in the form of decision support tools lead to improved outcome.
Methods: Seven PICO-questions guided our literature search in 4 biomedical databases (MEDLINE, Embase, Web of Science and Google Scholar). We selected English-language randomized controlled trials (RCTs), observational studies and expert opinions discussing the use of cognitive aids during life-threatening events in the operating theatre. Articles discussing non-urgent or non-operating room settings were excluded. The quality of evidence was evaluated with the Grading of Recommendations Assessment, Development and Evaluation (GRADE).
Results: We found 7 RCTs, 14 observational studies and 6 expert opinions. All trials were conducted in a simulation environment. The person who should trigger the use of a cognitive aid and the optimal timing of its initiation, could not be defined by the current literature. The ideal location of the cognitive aids remains also unclear.
A favorable lay-out of an aid should be well-structured, standardized and easily readable. In addition, several potentially beneficial design features are described.
RCT’s could not demonstrate a possible superiority of either electronic or paper-based aids. Both have their advantages and disadvantages. Furthermore, electronic decision support tools are potentially associated with an enhanced performance of the clinician. Likewise, the presence of a reader was associated with an improved performance of key steps in the management of a critical event. However, it remains unclear who should fulfill this role.
Conclusion: Several features of the design or utilization of CAs may play a role in enhancing the uptake of CAs in clinical practice during the management of a critical event in the operating room. However, robust evidence supporting the use of a certain feature over another is lacking.
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Rineau E, Collard A, Jean L, Guérin S, Maunoury L, Martin L, Lasocki S, Léger M. Cognitive Aid for Anesthetic Preparation in An Emergency Situation: A Simulation-Based Study. Healthcare (Basel) 2021; 9:1646. [PMID: 34946372 PMCID: PMC8700863 DOI: 10.3390/healthcare9121646] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 11/17/2021] [Accepted: 11/25/2021] [Indexed: 01/28/2023] Open
Abstract
When anesthesia checklists and preparations are performed urgently, omissions may occur and be deleterious to the patient. The aim of this study was to evaluate in simulation the interest of a cognitive aid to effectively prepare an anesthetic room for an emergency. In a prospective single-center simulation-based study, 32 anesthesia residents had to prepare an anesthetic room in an emergency scenario, without cognitive aid in the first phase. Three months later (phase 2), they were randomly assigned to receive a cognitive aid (aid group) or no additional aid (control) and were involved in the same scenario. The primary outcome was the validation rate of each essential item in the first 5 min in phase 2. Eight items were significantly more frequently completed in the first 5 min in the aid group in phase 2 (vs. phase 1), compared with two only in the control group. However, there were no significant differences in the overall number of completed items between the two groups, as both groups completed significantly more items in phase 2, either in the first 5 min (19 (14-23) vs. 13 (9-15) in phase 1 for all residents, p < 0.001) or without time limit. Preparation times were reduced in phase 2 in both groups. In conclusion, the use of a cognitive aid allowed anesthesia residents to complete some safety items of a simulated urgent anesthesia preparation more frequently. In addition, despite daily clinical experience, a single simulation session improved anesthesia preparation and reduced the preparation time with or without cognitive aid.
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Affiliation(s)
- Emmanuel Rineau
- All’Sims Center for Medical Simulation, Health Faculty and University Hospital of Angers, 49100 Angers, France; (A.C.); (L.J.); (S.G.); (L.M.); (L.M.); (S.L.); (M.L.)
- Department of Anesthesia and Critical Care, University Hospital of Angers, 49100 Angers, France
| | - Anna Collard
- All’Sims Center for Medical Simulation, Health Faculty and University Hospital of Angers, 49100 Angers, France; (A.C.); (L.J.); (S.G.); (L.M.); (L.M.); (S.L.); (M.L.)
- Department of Anesthesia and Critical Care, University Hospital of Angers, 49100 Angers, France
| | - Lorine Jean
- All’Sims Center for Medical Simulation, Health Faculty and University Hospital of Angers, 49100 Angers, France; (A.C.); (L.J.); (S.G.); (L.M.); (L.M.); (S.L.); (M.L.)
- Department of Anesthesia and Critical Care, University Hospital of Angers, 49100 Angers, France
| | - Sarah Guérin
- All’Sims Center for Medical Simulation, Health Faculty and University Hospital of Angers, 49100 Angers, France; (A.C.); (L.J.); (S.G.); (L.M.); (L.M.); (S.L.); (M.L.)
- Department of Anesthesia and Critical Care, University Hospital of Angers, 49100 Angers, France
| | - Louise Maunoury
- All’Sims Center for Medical Simulation, Health Faculty and University Hospital of Angers, 49100 Angers, France; (A.C.); (L.J.); (S.G.); (L.M.); (L.M.); (S.L.); (M.L.)
- Department of Anesthesia and Critical Care, University Hospital of Angers, 49100 Angers, France
| | - Ludovic Martin
- All’Sims Center for Medical Simulation, Health Faculty and University Hospital of Angers, 49100 Angers, France; (A.C.); (L.J.); (S.G.); (L.M.); (L.M.); (S.L.); (M.L.)
- Department of Dermatology, University Hospital of Angers, 49100 Angers, France
| | - Sigismond Lasocki
- All’Sims Center for Medical Simulation, Health Faculty and University Hospital of Angers, 49100 Angers, France; (A.C.); (L.J.); (S.G.); (L.M.); (L.M.); (S.L.); (M.L.)
- Department of Anesthesia and Critical Care, University Hospital of Angers, 49100 Angers, France
| | - Maxime Léger
- All’Sims Center for Medical Simulation, Health Faculty and University Hospital of Angers, 49100 Angers, France; (A.C.); (L.J.); (S.G.); (L.M.); (L.M.); (S.L.); (M.L.)
- Department of Anesthesia and Critical Care, University Hospital of Angers, 49100 Angers, France
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Peran D, Kodet J, Pekara J, Mala L, Truhlar A, Cmorej PC, Lauridsen KG, Sari F, Sykora R. ABCDE cognitive aid tool in patient assessment - development and validation in a multicenter pilot simulation study. BMC Emerg Med 2020; 20:95. [PMID: 33276731 PMCID: PMC7718686 DOI: 10.1186/s12873-020-00390-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 11/29/2020] [Indexed: 11/18/2022] Open
Abstract
Background The so called ABCDE approach (Airway-Breathing-Circulation-Disability-Exposure) is a golden standard of patient assessment. The efficacy of using cognitive aids (CA) in resuscitation and peri-arrest situations remains an important knowledge gap. This work aims to develop an ABCDE CA tool (CAT) and study its potential benefits in patient condition assessment. Methods The development of the ABCDE CAT was done by 3 rounds of modified Delphi method performed by the members of the Advanced Life Support Science and Education Committee of the European Resuscitation Council. A pilot multicentre study on 48 paramedic students performing patient assessment in pre-post cohorts (without and with the ABCDA CAT) was made in order to validate and evaluate the impact of the tool in simulated clinical scenarios. The cumulative number and proper order of steps in clinical assessment in simulated scenarios were recorded and the time of the assessment was measured. Results The Delphi method resulted in the ABCDE CAT. The use of ABCDE CAT was associated with more performed assessment steps (804: 868; OR = 1.17, 95% CI: 1.02 to 1.35, p = 0.023) which were significantly more frequently performed in proper order (220: 338; OR = 1.68, 95% CI: 1.40 to 2.02, p < 0.0001). The use of ABCDE CAT did not prolong the time of patient assessment. Conclusion The cognitive aid for ABCDE assessment was developed. The use of this cognitive aid for ABCDE helps paramedics to perform more procedures, more frequently in the right order and did not prolong the patient assessment in advanced life support and peri-arrest care. Supplementary Information The online version contains supplementary material available at 10.1186/s12873-020-00390-3.
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Affiliation(s)
- David Peran
- Prague Emergency Medical Services, Prague, Czech Republic. .,Division of Public Health, 3rd Faculty of Medicine, Charles University in Prague, Prague, Czech Republic. .,Secondary Nursing School and Nursing College in Prague, Prague, Czech Republic. .,Medical College, Prague, Czech Republic.
| | - Jiri Kodet
- Prague Emergency Medical Services, Prague, Czech Republic.,Emergency Department, Motol University Hospital, Prague, Czech Republic
| | - Jaroslav Pekara
- Prague Emergency Medical Services, Prague, Czech Republic.,Medical College, Prague, Czech Republic
| | - Lucie Mala
- Secondary Nursing School and Nursing College in Prague, Prague, Czech Republic
| | - Anatolij Truhlar
- Emergency Medical Services of the Hradec Kralove Region, Hradec Kralove, Czech Republic.,Faculty of Medicine in Hradec Kralove, University Hospital Hradec Kralove, Charles University in Prague, Hradec Kralove, Czech Republic
| | - Patrik Christian Cmorej
- Emergency Medical Services of the Usti nad Labem Region, Usti nad Labem, Czech Republic.,Faculty of Health Studies, Jan Evangelista Purkyne University, Usti nad Labem, Czech Republic
| | - Kasper Glerup Lauridsen
- Department of Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, USA.,Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Internal Medicine, Randers Regional Hospital, Randers, Denmark
| | - Ferenc Sari
- Emergency Department, Skellefteå District General Hospital, Skellefteå, Sweden
| | - Roman Sykora
- Department of Anaesthesia and Intensive Care Medicine, 3rd Faculty of Medicine CU and University Hospital Kralovske Vinohrady, Charles University, Prague, Czech Republic.,Emergency Medical Services of Karlovy Vary Region, Karlovy Vary, Czech Republic
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6
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Luedi MM, Weinger MB. Emergency Manuals in Context: One Component of Resilient Performance. Anesth Analg 2020; 131:1812-1814. [DOI: 10.1213/ane.0000000000005105] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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7
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Abstract
Critical events are rare and stressful. These properties make reliance on memory for clinical management highly susceptible to failure. In the past 10 to 20 years, health care has begun to accept the experience of aviation and other high-reliability organizations in addressing failure to rescue from these events through a combination of practice through simulation and the introduction of cognitive aids, known as checklists or emergency manuals. Cognitive aids have a persuasive body of evidence from simulation studies to establish their value in improving clinician performance. However, their introduction to practice is more complex than distribution of the tools.
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Affiliation(s)
- Alexander A Hannenberg
- Ariadne Labs, 401 Park Drive 3-West, Boston, MA 02215, USA; Tufts University School of Medicine, Boston, MA, USA.
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Urman RD, August DA, Chung S, Jiddou AH, Buckley C, Fields KG, Morrison JB, Palaganas JC, Raemer D. The effect of emergency manuals on team performance during two different simulated perioperative crises: A prospective, randomized controlled trial. J Clin Anesth 2020; 68:110080. [PMID: 33032123 DOI: 10.1016/j.jclinane.2020.110080] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 08/25/2020] [Accepted: 09/20/2020] [Indexed: 11/16/2022]
Abstract
STUDY OBJECTIVE Whether having an emergency manual (EM) available for use during perioperative crises enhances or detracts from team performance, especially for multi-factorial diagnostic situations that do not explicitly match a chapter of the EM. DESIGN A simulation-based, prospective randomized trial based upon two perioperative crises, one involving a patient with a transfusion reaction for which the EM contains a specific chapter, and the other involving a patient with refractory hypotension progressing into septic shock for which the EM does not have a specific chapter. SETTING 52 regularly scheduled 6-h courses at the Center for Medical Simulation in Boston, Massachusetts, USA. STUDY GROUP 304 US-trained practicing anesthesiologists. INTERVENTIONS The absence or presence of the EM during the simulation case. MEASUREMENTS Teams were rated in the following categories: primary underlying diagnosis, fluid resuscitation, treatment of primary diagnosis, cardiac arrest management, overall crisis management, and (if applicable) EM usage. Also, raters recorded free-text 'field notes' about the usage-patterns and perceived utility of the EM. Using these 'field notes' and a two-stage, inductively revised procedure, two independent reviewers examined a subset of case videos for action analysis. MAIN RESULTS Performance ratings for a total of 51 teams and 95 simulations were included in the final analysis. No effect on performance was demonstrated with providing the EM in either the refractory hypotension/septic shock case or the transfusion reaction case, with the exception of the PEA arrest category. In the subset of simulations in which resuscitation from PEA arrest performance could be evaluated, EM availability was associated with an adjusted mean 1.3 point (99% confidence interval [CI]: 0.2, 2.4) improvement in performance in the transfusion reaction case (p = 0.004), but only an adjusted mean 0.2 point (99% CI, -0.7, 1.1) improvement in the refractory hypotension/septic shock case (p = 0.530) (p for interaction = 0.069). Analysis of actions found that when available, the EM was usually used, but often not until after cardiac arrest had occurred. In some cases, teams persisted with incorrect diagnoses and treatments irrespective of the presence or absence of an EM. CONCLUSIONS Providing an EM did not affect team performance in areas like diagnosis, treatment, fluid resuscitation, communication, and teamwork in management of perioperative crises such as transfusion reaction where an explicit chapter in the EM exists and refractory hypotension / septic shock where an explicit chapter does not exist. A suggestion of improved cardiac arrest resuscitation with the availability of an EM was found, but should be interpreted with caution given a limited sample size. Observed actions using the EM demonstrated that only about half of the teams used the EM to any substantive degree and most used it relatively late in the crisis. By observation, the EM appeared to be helpful in about half of the cases and did not, by itself, deter from appropriate management.
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Affiliation(s)
- Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, United States of America; Center for Perioperative Research, Brigham and Women's Hospitals, Boston, MA, United States of America.
| | - David A August
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, United States of America
| | - Scott Chung
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, United States of America
| | - Amanda H Jiddou
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, United States of America
| | - Carolyn Buckley
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, United States of America
| | - Kara G Fields
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, United States of America
| | - J Bradley Morrison
- Brandeis International Business School, Waltham, MA, United States of America
| | - Janice C Palaganas
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, United States of America
| | - Daniel Raemer
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, United States of America
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Abir G, Austin N, Seligman KM, Burian BK, Goldhaber-Fiebert SN. Cognitive Aids in Obstetric Units: Design, Implementation, and Use. Anesth Analg 2020; 130:1341-1350. [PMID: 31425259 DOI: 10.1213/ane.0000000000004354] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Obstetrics has unique considerations for high stakes and dynamic clinical care of ≥2 patients. Obstetric crisis situations require efficient and coordinated responses from the entire multidisciplinary team. Actions that teams perform, or omit, can strongly impact peripartum and perinatal outcomes. Cognitive aids are tools that aim to improve patient safety, efficiency in health care management, and patient outcomes. However, they are intended to be combined with clinician judgment and training, not as absolute or exhaustive standards of care for patient management. There is simulation-based evidence showing efficacy of cognitive aids for enhancing appropriate team management during crises, especially with a reader role, with growing literature supporting use in obstetric and nonobstetric clinical settings when combined with local customization and implementation efforts. The purpose of this article is to summarize current understanding and available resources for cognitive aid design, implementation, and use in obstetrics and to highlight existing gaps that can stimulate further enhancement in this field.
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Affiliation(s)
- Gillian Abir
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Naola Austin
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Katherine M Seligman
- Department of Anesthesiology and Critical Care Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Barbara K Burian
- Human Systems Integration Division, National Aeronautics and Space Administration, Ames Research Center, Moffett Field, Mountain View, California
| | - Sara N Goldhaber-Fiebert
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
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Clebone A, Watkins SC, Tung A. The timing of cognitive aid access during simulated pediatric intraoperative critical events. Paediatr Anaesth 2020; 30:676-682. [PMID: 32271972 DOI: 10.1111/pan.13868] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 03/18/2020] [Accepted: 03/22/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Many cognitive aids are formatted in a step-by-step fashion with the intent that the aid will be accessed at the beginning of a critical event and that key behaviors will be performed in sequence. AIMS We hypothesized that, during simulated pediatric intraoperative critical events, anesthesia clinicians may not use cognitive aids immediately after the onset of a critical event but instead access the aid only after first performing several key behaviors. MATERIALS AND METHODS This manuscript is a re-analysis of previously published simulation data. The original study involved 89 clinicians participating in 143 pediatric intraoperative events divided into 6 types: arrhythmia, venous air embolus, hypoxemia, malignant hyperthermia, hypotension, and supraventricular tachycardia. For each trial involving cognitive aid use, we measured the time from event trigger to cognitive aid use, and the number and type of key behaviors performed by simulation participants prior to cognitive aid access. RESULTS Cognitive aid use was sought in 66 of 93 trials where it was available. Sufficient data for this analysis were available in 65 trials. The average time from event trigger to first cognitive aid use was 258 seconds. In 62/65 trials (95%), the cognitive aid was accessed after at least one key behavior had already been performed. The time from event trigger to cognitive aid use varied by type of scenario (P = .03, df 5, adjusted H 12.78), with the shortest time for "supraventricular tachycardia" (90 [66,156] seconds (median [IQR]) and the longest time for "hypoxemia" (354 [192,492] seconds). CONCLUSION In simulated critical events, anesthesia residents and student nurse anesthetists often consulted a cognitive aid only after first performing at least some key behaviors. Incorporating the possibility of delayed access into critical event cognitive aid design may facilitate the effectiveness of that aid.
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Affiliation(s)
- Anna Clebone
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois
| | - Scott C Watkins
- Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Avery Tung
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois
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Use of Cognitive Aids: Results from a National Survey among Anaesthesia Providers in France and Canada. Anesthesiol Res Pract 2020; 2020:1346051. [PMID: 32454815 PMCID: PMC7225858 DOI: 10.1155/2020/1346051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 04/09/2020] [Indexed: 12/13/2022] Open
Abstract
Introduction The use of cognitive aids (CAs) during critical events is thought to be useful. However, whether CAs are known and used by French and Canadian anaesthesia providers is not clear. Methods A survey was emailed to French and Canadian anaesthesia providers in 2017 through their respective national societies. It consisted of 23 questions about the participants' demographics and their knowledge, use, and impact of CAs. A second survey was sent to French simulation centres. Results 912 responses were recorded in France and 278 in Canada (overall response rate: 7% and 11%, respectively). Among the respondents, 700/899 in France (78%) versus 249/273 (91%) in Canada were familiar with the concept of cognitive dysfunction during a crisis and 501/893 (56%) in France versus 250/271 (92%) in Canada knew the concept of CAs. Amongst those respondents who knew about CAs, 189/492 (38%) in France versus 108/244 (44%) in Canada stated that they had already used a CA in real life and 225/493 (45%) in France versus 126/245 (51%) in Canada had received training in their use. Simulation was the principal modality for training in 150/225 (67%) of cases in France versus 47/126 (37%) in Canada. Among the 28/50 French simulation centres which responded (2018 January), 27 organised sessions in anaesthesia and 22 used CAs. Conclusion CAs were better known in Canada than in France, but their actual use in real life was low in both countries. Simulation appears to play a potentially important role training anaesthesia providers in the use of CAs.
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12
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Clebone A, Burian BK, Tung A. The effect of cognitive aid design on the perceived usability of critical event cognitive aids. Acta Anaesthesiol Scand 2020; 64:378-384. [PMID: 31709509 DOI: 10.1111/aas.13503] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 10/06/2019] [Accepted: 10/28/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Critical events require that clinicians process information and make decisions quickly. To reduce mental workload during such events, cognitive aids have been developed. We have previously observed that designing such aids to facilitate discrete information transfer decreased time to information finding. However, whether clinicians perceive aids designed for discrete information transfer as more usable than step-by-step designs remains unclear. We hypothesized that experimental cognitive aids designed for discrete information transfer would be judged more usable than step-by-step Linear aids. METHODS Volunteer clinicians were asked to use cognitive aids during low fidelity simulation scenarios. Experimental cognitive aids featuring color-coded, labeled, and consistently located content clusters were compared with aids formatted in a traditional step-by-step fashion. We then performed a quantitative assessment of perceived usability and conducted structured knowledge elicitation interviews. RESULTS Clinicians rated the two experimental cognitive aids as more usable than the Linear aid. On a 0-100 scale the median (IQR) rating was 25(18,23) for the Linear aid and 89(80,95) and 81(65,90) for the two experimental designs, respectively, with a higher number indicating greater ease of use (P < .01 for each). Narrative responses suggested specific features that improved usability and a thematic analysis identified six major themes driving preference for cognitive aid use. CONCLUSION During simulated critical events, cognitive aids designed for discrete information transfer were considered more usable than step by step Linear aids. Specific themes governing usability were identified during mixed methods analysis. Further work is needed to optimize cognitive aid use among anesthesia clinicians.
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Affiliation(s)
- Anna Clebone
- Department of Anesthesia and Critical Care University of Chicago Chicago IL USA
| | - Barbara K. Burian
- Human Systems Integration Division NASA Ames Research Center Mountain View CA USA
| | - Avery Tung
- Department of Anesthesia and Critical Care University of Chicago Chicago IL USA
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13
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Development and Evaluation of a Cognitive Aid Booklet for Use in Rapid Response Scenarios. Simul Healthc 2020; 14:217-222. [PMID: 31116168 DOI: 10.1097/sih.0000000000000369] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Rapid response teams (RRTs) have become ubiquitous among hospitals in North America, despite lack of robust evidence supporting their effectiveness. Many RRTs do not yet use cognitive aids during these high-stakes, low-frequency scenarios, and there are no standardized cognitive aids that are widely available for RRTs on medicine patients. We sought to design an emergency manual to improve resident performance in common RRT calls. METHODS Residents from the New York University School of Medicine Internal Medicine Residency Program were asked to volunteer for the study. The intervention group was provided with a 2-minute scripted informational session on cognitive aids as well as access to a cognitive aid booklet, which they were allowed to use during the simulation. RESULTS Resident performance was recorded and scored by a physician who was blinded to the purpose of the study using a predefined scoring card. Residents in the intervention group performed significantly better in the simulated RRT, by overall score (mean score = 7.33/10 and 6.26/10, respectively, P = 0.02), and by performance on the two critical interventions, giving the correct dose of naloxone (89% and 39%, respectively, P < 0.001) and checking the patient's blood glucose level (93% and 52%, respectively, P = 0.001). CONCLUSIONS In a simulated scenario of opiate overdose, internal medicine residents who used a cognitive aid performed better on critical tasks than those residents who did not have a cognitive aid. The use of an appropriately designed cognitive aid with sufficient education could improve performance in critical scenarios.
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14
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Kolawole H, Guttormsen AB, Hepner DL, Kroigaard M, Marshall S. Use of simulation to improve management of perioperative anaphylaxis: a narrative review. Br J Anaesth 2019; 123:e104-e109. [DOI: 10.1016/j.bja.2019.01.035] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 01/10/2019] [Accepted: 01/17/2019] [Indexed: 01/12/2023] Open
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Abstract
The aim of this review is to highlight the latest movements surrounding Emergency Manual (EM) implementation nationally and abroad within perioperative medicine with a focus on studies linking EM to patient safety. This is a comprehensive literature review which includes a brief introduction to the definition and history of EM as well as an overview of a successful implementation strategy, international influence and correlations to patient safety. The recent changes in healthcare and healthcare reimbursement have directed the focus throughout healthcare to quality improvement and patient safety. The potential of EMs' application to improve patient outcomes has influential implications both on patient outcomes as well as reimbursements. This study includes relevant citations with the large majority published in the last five years. EM implementation in healthcare has grown within the US and internationally over the last decade. Prominent organizations have created EMs containing principles of evidence-based medicine and widely accepted protocols that have been endorsed by major entities in the medical field. Successful implementation strategies primarily focus on different forms of simulation training and have been found to increase adherence to protocols through EM use. An increasing amount of educational institutions and healthcare facilities worldwide are perpetuating such implementation and a growing number of successful cases are being published.
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Affiliation(s)
- Wayne R Simmons
- Anesthesiology, Hospital Corporation of America West Florida Graduate Medical Education Consortium / Oak Hill Hospital, Brooksville, USA
| | - Jeff Huang
- Anesthesiology, University of Central Florida College of Medicine, Orlando, USA
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Huang J, Hoang P, Simmons WR, Zhang J. Free Emergency Manual Books Improve Actual Clinical Use During Crisis in China. Cureus 2019; 11:e4821. [PMID: 31403011 PMCID: PMC6682387 DOI: 10.7759/cureus.4821] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction Emergency manuals (EM) are widely implemented and effective tools for anesthesiologists and perioperative teams to manage patients during critical events. Team simulation studies have shown that the use of training aids and checklists decreases human error. Previous research has examined the use of EM at hospitals in the United States, but few studies have explored its impact in an international setting. In this paper, we conduct a nationwide survey in China to assess the implementation and effectiveness of EM in clinical settings. Methods Based on the known benefits of using these training aids, we hypothesize that introducing EM will improve team response and reduce errors during crisis management. Copies of the translated Stanford University Operating Room Emergency Handbook were distributed free of charge to hospital anesthesiology departments across China. A survey was then sent out to members of the New Youth Anesthesia Forum, a social networking group of over 100,000 anesthesiologists. Results Respondents (n = 818) were separated based on whether or not they received the free EM (yes = 410; no = 408). Our study found that groups who received the manuals demonstrated significantly higher levels of self-review, group study, simulation training participation, and usage during critical events than groups that did not receive the free books (respectively; p < 0.001). Conclusions These findings strengthen prior evidence suggesting that implementing EM can contribute to the effective management of acute events in a hospital and preoperative setting. Overall, EM can minimize preventable patient risk and benefit anesthesiologists in their clinical practice. These findings indicate that free books can enhance the implementation of emergency manual and actual emergency manual use during critical events.
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Affiliation(s)
- Jeffrey Huang
- Anesthesiology, University of Central Florida College of Medicine, Orlando, USA
| | - Peter Hoang
- Anesthesiology, University of Central Florida College of Medicine, Orlando, USA
| | - Wayne R Simmons
- Anesthesiology, Hospital Corporation of America West Florida Graduate Medical Education Consortium / Oak Hill Hospital, Brooksville, USA
| | - Jianfeng Zhang
- Anesthesiology, Xiangyang Central Hospital, Xiangyang, CHN
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Marshall SD. Lost in translation? Comparing the effectiveness of electronic-based and paper-based cognitive aids. Br J Anaesth 2019; 119:869-871. [PMID: 29028936 DOI: 10.1093/bja/aex263] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Affiliation(s)
- S D Marshall
- Department of Anaesthesia, and Perioperative Medicine, Monash University, Melbourne, Australia.,Department of Medical Education, University of Melbourne, Melbourne, Australia.,Department of Anaesthesia and Pain Medicine, Peninsula Health, Melbourne, Australia
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Schild S, Sedlmayr B, Schumacher AK, Sedlmayr M, Prokosch HU, St Pierre M. A Digital Cognitive Aid for Anesthesia to Support Intraoperative Crisis Management: Results of the User-Centered Design Process. JMIR Mhealth Uhealth 2019; 7:e13226. [PMID: 31033445 PMCID: PMC6658227 DOI: 10.2196/13226] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Revised: 02/05/2019] [Accepted: 02/09/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Stressful situations during intraoperative emergencies have negative impact on human cognitive functions. Consequently, task performance may decrease and patient safety may be compromised. Cognitive aids can counteract these effects and support anesthesiologists in their crisis management. The Professional Association of German Anesthesiologists set up a project to develop a comprehensive set of digital cognitive aids for intraoperative emergencies. A parallel development for several software platforms and stationary and mobile devices will accommodate the inhomogeneity of the information technology infrastructure within German anesthesia departments. OBJECTIVE This paper aimed to provide a detailed overview of how the task of developing a digital cognitive aid for intraoperative crisis management in anesthesia was addressed that meets user requirements and is highly user-friendly. METHODS A user-centered design (UCD) process was conducted to identify, specify, and supplement the requirements for a digital cognitive aid. The study covered 4 aspects: analysis of the context of use, specification of user requirements, development of design solutions, and evaluation of design solutions. Three prototypes were developed and evaluated by end users of the application. Following each evaluation, the new requirements were prioritized and used for redesign. For the first and third prototype, the System Usability Scale (SUS) score was determined. The second prototype was evaluated with an extensive Web-based questionnaire. The evaluation of the third prototype included a think-aloud protocol. RESULTS The chosen methods enabled a comprehensive collection of requirements and helped to improve the design of the application. The first prototype achieved an average SUS score of 74 (SD 12), indicating good usability. The second prototype included the following main revisions: 2-column layout, initial selection of patient type (infant, adult, or parturient), 4 offered search options, and the option to check off completed action steps. Its evaluation identified the following major revision points: add quick selection for resuscitation checklists, design the top bar and tabs slightly larger, and add more pictograms to the text. The third prototype achieved an average SUS score of 77 (SD 15). The evaluation of the think-aloud protocol revealed a good intuitiveness of the application and identified a missing home button as the main issue. CONCLUSIONS Anesthesiology-as an acute medical field-is particularly characterized by its high demands on decision making and action in dynamic, or time-critical situations. The integration of usability aspects is essential for everyday and emergency suitability. The UCD process allowed us to develop a prototypical digital cognitive aid, exhibiting high usability and user satisfaction in the demanding environment of anesthesiological emergencies. Both aspects are essential to increase the acceptance of the application in later stages. The study approach, combining different methods for determining user requirements, may be useful for other implementation projects in a highly demanding environment.
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Affiliation(s)
- Stefanie Schild
- Department of Medical Informatics, Biometrics and Epidemiology, Chair of Medical Informatics, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - Brita Sedlmayr
- Center for Evidence-based Healthcare, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Ann-Kathrin Schumacher
- Department of Medical Informatics, Biometrics and Epidemiology, Chair of Medical Informatics, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - Martin Sedlmayr
- Carl Gustav Carus Faculty of Medicine, Institute for Medical Informatics and Biometry, Technische Universität Dresden, Dresden, Germany
| | - Hans-Ulrich Prokosch
- Department of Medical Informatics, Biometrics and Epidemiology, Chair of Medical Informatics, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - Michael St Pierre
- Anästhesiologische Klinik, Universitätsklinikum Erlangen, Erlangen, Germany
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- Berufsverband Deutscher Anästhesisten, Nürnberg, Germany
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Matching design to use: a task analysis comparison of three cognitive aid designs used during simulated crisis management. Can J Anaesth 2019; 66:658-671. [DOI: 10.1007/s12630-019-01325-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 12/29/2018] [Accepted: 12/31/2018] [Indexed: 10/27/2022] Open
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Affiliation(s)
- Lisa Caplan
- *Department of Anesthesiology and Pediatrics, Baylor College of Medicine, Houston, Texas †Department of Anesthesiology, Perioperative, and Pain Medicine, Texas Children's Hospital, Houston, Texas
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Abstract
PURPOSE OF REVIEW Trauma is the most common cause of pediatric mortality. Much of the research that led to life-saving interventions in adults, however, has not been replicated in the pediatric population. Children have important physiologic and anatomic differences from adults, which impact hemostasis and transfusion. Hemorrhage is a leading cause of death in trauma, and children have important differences in their coagulation profiles. Transfusion strategies, including the massive transfusion protocol and use of antifibrinolytics, are still controversial. In addition to the blood that is lost from the injury itself, trauma leads to inflammation and to a dysfunction in hemostasis, causing coagulopathy. RECENT FINDINGS In one study in which children suffered from mainly blast and penetrating injuries in a combat setting (PEDTRAX trial), the early administration of tranexamic acid was associated with decreased mortality. Some authors suggest that this result may not apply to blunt trauma, which is much more common in children in noncombat settings. Using thromboelastography to guide the administration of recombinant Factor VIIa has been done in selected cases and may represent a future avenue of research. SUMMARY This article explores new research from the past year in pediatric trauma, starting with the physiologic differences in pediatric red blood cells and coagulation profiles. We also looked at the dramatic change in thinking over the past decade in the tolerable level of anemia in critically ill pediatric patients, as well as scales for determining the need for massive transfusion and exploring if the concepts of damage control resuscitation apply to children. Other strategies, such as avoiding hypothermia, and the selective administration of antifibriniolytics, are important in pediatric trauma as well. Future research that is pediatric focused is needed for the optimal care of our youngest patients.
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Goldhaber-Fiebert SN, Macrae C. Emergency Manuals: How Quality Improvement and Implementation Science Can Enable Better Perioperative Management During Crises. Anesthesiol Clin 2018; 36:45-62. [PMID: 29425598 DOI: 10.1016/j.anclin.2017.10.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
How can teams manage critical events more effectively? There are commonly gaps in performance during perioperative crises, and emergency manuals are recently available tools that can improve team performance under stress, via multiple mechanisms. This article examines how the principles of implementation science and quality improvement were applied by multiple teams in the development, testing, and systematic implementations of emergency manuals in perioperative care. The core principles of implementation have relevance for future patient safety innovations perioperatively and beyond, and the concepts of emergency manuals and interprofessional teamwork are applicable for diverse fields throughout health care.
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Affiliation(s)
- Sara N Goldhaber-Fiebert
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, 300 Pasteur Drive, Room H3580, Stanford, CA 94305-5640, USA.
| | - Carl Macrae
- Department of Experimental Psychology, University of Oxford, Tinbergen Building, 9 South Parks Road, Oxford OX1 3UD, UK
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Physiologically Triggered Digital Cognitive Aid Facilitates Crisis Management in a Simulated Operating Room. Simul Healthc 2017; 12:370-376. [DOI: 10.1097/sih.0000000000000270] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Crisis checklists and emergency manuals are cognitive aids that help team performance and adherence to evidence-based practices during operating room crises. Resources to enable local implementation and training (key for effective use) are linked at http://www.emergencymanuals.org.
Supplemental Digital Content is available in the text.
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Clebone A, Burian BK, Watkins SC, Gálvez JA, Lockman JL, Heitmiller ES. The Development and Implementation of Cognitive Aids for Critical Events in Pediatric Anesthesia: The Society for Pediatric Anesthesia Critical Events Checklists. Anesth Analg 2017; 124:900-907. [PMID: 28079584 DOI: 10.1213/ane.0000000000001746] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Cognitive aids such as checklists are commonly used in modern operating rooms for routine processes, and the use of such aids may be even more important during critical events. The Quality and Safety Committee of the Society for Pediatric Anesthesia (SPA) has developed a set of critical-event checklists and cognitive aids designed for 3 purposes: (1) as a repository of the latest evidence-based and expert opinion-based information to guide response and management of critical events, (2) as a source of just-in-time information during critical events, and (3) as a method to facilitate a shared understanding of required actions among team members during a critical event. Committee members, who represented children's hospitals from across the nation, used the recent literature and established guidelines (where available) and incorporated the expertise of colleagues at their institutions to develop these checklists, which included relevant factors to consider and steps to take in response to critical events. Human factors principles were incorporated to enhance checklist usability, facilitate error-free accomplishment, and ensure a common approach to checklist layout, formatting, structure, and design.The checklists were made available in multiple formats: a PDF version for easy printing, a mobile application, and at some institutions, a Web-based application using the anesthesia information management system. After the checklists were created, training commenced, and plans for validation were begun. User training is essential for successful implementation and should ideally include explanation of the organization of the checklists; familiarization of users with the layout, structure, and formatting of the checklists; coaching in how to use the checklists in a team environment; reviewing of the items; and simulation of checklist use. Because of the rare and unpredictable nature of critical events, clinical trials that use crisis checklists are difficult to conduct; however, recent and future simulation studies with adult checklists provide a promising avenue for future validation of the SPA checklists. This article will review the developmental steps in producing the SPA crisis checklists, including creation of content, incorporation of human factors elements, and validation in simulation. Critical-events checklists have the potential to improve patient care during emergency events, and it is hoped that incorporating the elements presented in this article will aid in successful implementation of these essential cognitive aids.
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Affiliation(s)
- Anna Clebone
- From the *Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois; †NASA Ames Research Center, Moffett Field, California; ‡Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee; §Department of Anesthesiology & Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania; and ‖Division of Anesthesiology, Pain and Perioperative Medicine, Children's National Health System, Washington, DC
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Marshall SD. Helping experts and expert teams perform under duress: an agenda for cognitive aid research. Anaesthesia 2017; 72:289-295. [PMID: 27804114 PMCID: PMC5324704 DOI: 10.1111/anae.13707] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- S. D. Marshall
- Central Clinical SchoolMonash UniversityAustralia
- University of MelbourneAustralia
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Hendrickx JFA, De Wolf AM. Journal of clinical monitoring and computing 2016 end of year summary: anesthesia. J Clin Monit Comput 2017; 31:1-4. [PMID: 28064412 DOI: 10.1007/s10877-017-9977-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 12/21/2016] [Indexed: 11/28/2022]
Abstract
Clinical monitoring and computing are essential during general anesthesia. As a result it would be impossible to review all the articles published in the Journal of Clinical Monitoring and Computing that are relevant to anesthesia. We therefore will limit this summary to those articles that are uniquely related to anesthesia. The topics include: anesthesia machines; ensuring the airway; anesthetic depth; neuromuscular transmission monitoring; locoregional anesthesia; ultrasound; and pain.
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Affiliation(s)
- Jan F A Hendrickx
- Department of Anesthesiology, Intensive Care and Pain Therapy, OLV Hospital, Moorselbaan 164, 9300, Aalst, Belgium.
| | - Andre M De Wolf
- Department of Anesthesiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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