Do Checklists Improve Emergency Management?

INTRODUCTION

The use of cognitive aids in health care, specifically in the field of anesthesiology, is becoming increasingly popular. Cognitive aids are tools that help users complete a specific task, and checklists are a type of cognitive aid that detail the specific, necessary steps. Emergency manuals are collections of cognitive aids that can be used during critical events.

Before we discuss the history of how crisis checklists were developed within the field of anesthesiology, we will first discuss the evolution of crew/crisis resource management within the aviation field. Between 1959 and 1989, flight crew action was the cause for more than 70% of accidents that led to aircraft damage beyond repair. In 1979, the National Aeronautics and Space Administration convened aviation experts in a workshop called Resource Management on the Flightdeck, where they created the term “cockpit resource management” (later termed crew resource management ), which led to flight crew simulation trainings and checklist use during routine and emergency situations to reduce human errors.

The idea of using cognitive aids in health care dates back to at least the 1920s, when the surgeon W. Wayne Babcock wrote about the importance of teamwork and using cognitive aids during perioperative emergencies. He wrote, “… a fixed emergency routine, posted on the walls of every operating room and drilled into every member of the staff, should be enforced.” Decades later, in 1978, Cooper et al. studied the role of human factors in preventable anesthesia mishaps. In 1987, Gaba et al., in a publication on accident evolution across several high-stakes industries, noted the idea of cognitive aids for critical incidents, akin to efforts that had been done for malignant hyperthermia and basic/advanced life support. Over the past several decades, crisis checklists and emergency manuals within health care have been developed, studied, and implemented in hospitals across the world. This chapter aims to provide an update on the current tools available, detail the literature surrounding cognitive aids in medicine, and assist readers in the integration of these tools within their practice.

OPTIONS/THERAPIES

There are now many different crisis checklists, emergency manuals, and other cognitive aids that are well known and widely used within health care. The following section will highlight a select few of these cognitive aids/emergency manuals that are prevalent within medicine and the field of anesthesiology. This discussion does not attempt to be comprehensive but rather to demonstrate that these education and patient safety tools exist and continue to grow.

Perhaps the most established and recognizable cognitive aid within the health care field is the Advanced Cardiovascular Life Support (ACLS) reference card set, created by the American Heart Association (AHA). ^, The AHA updates the ACLS guidelines and their “pocket cards,” with major updates typically every 5 years. Of note, the ACLS guidelines established by the AHA are intended for a broad audience. In contrast, perioperative cardiac arrests and other crises are typically witnessed and the underlying cause can often be determined (such as hypovolemia or air embolism). Because of this, there has been an increasing amount of research surrounding perioperative cardiac arrests/crises and management algorithms for anesthesia providers. ^,

Crisis Management in Anesthesiology was one of the first emergency manuals created within the field of anesthesiology; it not only details nearly 100 critical events in anesthesiology and how to manage them but also discusses fundamental skills in crisis management such as dynamic decision making and the importance of debriefing. This book paved the way for future development, study, and implementation in perioperative care across the country.

One example of an operating room crisis checklist set is the one developed by Ariadne Labs, a joint center at Brigham and Women’s Hospital and Harvard T.H. Chan School of Public Health ( Fig. 17.1 ). A group of experts chose 12 life-threatening, critical operating room (OR) scenarios and detailed the necessary steps to manage the critical events based on evidence-based practices. A simulation study was performed, which demonstrated better performance in crisis management for teams using the Ariadne checklists compared with those without checklists. Another perioperative emergency manual is the one developed by the Stanford Anesthesia Cognitive Aid Group, which includes 25 critical events and management algorithms ( Fig. 17.2 ). A pilot study was performed with Stanford’s emergency manual, and it demonstrated successful use of manuals by many anesthesiology residents during real, critical events. Both OR crisis checklists, from Ariadne Labs and the Stanford Anesthesia Cognitive Aid Group, are currently available for free download. ^,

There are also numerous cognitive aids available for specific, non-ACLS intraoperative events, designed by different organizations. The Malignant Hyperthermia Association of the United States (MHAUS) frequently updates their guidelines for the treatment protocol for malignant hyperthermia and also provides an associated OR poster. Additionally, the American Society for Regional Anesthesia and Pain Medicine (ASRA) has developed a checklist for the treatment of local anesthesia systemic toxicity (LAST), which is currently available for free download.

Anesthesiology subspecialties have adapted emergency checklists and cognitive aids within their fields as well. Newton-Wellesley Hospital created a set of labor and delivery crisis checklists for such obstetric-specific emergencies as cord prolapse, shoulder dystocia, and eclampsia. The Society of Pediatric Anesthesia has also created a critical event checklist set, including 22 different pediatric OR events and weight-based dosing regimens, a feature that is necessary in the pediatric anesthesiology field. The Anaesthesia Cognitive Aids and Resources (ASCAR) group has developed a set of cognitive aids specifically for COVID-19, including checklists for intubating, extubating, and disconnecting circuits for patients with COVID-19.

The Emergency Manuals Implementation Collaborative (EMIC) details where to find all of the latest versions of these tools, along with many other cognitive aids, on their website, www.emergencymanuals.org . Additionally, there is an emergency manual implementation toolkit for hospitals wishing to customize and implement their own checklists within their hospital system ( https://www.implementingemergencychecklists.org/ ).