Cognitive aids for perioperative emergencies

INTRODUCTION — During surgical and other interventional procedures, cognitive aids for specific emergencies in these settings are immediately available to ensure that best practices are followed and no critical steps are missed. This topic reviews optimal use of such cognitive aids (also termed emergency manuals, crisis checklists, rapid overviews, or emergency management algorithms).

Complete reviews of specific operating room emergencies are available in several separate topics that include such cognitive aids:

●Anaphylaxis (table 1) – (see "Perioperative anaphylaxis: Clinical manifestations, etiology, and management")

●Malignant hyperthermia (MH) (table 2) – (see "Malignant hyperthermia: Diagnosis and management of acute crisis")

●Local anesthetic systemic toxicity (LAST) (table 3) – (see "Local anesthetic systemic toxicity")

●Operating room fires (algorithm 1) – (see "Fire safety in the operating room")

●Perioperative advanced cardiac life support – (see "Intraoperative advanced cardiac life support (ACLS)")

A general review of hazards in the operating room is presented in a separate topic, including routine use of other types of cognitive aids in nonemergency situations, as well as other strategies to improve perioperative patient safety. (See "Patient safety in the operating room".)

POTENTIAL BENEFITS OF COGNITIVE AIDS — Examples of cognitive aids developed for perioperative emergencies include anaphylaxis (table 1), malignant hyperthermia (MH) (table 2), local anesthetic systemic toxicity (LAST) (table 3), and OR fires (algorithm 1).

Reduced human error to ensure compliance with best practices — Cognitive aids are used to reduce human error and ensure adherence to best practices with completion of all critical tasks during evaluation and management of clinical emergencies in perioperative settings [1].

A clinician’s cognitive performance is limited in medical emergencies because a high cognitive load impairs working memory [2], and stress reactions mediated by catecholamines affect cognitive function [3]. Clear pathways and guidelines for optimal management do exist for most perioperative emergency situations. As clinicians gain experience, they are able to group together related individual pieces of information to represent somewhat predictable patterns that typically unfold in sequence during a major clinical event. Such grouping of constellations of signs and symptoms into patterns reduces the expert's cognitive load and enables efficient (and usually accurate) evaluation and management in an emergency. The resulting subconscious decisions and "autopilot" behavior of the expert decision-maker are often advantageous [4]. However, such expertise may also increase risk of error due to failure to consider all possible diagnoses, particularly for problems that seem easy or obvious. Overconfidence increases this vulnerability. Other factors that may interfere with cognitive performance or distort memory in rare emergencies include using potentially inaccurate data, bias, frequent interruptions, time pressure, emotional stress due to high-stakes outcomes, and perceptions regarding blame if an adverse outcome occurs [5]. For these reasons, even expert and highly trained clinicians may not be able to recall and thoroughly implement every detail of a standardized management protocol when a crisis generates a high cognitive load. As a result, omissions or delay of critical actions may occur during the emergency, particularly if the circumstances are rare [6].

Cognitive aids are used to improve timely and thorough performance of correct actions during emergencies and can reduce decision-based errors [4,5,7]. Examples include incorrect diagnostic and therapeutic decisions, as well as failures of prospective memory (ie, forgetting to do an intended therapeutic task) [8,9]. In simulated perioperative crises, operating room (OR) teams with access to cognitive aids for performance of critical steps had fewer human errors and better overall performance than those without access to these cognitive aids [10]. A 2023 systematic review of 13 randomized trials noted that use of cognitive aids resulted in fewer missed care steps (ie, errors of omission) compared with usual care (11 versus 43 percent; risk ratio [RR] 0.29, 95% CI 0.15-0.16) [11]. Similarly, simulation-based studies have noted that use of cognitive aids improves performance in other high-risk industries (eg, aviation, nuclear power production, military operations).

Compensation for physical and mental fatigue — Fatigue is a complex physiologic phenomenon that affects both cognitive and psychomotor performance, as well as emotional state [12]. Physical (sleep-related) fatigue includes transient, cumulative, or circadian fatigue. Transient fatigue is acute, brought on by extreme sleep restriction over a short period of several days, while cumulative fatigue results from repeated mild sleep deprivation or extended awake hours across a longer course of time. Circadian fatigue refers to the reduced performance during an individual's "window of circadian low", which generally occurs during nighttime hours between 2:00 and 6:00 AM. Mental fatigue results from a high volume of intense mental tasks and is distinct from physical fatigue. Even after an adequate amount of sleep, mental fatigue can affect attention, working memory, and precise control of actions.

Anesthesiologists, surgeons, OR nurses, and other clinicians in the OR setting often work under all of these fatigue-inducing conditions and are subject to degradation of individual cognitive performance. Use of cognitive aids can mitigate these effects during crisis situations when optimal cognitive performance is particularly critical [7].

Improvement of team performance — Teams perform better with more appropriate responses and less delay in implementing life-saving measures when cognitive aids are employed during simulated OR emergencies (eg, malignant hyperthermia [MH], arrhythmias causing hemodynamic instability) [7]. In one study of the perceived impact of emergency manuals during 69 unique clinical crisis situations, anesthesiology team members reported decreased individual stress, improved ability to note errors of omission (eg, turning off anesthetic agent during cardiac arrest), and better teamwork dynamics [13].

DEVELOPMENT OF PERIOPERATIVE COGNITIVE AIDS

General principles — Several resources are available for emergency cognitive aids specifically developed for use in the perioperative setting [1,9,10,14-16]. Although these vary in their format and specific content, certain common features are found:

●Elements of crisis resource management (CRM) principles, originally developed to reduce errors in aviation, are incorporated within the cognitive aid [17]. Although CRM principles are simple, failure to adhere to them is often the root cause of sentinel clinical events. Core features of CRM include (figure 1) [18]:

•Explicit roles of participants to ensure optimal utilization of resources:

-Designation of a leader

-Explicit delegation of tasks by the leader

-The leader observes and delegates, but does not perform tasks

•Calling early for help, as well as for equipment that may be needed.

•Use of structured or closed-loop communication is emphasized. (See "Patient safety in the operating room", section on 'Communication-based errors'.)

●Intentional design presents the visual data within the cognitive aid, which facilitates rapid and accurate use (although specific details vary).

●A stepwise approach to management is employed, with visual elements that are designed to aid in navigating these steps, particularly if navigation is nonlinear.

●Explicit emphasis of the ways in which management may differ from standard management is a necessary component of cognitive aids designed for emergencies in selected patients in specific settings. Examples include perioperative anaphylaxis, local anesthetic systemic toxicity (LAST), effects of maternal physiology during management of labor and delivery emergencies, and pediatric dosing of emergency drugs.

Also, reevaluation of the presumed diagnosis and effects of treatment after specific intervals is typical. This practice allows for more rapid "catching and correction" of misdiagnosis due to cognitive biases. Input is solicited from all team members.

Resources for selected available cognitive aids — The variety of available cognitive aids for perioperative emergencies differs somewhat in both content and visual display. Cognitive aids with content most relevant for a specific perioperative setting should be selected. Such aids should be checked to ensure that the most current versions are being used since they are typically updated on a regular basis. The following examples are available free of charge:

●Stanford Emergency Manual – The Stanford Anesthesia Cognitive Aid Group has developed a cognitive aid with 25 critical events that may occur in the perioperative setting. It is periodically updated, and revisions incorporate improvements resulting from iterative simulation testing, feedback from real clinical events, and literature updates. This aid is available in multiple languages at the Stanford website. The contents are generally organized into perioperative advanced cardiac life support algorithms, broad differential diagnoses for abnormal vital signs, and specific recognized emergencies that include failed airway, malignant hyperthermia (MH), transfusion reaction, total spinal, LAST, amniotic fluid embolus, operating room (OR) fire, and power failure. This manual also contains information regarding core CRM concepts. Institutions utilizing these cognitive aids are encouraged to adapt for local purpose via a creative commons license.

●OR crisis checklists – Another resource is a set of checklists involving 12 of the most common OR crises, which was developed by a joint collaborative between Brigham and Women’s Hospital and the Harvard TH Chan School of Public Health (which later became Ariadne Labs). These checklists were tested in randomized trials that involved entire OR teams participating in simulated crises [7,10]. Results showed consistently better team performance with checklist use, including a 75 percent reduction in team failures to adhere to critical steps in emergency management. These aids are available at the Ariadne Labs website.

●Emergency Manuals Implementation Collaborative – A collaborative of several leading institutions (including Stanford Anesthesia Cognitive Aid Group and Ariadne Labs) working with emergency cognitive aids is available at the EMIC website [9]. Furthermore, this collaborative has developed an implementation guide and design notes to facilitate customization for institutional use.

●Labor and delivery crisis checklists – Checklists that are specific for obstetrical emergencies and urgent situations such as obstetric hemorrhage, hypertensive emergency, and shoulder dystocia have been developed by the American College of Obstetricians and Gynecologists. Other cognitive aids have been developed for obstetrical units [19].

●Pediatric critical event cards – The Society for Pediatric Anesthesia has created the PediCrisis Critical Event Cards, which includes anaphylaxis, MH, vital sign instability, failed airway, anterior mediastinal mass, tension pneumothorax, and other pediatric emergencies. It includes dose adjustments for age and weight. This aid is available as an application for smart phones or tablets at the Society for Pediatric Anesthesia website.

●Checklist for trauma and emergency anesthesia – An adult trauma checklist includes essential steps to be performed before and after patient arrival to the hospital, including anesthetic management during initial assessment in the emergency department and in the OR, the resuscitation phase, and transition to postoperative care (table 4) [20].

●Thoracic anesthesia emergency cognitive aids – A Thoracic Crisis Manual has been developed by a Canadian thoracic taskforce consisting of 12 anesthesia caregivers with thoracic anesthesia experience. The manual is available via the article’s supplemental material and is formatted based off the Ariadne Labs’ open source template [21,22].

●Digital cognitive aids – An interactive digital cognitive aid has been developed by the German Cognitive Aid Working Group, eGENA, and is available for use at the eGENA website. This collection of cognitive aids includes guidance for pediatric, adult, and pregnancy-related acute conditions. According to their website, registering with their society allows for customizing the eGENA app for local use.

●Checklist for suspected local anesthetic systemic toxicity (LAST) – The American Society of Regional Anesthesia and Pain Medicine offers a specific checklist for LAST, with emphasis on how pharmacologic management of this entity differs from other cardiac arrest situations (table 3). This is available at the American Society of Regional Anesthesia and Pain Medicine website, and further details are provided in a separate topic. (See "Local anesthetic systemic toxicity".)

●Checklist for suspected MH – The Malignant Hyperthermia Association of the United States offers MH checklists in a variety of formats (table 2), as well as direct support via a telephone hotline to an expert. These resources are available at the Malignant Hyperthermia Association of the United States website; further details are provided in a separate topic. (See "Malignant hyperthermia: Diagnosis and management of acute crisis".)

IMPLEMENTING COGNITIVE AIDS

Availability and optimal use of cognitive aids — Ideally, a set of cognitive aids is posted in all procedural areas and on every advanced cardiac life support emergency cart in any hospital that provides perioperative care (including a cognitive aid that specifically addresses management of malignant hyperthermia [MH] attached to each MH cart). It is important that anesthesiologists and other operating room (OR) team members become familiar with their institution's cognitive aids before they are needed to manage a rare emergency. Many institutions use paper bound versions; others use posters that are easily located. Large poster displays or projection of the aids on a screen or OR wall are visible to the entire OR team and assist with shared mental models. Although conclusive data are not yet available, evidence exists that such familiarity may be gained in as little as 15 minutes and retained up to one month later, with faster decision-making seen in a simulated difficult airway scenario [23].

During an actual emergency, a key task is to consult a cognitive aid as soon as possible. However, research suggests that this task should be delegated to one member of the emergency management team whenever feasible (figure 1) [24]. Thus, as soon as an adequate number of personnel are available to help, the team leader will designate a "reader" to be solely responsible for consulting the relevant cognitive aid(s). This reader works together with the team leader to ensure that the emergency is being optimally managed, allowing the leader to maintain situational awareness of evolving clinical events and avoid diversion of cognitive focus. (See 'Reduced human error to ensure compliance with best practices' above.)

Challenges for implementing use of cognitive aids — Cognitive aids and simulation are now used in most hospitals for many clinical crises, with perceived benefits for delivering optimal patient care during emergencies [13]. However, simply placing such aids in the OR will not lead to their appropriate use or change perioperative outcomes. Some clinicians have the perception that "checklist fatigue" may be an undesirable consequence of such use [25-29]. Furthermore, the first treatment steps during a crisis often need to be initiated without a cognitive aid.

Studies have demonstrated that the benefits of perioperative cognitive aids and other types of hospital checklists depend on factors that include [30,31]:

●Good visual design and content that is clearly relevant for the setting

●Adequate introduction with engagement and "buy-in" of the clinician end-users (eg, anesthesiologists, surgeons, OR nurses)

●Appropriate implementation that includes systematic team training

●Ongoing opportunities for simulation and practice

Successful implementation of emergency manual use in various institutions has included workshops at national and international professional society meetings, simulation training programs including "training the trainer," and readily available hard-copy (ie, paper) and/or electronic emergency manuals [32]. In one study, a structured process for implementing a customized emergency manual (EM) in a large academic anesthesia practice included forming an EM implementation team, considering institution-specific factors, selecting the preferred EM characteristics, recognizing logistical barriers, and educating staff [33]. However, six months after implementation, only 42 percent of 60 anesthesia team members used the EM to verbalize critical steps in treatment in simulated crisis events. Notably, those who used the EM performed better in the simulated crises than those who did not [33]. Thus, ongoing simulation or other reinforcement of initial training is necessary to ensure that using cognitive aids becomes routine, habitual, expected, and part of institutional culture.

In other industries where safety is critical (eg, aviation, nuclear power production, military operations), cognitive aids are used during regular training that includes simulating crisis situations, as well as during actual emergencies. It is thought that the adaptive work of the team is as important in generating measurable improvements in performance as the technology of the cognitive aid itself [9,30]. (See "Patient safety in the operating room", section on 'Timeouts, briefing, and debriefing'.)

In one author’s work aimed at building crisis-ready teams through simulation programs instituted at hospitals internationally, cognitive aids adapted to meet the specific hospital’s needs prove invaluable for initial buy-in. This is not foolproof, since implementation hurdles may still exist despite customization, and include needing buy-in from an interprofessional group to support their use [33]. However, once cognitive aids are integrated into the culture of an institution via interprofessional education, sustained use can be seen over many years [34].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Patient safety in the operating room".)

SUMMARY AND RECOMMENDATIONS

●Potential benefits of cognitive aids – Perioperative emergency cognitive aids (also termed emergency manuals, crisis checklists, rapid overviews, or emergency management algorithms) are used to ensure adherence to best practices with completion of all critical tasks, reduce potential for human error, and compensate for physical and mental fatigue in operating room (OR) emergencies. Examples include cognitive aids for management of anaphylaxis (table 1), malignant hyperthermia (MH) (table 2), local anesthetic systemic toxicity (LAST) (table 3), and OR fires (algorithm 1). (See 'Potential benefits of cognitive aids' above.)

●General principles – Most cognitive aids contain elements of crisis resource management (CRM) principles and incorporate a stepwise approach with visual elements designed to aid in navigating all steps (figure 1). Explicitly emphasizing the ways in which management may differ from other standard approaches is a necessary component of aids designed for specific emergencies in perioperative patients. (See 'General principles' above.)

●Specific resources – Several resources are available for emergency cognitive aids specifically developed for use in OR settings. (See 'Resources for selected available cognitive aids' above.)

●Considerations for implementation

•Optimal use – Ideally, the selected set of cognitive aids is posted in all procedural areas as well as on every advanced cardiac life support and other emergency carts (eg, with equipment for MH, difficult airway, LAST, etc) in all perioperative settings within hospitals that provide such care. It is critical that anesthesiologists and other OR team members become familiar with their institution’s cognitive aids before they are needed to manage a rare emergency. (See 'Implementing cognitive aids' above.)

•Challenges – Consistent use to achieve the benefits of perioperative cognitive aids depends on factors that include (see 'Challenges for implementing use of cognitive aids' above):

-Good visual design and content that is clearly relevant for the setting

-Adequate introduction with engagement and "buy-in" of the clinician end-users (eg, anesthesiologists, surgeons, OR nurses)

-Appropriate implementation that includes systematic team training

-Ongoing opportunities for simulation and practice

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Marjorie Stiegler, MD, who contributed to an earlier version of this topic review.