Emergency Manual Uses During Actual Critical Events and Changes in Safety Culture From the Perspective of Anesthesia Residents: A Pilot Study

Goldhaber-Fiebert, S. et al. Anesthesia & Analgesia. 123(3) pp. 641–649


Background: Emergency manuals (EMs), context-relevant sets of cognitive aids or crisis checklists, have been used in high-hazard industries for decades, although this is a nascent field in health care. In the fall of 2012, Stanford clinically implemented EMs, including hanging physical copies in all Stanford operating rooms (ORs) and training OR clinicians on the use of, and rationale for, EMs. Although simulation studies have shown the effectiveness of EMs and similar tools when used by OR teams during crises, there are little data on clinical implementations and uses. In a subset of clinical users (ie, anesthesia residents), the objectives of this pilot study were to (1) assess perspectives on local OR safety culture regarding cognitive aid use before and after a systematic clinical implementation of EMs, although in the context of long-standing resident simulation trainings; and (2) to describe early clinical uses of EMs during critical events.

Methods: Surveys collecting both quantitative and qualitative data were used to assess clinical adoption of EMs in the OR. A pre-implementation survey was e-mailed to Stanford anesthesia residents in mid-2011, followed by a post-implementation survey to a new cohort of residents in early 2014. The post-implementation survey included pre-implementation survey questions for exploratory comparison and additional questions for mixed-methods descriptive analyses regarding EM implementation, training, and clinical use during critical events since implementation.

Results: Response rates were similar for the pre- and post-implementation surveys, 52% and 57%, respectively. Comparing post- versus pre-implementation surveys in this pilot study, more residents: agreed or strongly agreed “the culture in the ORs where I work supports consulting a cognitive aid when appropriate” (73.8%, n = 31 vs 52.9%, n = 18, P = .0017) and chose more types of anesthesia professionals that “should use cognitive aids in some way,” including fully trained anesthesiologists (z = −2.151, P = .0315). Fifteen months after clinical implementation of EMs, 19 respondents (45%) had used an EM during an actual critical event and 15 (78.9% of these) agreed or strongly agreed “the EM helped the team deliver better care to the patient” during that event, with the rest neutral. We present qualitative data for 16 of the 19 EM clinical use reports from free-text responses within the following domains: (1) triggering EM use, (2) reader role, (3) diagnosis and treatment, (4) patient care impact, and (5) barriers to EM use.

Conclusions: Since Stanford’s clinical implementation of EMs in 2012, many residents’ self-report successful use of EMs during clinical critical events. Although these reports all come from a pilot study at a single institution, they serve as an early proof of concept for feasibility of clinical EM implementation and use. Larger, mixed-methods studies will be needed to better understand emerging facilitators and barriers and to determine generalizability.

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High volume emergency surgery units do not improve outcomes, report finds

Gulland, A. BMJ. 2016. 353:i2054

The move to centralised services for emergency general surgery would not improve outcomes or reduce mortality rates, a report has found.1

The Nuffield Trust looked at the problems facing emergency general surgery and found that the “widely held perception that centralisation will drive up quality” did not hold true. It found that there was no clear relationship between the number of procedures performed and surgical outcomes.


Image source: Nuffield Trust

The report, commissioned by the Royal College of Surgeons of England, found that there was little variation in mortality between sites that performed a large number of procedures and those that did not. The report looked at hospital episode statistics at 154 sites in England between 2009-10 and 2012-13 to compare mortality rates between those that performed a large number of procedures and those that did not.

It found that hospitals that performed around 50 or fewer major emergency surgical procedures annually had a mortality rate of just over 12%. Sites that performed more than 250 procedures a year had a mortality rate of just under 12%, and sites that performed 51 to 100 procedures annually had the lowest mortality rate of about 11%.

When researchers looked at very low volume sites—those performing less than 20 procedures annually—they found that there was no clear pattern of higher mortality.

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