Emergency Manuals

Contributors: Monica W. Harbell, M.D.; Amanda Rhee, M.D.; R. Christopher Call, M.D.; Luis Tollinche, M.D.; Peter A. DeSocio, D.O., M.B.A., CPE, FASA; Aalok Agarwala, M.D.

updated May 5, 2020

What are Emergency Manuals?

Emergency Manuals (EMs) are cognitive aids that assist providers in treating critical events. The ideal EMs synthesize evidence-based and best practices in a format that is easy for the anesthesia provider to use during a critical event. This can decrease cognitive load during the event and help ensure that key steps are not missed when treating a critical event. There are multiple, widely used EMs available for perioperative events.

Helpful Emergency Manuals for anesthesiologists:

• Emergency Manuals Implementation Collaborative (EMIC):
  The Emergency Manuals Implementation Collaborative is a group which shares various EMs, many of which are free resources. These include the Stanford EMs and Ariadne Lab EMs (see below), but also include crisis checklists for Labor and Delivery crisis, Neuroanesthesia, Trauma, and Office-based Surgery.
• Stanford Emergency Manual:
  This resource includes cognitive aids for 25 critical events as well as Crisis Resource Management key points.
• Ariadne Labs:
  Ariadne Labs have developed checklists that focus on 12 of the most common operating room crises. Use of these checklists in simulation led to a 75% reduction in failure toadhere to critical steps in management.
• projectcheck.org
• nejm.org
• Malignant Hyperthermia (MH) checklist:
  The Malignant Hyperthermia Association of the United States (MHAUS) has a helpful website that offers recommendations on how to manage an acute MH event, as well as the 24-hour MH hotline number.
• ASRA LAST checklist:
  The American Society of Regional Anesthesia and Pain Medicine (ASRA) has a checklist regarding the treatment of Local Anesthetic Systemic Toxicity (LAST).
• SPA Pediatric Crisis Checklist:
  The Society for Pediatric Anesthesia (SPA) has crisis checklists for pediatric patients in multiple languages.
• SNACC Neuroanesthesia Checklist:
  The Society of Neuroscience in Anesthesiology and Critical Care Education Committee (SNACC) developed cognitive aids for the diagnosis and treatment of neuroanesthesia emergencies.

What you should know about Emergency Manuals:

• How can emergency manuals help in critical anesthesia events? Why should I use an emergency manual?
  

  The reality of the operating room environment is such that there are often a variety of things happening simultaneously and a number of distractions piled onto each situation. During a medical emergency, it is useful to have a cognitive aid to help organize an approach and provide reminders for critical bullet points that these situations require. This allows the provider to free up some cognitive reserve to focus on other priorities. It may be especially useful to have a quick reference for rare emergency situations or in practices where emergencies happen very infrequently or in remote non-OR settings, such as in the gastroenterology suite, interventional cardiology, interventional radiology, and office-based anesthesia surgical settings. Cognitive aids have been shown to help improve performance in certain critical anesthesia events, such as Malignant Hyperthermia. Cognitive aids can also serve to coordinate care in a multidisciplinary team so that all providers are aware of the tasks that need to be accomplished, and roles and responsibilities can be clearly delineated and understood by all.

  REFERENCES

  Bereknyei MS, Gaba DM, Agarwala AV, et al. Use of an Emergency Manual during an intraoperative cardiac arrest by an interprofessional team: A positive-exemplar case study of a new patient safety tool. Jt Comm J Qual Patient Saf. 2018;44(8):477-484.

  Gleich SJ, Pearson ACS, Lindeen KC, et al. Emergency Manual implementation in a large academic anesthesia practice: Strategy and improvement in performance on critical steps. Anesth Analg. 2019;128(2):335-341.

  Goldhaber-Fiebert SN, Howard SK. Implementing emergency manuals: can cognitive aids help translate best practices for patient care during acute events? Anesth Analg. 2013;117(5):1149–1161.

  Marshall S. The use of cognitive aids during emergencies in anesthesia: a review of the literature [published online Nov 2013]. Anesth Analg. 2013;117(5):1162-71. doi: 10.1213/ANE.0b013e31829c397b

  Hepner DL, Arriaga AF, Cooper JB, et al. Operating room crisis checklists and emergency manuals [published online Aug 2017]. Anesthesiology. 2017;127(2):384-392. doi: 10.1097/ALN.0000000000001731

  Agarwala AV, Spanakis SG, Nixon H. Cognitive aids: Does patient safety depend on a manual? Int. Anesthesiol Clin. 2019;57(3):48-61.

• How can you use an Emergency Manual in clinical practice?
  

  Emergency manuals can be used during critical events to effectively assist perioperative clinicians in applying best known practices. EMs facilitate a structured approach to a crisis, serve as a reminder of recommended management actions, and cue clinicians to consider a comprehensive differential diagnosis. Stress negatively impacts “retrieval of knowledge, working memory for calculations and prospective memory for future tasks.”1 These manuals mitigate the impact of stress on higher cognitive function during crises. It can be very helpful to designate a reader to read the EMs aloud during a critical event to ensure that no key steps in treatment were missed. EMs led by a designated reader can help balance the benefit of intuition while minimizing fixation.

  EMs can also be effective teaching tools for both resident education and practicing anesthesia providers and can have an important role in simulation training. Simulation studies demonstrate that perioperative teams execute best practices more often and more effectively when using EMs. Simulation-based crisis training supports the effective incorporation of EMs with other crisis-based skills and resources. EMs are a valuable educational resource for trainees, not only for educational review, but also as a tool in learning, devising and implementing algorithms in clinical scenarios.

  REFERENCES

  Semler, MW, Keriwala RD, Clune JK, et al. A randomized trial comparing didactics, demonstration, and simulation for teaching teamwork to medical residents. Ann Am Thorac Soc. 2015;12(4): 512-519.

  Goldhaber-Fiebert SN, Pollock J, Howard SK, 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): 641-649.
  1Goldhaber-Fiebert, SN, Howard S. Implementing Emergency Manuals: Can cognitive aids help translate best practices for patient care during acute events? Anesthesia & Analgesia 2013;117(5): 1149-61.

  Goldhaber-Fiebert SN, Lei V, Nandagopal K, Bereknyei S. 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):212-220.

• How do you implement Emergency Manuals in your institution?
  

  As with any quality improvement project, implementation of Emergency Manuals is most effective if there is a champion and a step-by-step plan. There are now several resources and publications detailing how EMs have been implemented into practice, and any anesthesia department or group that wishes to introduce these valuable tools into practice should take advantage of these comprehensive resources.

  In brief, in order to successfully implement EMs in your institution, the following critical steps should be followed (adapted from the Operating Room Emergency Checklist Implementation Toolkit):

  1. Identify a local champion who is committed to bringing EMs to the institution, and who will invest the effort required for effective implementation. Qualities present in the ideal champion include strong communication skills, ability to collaborate well with other disciplines, and someone who is well-respected as a clinician.
  2. Get buy-in for the project by involving clinical and administrative leadership early and often in the planning. Be ready with evidence and help others see the value in implementing EMs.
  3. Create a multidisciplinary team, with representation from all perioperative role groups, including surgery, anesthesiology and nursing. Utilizing the experience of others who have led change initiatives previously can be helpful, and including people who are thoughtful and well respected will ease acceptance.
  4. Select a checklist, customize it for your institutional needs and available resources, and test them in simulations to ensure that they include key resources and are not confusing.
  5. Train staff to become familiar with the checklists and how to use them. This can be done with a combination of low-tech, tabletop simulation, trigger videos or live simulation. Be sure to include time for debriefing and discussion.
  6. Introduce the EMs into the Operating Room (O.R.) and start using them. Consider starting with a subset of O.R.s in a large department.
  7. Monitor use of the EMs and listen for feedback about how they are useful, and limitations that may need to be addressed.

  Successful implementation of EMs in a large department can take months to do well, but the effort invested into following the above steps will result in a greater likelihood that clinicians will use the checklists when needed most.

  REFERENCES

  Agarwala AV, McRichards LK, Rao V, Kurzweil V, Goldhaber-Fiebert SN. Bringing perioperative Emergency Manuals to your institution: a "how to" from concept to implementation in 10 steps [published online Oct 16 2018]. Jt Comm J Qual Patient Saf. 2019;45(3):170-179. doi: 10.1016/j.jcjq.2018.08.012

  Gleich SJ, Pearson ACS, Lindeen KC, et al. Emergency Manual implementation in a large academic anesthesia practice: strategy and improvement in performance on critical steps. Anesth Analg. 2019;128(2):335-341.

  Alidina S, Goldhaber-Fiebert SN, Hannenberg AA, et al. Factors associated with the use of cognitive aids in operating room crises: a cross-sectional study of US hospitals and ambulatory surgical centers. Implement Sci. 2018;13(1):50.