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Are you utilizing an Emergency Manual in your operating rooms? You should be. Let me explain why.
Case 1. A 36-year-old morbidly obese woman who smokes two packs of cigarettes per day undergoes general anesthesia for a laser laparoscopy for endometriosis. Thirty minutes into the surgery, the patient’s blood pressure drops to 50/30 for unclear reasons. The anesthesiologist administers phenylephrine and alerts the surgeon, but within seconds the patient has no obtainable blood pressure. Her ECG rhythm continues at a sinus tachycardia of 120 beats per minute. The anesthesiologist administers epinephrine IV, but the patient has no pulses, CPR is started, and a Code Blue is continued for thirty minutes without success. The patient is eventually declared dead.
Case 2. The same patient scenario as Case 1 unfolds, but at the point when the patient has no obtainable blood pressure and sinus tachycardia at 120 beats per minute, the anesthesiologist calls for the Stanford Emergency Manual and asks the circulating nurse to read out loud the page for PEA (PULSELESS ELECTRICAL ACTIVITY). Together they work through the algorithm, to the point where they must rule out tension pneumothorax or cardiac tamponade. Examination of the lungs shows no breath sounds on the right lung. The trachea is deviated to the left. The anesthesiologist decompresses the tension pneumothorax with a 14-gauge needle/IV catheter placed in the 4th intercostal space between the anterior and mid-axillary line, a “whoosh” results as the air escapes, and the blood pressure returns within one minute. The patient survives.
Unexpected emergencies in the operating room are rare, but when they occur there’s no time for delay in appropriate treatment. Anesthesiologists are vulnerable to human error, and their judgment and decision-making can be flawed or incomplete in stressful situations. A cognitive aid, or Emergency Manual, which contains algorithms regarding the assessment and treatment of an emergency, can be a valuable tool to direct clinicians to the proper diagnosis and treatment when it’s difficult to think straight or remember every detail of appropriate therapy.
A cognitive aid is defined a “structured pieces of information designed to enhance cognition and adherence to medical best practices.” The Stanford Emergency Manual is a hard-copy reference available for free download on the internet. An Emergency Manual draws from the experience in the aviation and nuclear power industries, where cognitive aids and emergency operating procedures have long been implemented to support performance during crises.
The infrequent occurrence of crises in an operating room, cockpit, or nuclear power plant makes studying these interventions challenging. All three industries have made cognitive aid algorithms available to accurately troubleshoot and manage emergencies. Operating room Emergency Manuals are designed to aid physician memory, facilitate decision-making, and standardize actions. Emergency Manuals developed by the Stanford University School of Medicine, and by Ariadne Labs (Boston, MA), are examples of cognitive aids designed to support operating room teams during a crisis.
An inadequately treated emergency in the operating room can lead to irreversible anoxic brain damage in as little as five minutes. Seconds matter in operating room emergencies. There’s little time to waste on indecision or uncertainty.
Do cognitive aids work? Yes. In a 2019 randomized clinical trial from Amsterdam in a simulator setting, the use of cognitive aids “decreased the omissions of critical management steps in the management of deteriorating surgical patients by 70%. In a multivariate analysis, the use of cognitive aids was the only significant factor in reducing the omission of critical management steps.” In this study, fifty surgical teams were randomized to the use of cognitive aids or a control group in 150 deteriorating surgical patient cases in a simulator setting. All participants were novices regarding the practice of using cognitive aids. They were introduced to the tool by viewing a standardized video introduction regarding the aim of the study and the use of cognitive aids. The use of cognitive aids resulted in a reduction of omitted critical management steps from 33% to 10%, which was a 70% (P < .001) reduction. The study concluded that “Human error is often the underlying cause of failure to rescue. Human error can be reduced by the use of cognitive aids,” and “Cognitive aids target all three key domains associated with the timely recognition and effective management of complications in the surgical population: they improve communication, teamwork, and leadership, and the surgical safety culture, and are therefore likely to be effective in decreasing failure to rescue.” A limitation of the study was that it was performed in a simulator setting. The effect of using cognitive aids for deteriorating surgical patients in an actual clinical setting was not established.
Achieving benefits from Emergency Manuals requires that operating room teams use them during crises. Per Dr. Atul Gawande’s book The Checklist Manifesto, historic models of operating room surgical care did not feature memory aids. Some clinicians object to changing routines, and long-standing hierarchies (i.e. surgeons who feel they outrank their anesthesia colleagues) undermine the team-based care promoted in cognitive aids. The availability and distribution of Emergency Manuals into operating rooms is not enough. Reliable use of the Emergency Manuals by a well-trained team is what matters. Some organizations are more successful than others in effectively implementing tools used sporadically like operating room cognitive aids for crises. A survey of individuals who downloaded operating room cognitive aids from the websites of the Ariadne Labs or the Stanford Emergency Manual reported on the experience of 368 respondents from United States hospitals and ambulatory surgical centers. Four criteria were associated with successful implementation of cognitive aids: a small facility size (p = 0.0092); completing more implementation steps (p ≤ 0.0001); leadership support (p < 0.0001); and dedicated time to train staff (p = 0.0189). Three criteria were associated with unsuccessful implementation of cognitive aids: resistance among clinicians regarding using cognitive aids (p < 0.0001); absence of an implementation champion (p = 0.0126); and unsatisfactory content or design of the cognitive aid (p = 0.0112). These findings were echoed in the 2018 study “Factors associated with the use of cognitive aids in operating room crises: a cross-sectional study of US hospitals and ambulatory surgical centers,” in which several factors were associated with successful implementation of cognitive aides: “the tool was presented at staff, physician, or departmental meetings (p < 0.0001); a multidisciplinary team was established to review the tool (p < 0.0001); the tool was customized to fit the local context (p = 0.0002); the tool was pilot-tested (p < 0.0001); providers were trained in the use of the tool (p < 0.0001); ongoing/routine training was provided on the tool (p < 0.0001); the use of the tool was monitored (p < 0.0001); and the use of the tool was expanded to additional areas in the facility outside the OR where anesthesia was administered (p < 0.0001) . . . More successful implementation was associated with the use of the tool in emergency drills (p < 0.0001), in preparation for complex cases (p = 0.0328), and in debriefing after a critical event (p < 0.0001).”
A study using the Stanford Emergency Manual during critical events found that fifteen months after the implementation of the manuals in the clinical setting, 45% of respondents had used the Manual in an actual critical event. Eighty percent of these individuals agreed or strongly agreed that the tool resulted in better care delivered by the team to the patient.
A meta-analysis of 13 randomized controlled trials stated, “the use of a cognitive aid increased the completeness of care delivered to patients with moderate certainty, decreasing the incidence of errors and increasing the rate of correctly performed steps . . . We believe it is intuitive that delivered care should be more complete with fewer errors in the presence of a cognitive aid to guide and standardize management.”
In 2015 the Anesthesia Patient Safety Foundation (APSF) sponsored a “Workshop on Implementing Emergency Manual Use.” Their accompanying APSF publication estimated it would require 1.6 million patients and over three years to conduct a large-scale prospective study to evaluate the efficacy of Emergency Manuals. Dr. John Eichhorn, the founding editor of the APSF Newsletter, recommended the APSF work to dispel the notion that the use of cognitive aids was a weakness, but rather tout it as a strength. He reminded the audience that the APSF does not set standards of care, but rather the organization can spread the word via the APSF Newsletter. A large majority of the audience believed the APSF should take a leading role in promoting Emergency Manuals. The workshop concluded that the American Society of Anesthesiologists (ASA) was the organization best positioned to declare Emergency Manuals a standard of care.
The use of pulse oximetry and end-tidal CO2 monitoring in operating rooms were intuitively positive improvements, which did not require large scale prospective randomized studies to become ASA standards of care. At its annual meetingin 1986, the ASA adopted its first “Standards for Basic Intra-Operative Monitoring,” which encouraged, but did not mandate, the use of pulse oximetry. By 1989 pulse oximetry’s value and accessibility had become unquestioned, and the ASA amended the standards to officially require the use of a quantitative method for assessing blood oxygenation, with pulse oximetry being the device of choice.
Why should Emergency Manuals, also intuitively valuable with little prospective for a significant downside, require large prospective randomized studies to prove their value?
Stanford Emergency Manuals have been in use in all Stanford Hospital anesthetizing locations since fall 2012. The publisher has printed and shipped thousands of manuals for hundreds of institutions around the United States and around the world since that time. Stanford has made it a priority to make utilization of their Emergency Manual a standard of care.
At the freestanding surgery center where I’m the Medical Director (Waverley Surgery Center, Palo Alto, California), the Stanford Emergency Manual is available in every operating room and on the Code Blue cart. Adoption of the Emergency Manual at Waverley has been successful because (a) Waverley has institutional support—I have been a champion and a leader in asserting that the Stanford Emergency Manual is available, (b) the nurses and the surgeons have bought in to the use of the Emergency Manual as a standard of care; and (c) we run Mock Codes drills regularly with the nursing staff to assure the RNs are aware and comfortable with their role in seizing the Emergency Manual early in any crisis and reciting the lists of necessary assessment and therapeutic steps as outlined in the algorithms.
The Stanford Emergency Manual contains 26 scenarios in 44 pages. The outline of each page is in the form of Treatment, at times preceded by a Differential Diagnosis. The Manual can be downloaded for free at https://emergencymanual.stanford.edu. A laminated, ring-bound version of the Manual is available for purchase at the same website for $98.95, and a pocket version of the Manual is available for $23.95.
The Stanford Emergency Manual App is now available cost-free on the AppleTM App Store, and you can have the Manual available 24/7 on your smartphone.
Typical pages in the Stanford Emergency Manual look like these:
Stanford colleagues and others offer their testimonials on the Emergency Manual web page:
ANITA HONKANEN MD, CHIEF OF PEDIATRIC ANESTHESIA DIVISION: “During a recent MH crisis, I assigned a ‘reader’ to read aloud from the accessible Emergency Manual. As event leader it was extremely helpful. The clear directions helped guide a calm, unified, team response. I knew that no evidence-based part of the treatment algorithm would be missed, giving our patient the best chance for full recovery.”
RICHARD P. DUTTON, MD, MBA, EXECUTIVE DIRECTOR, ANESTHESIA QUALITY INSTITUTE, 2014: “Anesthesiologists have developed many tools to rescue patients from life-threatening situations, from the laryngoscope to the pulse oximeter to crisis management in the simulator. The latest of these is the Emergency Manual, a cognitive aid for any medical provider confronted with a crashing patient. This tool will save lives.”
BRYAN BOHMAN MD, CHIEF MEDICAL OFFICER FOR UNIVERSITY HEALTH ALLIANCE, STANFORD: “This manual is an excellent addition to every anesthesia cart and OR nursing station. It is helpful pre-, during, and post-crises. A great deal of expert medical wisdom, academic research and practical, simulation-tested protocols are condensed into this compact, accessible manual.
BRICE GAUDILLIERE MD, Assistant Professor of Anesthesiology:“I noted climbing ETCO2, despite increased minute ventilation. Having used the Emergency Manual to review ‘what if’ cases, I thought to reach for it and found the correct page within seconds of considering the diagnosis of malignant hyperthermia. It helped our team to manage this unexpected event efficiently and accurately.”
LAUREN FRIEDMAN MD, KAISER PERMANENTE ANESTHESIOLOGIST: “Having the Emergency Manual as a staple resource in the OR and at home is extremely helpful . . . I look to the manual to guide me, either during an event or after one to make sure that I have covered everything.”
On their web page, NORTHWEST ANESTHESIA PHYSICIANS, of Springfield, Oregon in conjunction with Sacred Heart Medical Center, state: “We have implemented the use of Stanford Emergency Manuals in all locations where anesthesia care is provided. The Stanford Emergency Manual is the gold standard for operating room emergency reference. Anesthesia physicians are working with operating room personnel to simulate emergency scenarios to enable optimum performance in the event of a crisis. NAP is focused on patient safety and proud to implement practices that improve the quality care we provide to our patients every day.”
If you are NOT utilizing cognitive aids such as the Stanford Emergency Manual in your operating room suites, I suggest you do, both for safe care of your patients and for safe standardized practice among your clinicians. I refer you to an article published by The Joint Commission in 2019 titled, “Bringing Perioperative Emergency Manuals to Your Institution: A ‘How To’ from Concept to Implementation in 10 Steps.”
If you are ever sued for an adverse patient outcome, your malpractice defense will hinge on affirming you practiced at the standard of care. Emergency Manuals outline the standard of care.
Should having an Emergency Manual available in all anesthetizing locations be a standard of care? Yes, I believe it should. If your hospital or surgery centers won’t supply an Emergency Manual in your operating rooms, do yourself and your patients a favor—buy a $23.95 pocket version and carry it in your briefcase. You won’t regret it.
DISCLAIMER: Neither I nor any of the physicians listed above have any financial stake in the success of the Stanford Emergency Manual distribution.
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I am a recently retired university-based cardiothoracic surgeon & Professor at a medical school; what is being promoted here is a scenario of intellectual laziness or ineptitude on behalf of a surgeon & an anesthesiologist on how to manage a not-so-uncommon life threatening encounter in the OR setting, and an offer for a “solution” to assuage the guilt & remorse for being a substandard physician. The logical infinite regression of this type of scenario is why not have the entirety of a medical school education, residency, & experience of decades of practice condensed into an AI rapid response algorithm that allows it to diagnose, recommend, and/or eventually effect treatment of the crashing patient. To follow this recommendation is to embark on a fool’s errand, the ultimate outcome of which is to create a dependent class of intellectually ungifted physicians who are simply unqualified to care for the urgently ill. To even make such a recommendation as dependence on a written how-to manual, or even a computerized manual, or an AI version that is more interactive than either of these choices is the very antithesis of what we should be doing in medicine. It’s the dumbing down of medicine, I’ve seen this coming for the past 4 decades, and I’m unflinchingly opposed to it. Do this, at your own peril…but don’t ever be my personal doctor.
To my surgical colleague,
Our mission as physicians is to care for our patients at the highest level possible. Expecting anesthesiologists to have flawless memories and perfect judgment under all emergency conditions in the operating room isn’t realistic or feasible. I’ve consulted on dozens of medical-legal cases in which anesthesiologists have not followed the standard of care in acute emergency settings, and these human errors have led to patient complications including death. These events are tragedies which are preventable, as a cognitive aid is available to guide appropriate emergency treatment. Telling the family of a dead surgical patient that a guide to the safe treatment of their loved one was available, but it was not accessed or followed because a surgical colleague believed it was “the dumbing down of medicine,” is also a preventable tragedy. Uniform adoption of cognitive aids will take time, as do all changes or improvements in medicine, but it is coming, and it will be a positive advance in safe patient care.