Emergency manual implementation: can brief simulation-based or staff trainings increase familiarity and planned clinical use?

Use of Emergency Manuals to Treat Delayed Emergence After Robotic-Assisted Cholecystectomy

Delayed emergence is defined as failure to regain consciousness 30 to 60 minutes after general anesthesia. Although incidence is low and difficult to accurately estimate, there is a wide differential diagnosis to be considered. Emergency manuals (EMs) are visual cognitive aids that can be used in the operating room to help manage intraoperative complications. They provide immediate access to evidence-based guidelines to optimize management of intraoperative complications. They are being increasingly implemented in the clinical setting and have been shown to improve patient safety. A case of a patient with delayed emergence after undergoing robotic-assisted cholecystectomy is described here. The delayed emergence section of the Stanford Anesthesia Emergency Model was referenced immediately and guided management of the patient. Utilization of an EM resulted in rapid return to baseline mental status. EMs allow health care providers to respond to intraoperative scenarios efficiently and effectively and ultimately improve patient care.

Use of Emergency Manuals to Treat Intraoperative Supraventricular Tachycardia and Hypotension During Exploratory Laparotomy

Although intraoperative tachyarrhythmias are relatively common, their appropriate management is pertinent to reducing morbidity and mortality. In certain clinical scenarios, the initial steps of managing intraoperative tachyarrhythmias may be ambiguous. Emergency manuals (EMs) are cognitive aids that improve the outcome of critical events by providing current, medically established guidelines on management. The case of a patient with an intraoperative supraventricular tachycardia with narrow, irregular QRS complexes and refractory hypotension is described here. Relevant sections of Stanford Anesthesia Emergency Manual were activated immediately and guided the anesthesiologists in treating the patient’s arrhythmia. The utilization of an EM allowed rapid selection of a pharmacologic agent that achieved hemodynamic stability. EMs allow healthcare providers to respond more appropriately and efficiently during critical events and thus directly improve patient care.

Use of an Emergency Manual During an Intraoperative Pulmonary Arterial Rupture, Hypoxemia, and Bradycardia

The use of an emergency manual can improve team performance on critical steps during crisis events. Measures of improved performance have so far been captured through survey and simulation data; however, real-life case studies showing successful use of the manuals are fewer in number. The case of a patient with an unexpected rupture of the pulmonary artery, hypoxemia, and bradycardia during a video-assisted thoracic surgery lobectomy is described here. Relevant sections of Stanford University Operating Room Emergency Manuals were activated immediately and used during the rescue. The team of surgeons, anesthesiologists, and nurses managed the crisis in an orderly, smooth, and efficient manner, and the patient recovered without any complication. The use of the emergency manual reinforced by regular simulation-based training benefited the team and ultimately, the patient’s safety.

Emergency Manual Implementation in a Large Academic Anesthesia Practice: Strategy and Improvement in Performance on Critical Steps

BACKGROUND

The use of cognitive aids, such as emergency manuals (EMs), improves team performance on critical steps during crisis events. In our large academic anesthesia practice, we sought to broadly implement an EM and subsequently evaluate team member performance on critical steps.

METHODS

We observed the phases of implementing an EM at a large academic anesthesia practice from 2013 to 2016, including the formation of the EM implementation team, identification of preferred EM characteristics, consideration of institution-specific factors, selection of the preferred EM, recognition of logistical barriers, and staff education. Utilization of the EM was tested in a regular clinical environment with all available resources using a standardized verbal simulation of 3 crisis events both preimplementation and 6 months postimplementation. Individual members of the anesthesia team were asked to verbalize interventions for specific crisis events over 60 seconds.

RESULTS

We introduced a customized version of the Stanford Emergency Manual on January 26, 2015. Fifty-nine total participants (equal proportion of anesthesiology attending physicians, resident physicians, certified registered nurse anesthetists, and student registered nurse anesthetist staff) were surveyed in the preimplementation phase and 60 in the 6-month postimplementation phase. In the postimplementation phase, a minority (41.7%) utilized the EM for the verbal-simulated crisis events. Those who used the EM performed better than those who did not (median 21.0 critical steps out of a possible 30 total steps [70.0%], interquartile range 19-25 vs 18.0 critical steps verbalized [60.0%], interquartile range 16-20; P < .001). Among all subjects, the median number of critical steps verbalized was 16 (53.3%) preimplementation and 19.5 critical steps (65.0%) postimplementation.

CONCLUSIONS

Implementation of an EM in a large academic anesthesia practice is not without challenges. While full integration of the EM was not achieved 6 months after implementation, verbalization of critical steps on 3 simulated crisis events improved when the EM was utilized.

Operating Room Emergency Manuals Improve Patient Safety: A Systemic Review

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. 

Free Emergency Manual Books Improve Actual Clinical Use During Crisis in China

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.

Impact of Critical Event Checklists on Anaesthetist Performance in Simulated Operating Theatre Emergencies

Introduction Crises in the operating theatre during a paediatric case are rare with the incidence of anesthesia-related cardiac arrest in non-cardiac patients being 1.4/10,000. In order to address this, the Society for Pediatric Anesthesia (SPA) developed cognitive aids (CAs) in the form of Critical Event Checklists (SPA CECs). Several studies have demonstrated the benefit of CAs in improving performance of critical tasks. Despite the presence of CAs, individuals often do not use the aids consistently. The objective of our study was to investigate whether the presence of SPA CECs, and orientation to these tools, improve the performance of trainees during simulated critical events. Methods With local Research Ethics Board (REB) approval we used a randomized, 2 x 2 factorial design. The first randomization was the participant orientation to the SPA CECs (e-module vs. didactic). The second randomization assigned participants to complete the simulations with or without SPA CECs available. The simulations were videoed and rated by two raters using a scenario-specific checklist and global rating scale (GRS). Results We conducted 78 simulations. The SPA CEC was used in 17.9% of scenarios. The SPA CEC was used in 44.8% of diagnosis-based scenarios and only 2.0% of generic problem-based scenarios. Participants' performance was superior with the SPA CEC present (GRS mean 3 [SD 1.27]) than without the SPA CEC available (GRS mean 2.43 [SD 0.89]) (p = 0.048). Conclusion Overall, we showed that uptake of the SPA CECs is poor. We also demonstrated that when the SPA CECs are utilized, they enhance the performance of trainees in simulated operating room (OR) critical events.

Bringing Perioperative Emergency Manuals to Your Institution: A "How To" from Concept to Implementation in 10 Steps

BACKGROUND

Emergency manuals (EMs) are context-relevant sets of crisis checklists or cognitive aids designed to enable professional teams to deliver optimal care during critical events. Evidence from simulation and other high-risk industries have proven that use of these types of checklists can significantly improve event management and decrease omissions of key steps. However, simply printing and placing tools in operating rooms (ORs) is unlikely to be effective. How interventions are implemented influences whether clinicians actually change practice and whether patient care is affected. This article provides an in-depth description of a rigorous implementation plan with three goals: (1) place EMs in every anesthetizing location, (2) create interprofessional engagement, and (3) demonstrate that a majority of anesthesia clinicians would use the new tool in some way within the first year.

METHODS

The implementation of EMs included 10 steps across four distinct phases. EM use was measured using an electronic quality assurance tool, with data collected after each case about whether and how the EM was used.

RESULTS

During the six months following implementation, 67.0% of clinicians had used the manual, with 24.1% using it for clinical care and 9.2% using it during a critical event.

CONCLUSION

This article presents a framework and detailed description of the steps a large academic institution followed in successfully implementing EMs. In conjunction with other available resources, those interested in introducing OR EMs at large, complex institutions may benefit from the experience shared in anticipating challenges and overcoming barriers to adoption.

Using Simulation to Implement an OR Cardiac Arrest Crisis Checklist

Crisis checklists are cognitive aids used to coordinate care during critical events. Simulation training is a method to validate process improvement initiatives such as checklist implementation. In response to concerns staff members expressed regarding their comfort level when responding to infrequent occurrences such as cardiac arrest and other OR emergencies, the OR Comprehensive Unit-based Safety Program team at our facility decided to institute the use of crisis checklists in the OR during critical events. We provided 90-minute education sessions, simulation opportunities, and debriefings to help staff members become more comfortable using these checklists. Based on program evaluations, 80% of staff members who participated in the training expressed an increased comfort level when caring for a patient in cardiac arrest.

The Development and Implementation of Cognitive Aids for Critical Events in Pediatric Anesthesia: The Society for Pediatric Anesthesia Critical Events Checklists

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.

In Situ Operating Room-Based Simulation: A Review

OBJECTIVE

To systematically review the literature surrounding operating room-based in situ training in surgery.

METHODS

A systematic review was conducted of MEDLINE. The review was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology, and employed the Population, Intervention, Comparator, Outcome (PICO) structure to define inclusion/exclusion criteria. The Kirkpatrick model was used to further classify the outcome of in situ training when possible.

RESULTS

The search returned 308 database hits, and ultimately 19 articles were identified that met the stated PICO inclusion criteria. Operating room-based in situ simulation is used for a variety of purposes and in a variety of settings, and it has the potential to offer unique advantages over other types of simulation. Only one randomized controlled trial was conducted comparing in situ simulation to off-site simulation, which found few significant differences. One large-scale outcome study showed improved perinatal outcomes in obstetrics.

CONCLUSIONS

Although in situ simulation theoretically offers certain advantages over other types of simulation, especially in addressing system-wide or environmental threats, its efficacy has yet to be clearly demonstrated.

Crisis checklists for in-hospital emergencies: expert consensus, simulation testing and recommendations for a template determined by a multi-institutional and multi-disciplinary learning collaborative

Background

‘Failure to rescue’ of hospitalized patients with deteriorating physiology on general wards is caused by a complex array of organisational, technical and cultural failures including a lack of standardized team and individual expected responses and actions. The aim of this study using a learning collaborative method was to develop consensus recomendations on the utility and effectiveness of checklists as training and operational tools to assist in improving the skills of general ward staff on the effective rescue of patients with abnormal physiology.

Methods

A scoping study of the literature was followed by a multi-institutional and multi-disciplinary international learning collaborative. We sought to achieve a consensus on procedures and clinical simulation technology to determine the requirements, develop and test a safe using a checklist template that is rapidly accessible to assist in emergency management of common events for general ward use.

Results

Safety considerations about deteriorating patients were agreed upon and summarized. A consensus was achieved among an international group of experts on currently available checklist formats performing poorly in simulation testing as first responders in general ward clinical crises. The Crisis Checklist Collaborative ratified a consensus template for a general ward checklist that provides a list of issues for first responders to address (i.e. ‘Check In’), a list of prompts regarding common omissions (i.e. ‘Stop & Think’), and, a list of items required for the safe “handover” of patients that remain on the general ward (i.e. ‘Check Out’). Simulation usability assessment of the template demonstrated feasibility for clinical management of deteriorating patients.

Conclusions

Emergency checklists custom-designed for general ward patients have the potential to guide the treatment speed and reliability of responses for emergency management of patients with abnormal physiology while minimizing the risk of adverse events. Interventional trials are needed.

Cognitive Aids for Role Definition (CARD) to improve interprofessional team crisis resource management: An exploratory study

This study aimed to assess the perceived value of the Cognitive Aids for Role Definition (CARD) protocol for simulated intraoperative cardiac arrests. Sixteen interprofessional operating room teams completed three consecutive simulated intraoperative cardiac arrest scenarios: current standard, no CARD; CARD, no CARD teaching; and CARD, didactic teaching. Each team participated in a focus group interview immediately following the third scenario; data were transcribed verbatim and qualitatively analysed. After 6 months, participants formed eight new teams randomised to two groups (CARD or no CARD) and completed a retention intraoperative cardiac arrest simulation scenario. All simulation sessions were video recorded and expert raters assessed team performance. Qualitative analysis of the 16 focus group interviews revealed 3 thematic dimensions: role definition in crisis management; logistical issues; and the "real life" applicability of CARD. Members of the interprofessional team perceived CARD very positively. Exploratory quantitative analysis found no significant differences in team performance with or without CARD (p > 0.05). In conclusion, qualitative data suggest that the CARD protocol clarifies roles and team coordination during interprofessional crisis management and has the potential to improve the team performance. The concept of a self-organising team with defined roles is promising for patient safety.