1. The Emergency Manual as an Intraoperative Cognitive Aid
Resident Quality Improvement Project
The Emergency Manual as an Intraoperative Cognitive Aid
Residents: Nick Schiavoni MD, Tasia Giebler DO & Ben Lippert DO
Faculty: Leslie Jameson MD & Stacy Fairbanks MD
May 8, 2017

2. Introduction History:
Cognitive aids are checklists shown to improve recognition and management of crisis situations, and have been used in high-risk industries, such as aviation and nuclear power, for decades. They are less commonly used in health care
An article published by Babcock in A&A in 1924 highlighted the need for emergency resuscitation protocols to manage crises in the OR
Although not an emergency checklist, the 1980s FDA Anesthesia Apparatus Checkout Recommendations was the first checklist to be introduced in anesthesia
-Jan 2009: Captain Sully safely landed a plane in the Hudson River with the assistance of the first officer reading the dual engine failure checklist

3. Why Use Checklists?
Critical steps during intraoperative emergency management are frequently missed, especially for rare and unpredictable events
In stressful and/or uncertain situations, memory is often unreliable with subsequent errors and omissions in treatment
Studies have shown that cognitive aids can improve safety and management of intraoperative crises by improving recognition and adherence to evidence-based practice and minimizing omission of critical steps

4. Checklist Studies What does the literature show?
A study published in NEJM in 2013 compared the use of checklists to working memory in simulated crises including VAE, anaphylaxis, and asystolic cardiac arrest
Checklist use was associated with significantly improved management of OR crises
A group at Stanford showed that the use of cognitive aids during high-fidelity simulations of a malignant hyperthermia event as well as a massive transfusion L&D event led to significantly superior critical event management
Pilot study from Stanford recently published in A&A 2016 (3)
After 15mo of clinical implementation, 45% (19/42) of resident respondents had used an EM during a critical event and of those who used it, 78.9% (15/19) agreed or strongly agreed that “the EM helped the team deliver better care to the patient”

5. Why iCare? Comprehensive, user-friendly, easily available on EPIC
Created by physician anesthesiologists at Children’s Hospital Colorado
Based on Stanford’s Emergency Manual model, seen as the “Gold Standard”
Dosages calculated for specific patient
Already successfully launched at DH and CHCO

6. Methods
Literature search for implementation and effectiveness of anesthesiology-specific emergency manuals
Developed an interactive in-service training program to introduce iCare and demonstrate usability of an intraoperative critical events checklist
40 anesthesia providers participated in the training
Study participants surveyed for potential of incorporating iCare into their own practice
We hypothesized that checklists would contribute to the safety and management of intraoperative crises by improving recognition and adherence to evidence-based practice, and by minimizing errors or omissions in treatment

7. Results: Study Participants

8. Results: Awareness of iCare

9. Results: Previous iCare Use

10. Results: Value of In-Service

11. Results: Utility of iCare

12. Results: iCare Format

13. Next Steps
Design
Add additional crises (transfusion reaction, venous air embolism, etc)
Work with engineers to develop an interactive checklist
Hardcopy?

14. Next Steps Familiarize, use and integrate
Repeat surveys at 6 and 12 months
Add a checkbox on the QI page to indicate if iCare was used for direct patient care
Integrate iCare into orientation for all new anesthesia providers (CA-1s, AA students, etc)
Incorporate iCare into simulation training

15. References
Augoustides J et al. Much Ado About Checklists: Who Says I Need Them and Who Moved My Cheese?. Anesth Analg. 2013;117:
Babcock W. Resuscitation During Anesthesia. Anesth Analg. 1924;3:
Goldhaber-Fiebert, S N, et al. Emergency Manual Implementation: Can Brief Simulation-based OR Staff Trainings Increase Familiarity and Planned Clinical Use?. Jt Comm J Qual Patient Saf 2015;41.5:212-AP7.
Goldhaber-Fiebert, S N, et al. Emergency Manual Uses During Actual Critical Events and Changes in Safety Culture From the Perspective of Anesthesia Residents: A Pilot Study. Anesth Analg. 2016;123(3):
Harrison T, et al. Use of Cognitive Aids in a Simulated Anesthetic Crisis. IARS 2009;103:
McEvoy MD, et al. Use of Cognitive Aids Significantly Increases Retention of Skill for Management of Cardiac Arrest [abstract]. Paper presented at: American Society of Anesthesiologist Annual Meeting, 2010, San Diego, CA.
Nanji KC, Cooper JB. It Is Time to Use Checklists for Anesthesia Emergencies: Simulation Is the Vehicle for Testing and Learning. Reg Anesth Pain Med. 2012;37:1-2.
Semeraro F, Signore L, Cerchiari EL. Retention of CPR Performance in Anaesthetists. Resuscitation 2006;68:101-8.