Crisis Checklists Improve Management of Rarely Occurring Events
Abstract & Commentary
By Leslie A. Hoffman, RN, PhD, Professor Emeritus, Nursing and Clinical & Translational Science, University of Pittsburgh. SYNOPSIS: In a simulation study, checklist use was associated with significant improvement in management of infrequent crisis events, suggesting the potential to improve care.
SOURCE: Arriaga AF, et al. Simulation-based trial of surgical-crisis checklists. N Engl J Med 2013;368:246-253.
This study, conducted using high-fidelity simulation, was designed to determine if a checklist could improve adherence to best practices during crisis events in the operating room (OR). The events selected were situations that required a rapid, coordinated, time-critical response, but were unlikely to be frequently encountered, e.g., failed airway, cardiac arrest, air embolism, anaphylaxis, massive hemorrhage, unstable bradycardia, unstable tachycardia, malignant hyperthermia, etc. Participants were 17 surgical teams recruited from one community and two academic institutions in the Boston area. The teams consisted of anesthesia staff (attending physicians, residents, certified registered nurse anesthetists, OR nurses, surgical technicians) and "mock" surgeons. Mock surgeons were used because few surgeons or surgical residents chose to volunteer. Each team was randomly assigned to manage half the scenarios with a set of crisis checklists and the remaining from memory. The primary outcome was failure to adhere to critical processes of care. Key processes were identified for each scenario and scored by three physicians. Disagreements were resolved by expert review by senior faculty.
Checklist use resulted in a nearly 75% reduction in failure to adhere to critical steps in management (P < 0.001). Results were unchanged when the analysis was repeated after adjusting for simulation learning or fatigue effects (testing was done on 1 day). Also, there were no differences related to institution or setting (academic vs community hospital). Participants were asked to complete a brief four-question survey using ratings of 1 (disagree strongly) to 5 (agree strongly). Ratings for the four questions were: "checklist helped me feel better prepared" (4.4 ± 0.8), "easy to use" (4.3 ± 0.8), "would use again in an emergency" (4.5 ± 0.8), and "would want this checklist to be used if I were having an operation and experienced this emergency" (4.7 ± 0.6).
Although conducted in the OR, this study has parallel implications for critical care. The checklists (http://www.projectcheck.org/crisis) were formatted using 8 × 11 inch cards that listed appropriate actions, medications and dosages and a section titled, "Have we considered?" The intent was to select conditions in which prompt, targeted action could make the difference between survival and death. Termed "crisis-related cognitive aids," they were designed to ensure more rapid and appropriate actions in such emergencies. Checklists targeted to emergent events that occur in the ICU would likely be similarly beneficial. They could aid housestaff new to a particular service or setting, acute care nurse practitioners or physician assistants assigned to off tours, as well as experienced clinicians who might not have encountered such events in the recent past. Notably, 97% of participants gave a score of 4 or higher to the statement, "If I were having an operation and experienced this intraoperative emergency, I would want the checklist to be used." Examples of actions not taken or delayed in the absence of checklists were given for bradycardia (> 10-minute delay to transcutaneous pacing because the selected setting was insufficient to enable pacing of the heart) and for anaphylaxis (insufficient fluid resuscitation), as well as other conditions.
Although, as the authors note, a shift in culture may be necessary before we routinely consult a cognitive aid during an emergency, findings of this study suggest that reliance on such memory aids can improve patient safety. Checklists should be viewed as an additional resource that can be used as an adjunct in emergent real-life scenarios.