Hundreds of facilities have started to put emergency manuals into place. Here are some of their stories of how they put these tools into practice and benefits they have seen from using them.
Implementing an Emergency Manual in a 300 bed hospital
After adopting the WHO surgical checklist in 2009, our anesthesia group inevitably asked ourselves if we could see a role for the other aviation safety tool, emergency checklists. We already had a proliferation of such devices almost cluttering our workspaces- the ACLS algorithms, the Malignant Hyperthermia checklist, the ASA Difficult Airway algorithm, the newly emerging Local Anesthetic Systemic Toxicity (LAST) guidelines, and our own local fire safety plans. A team assembled (including one of the staff who is a licensed pilot) and looked for a way to group these and add some other basic “disaster plans” in a useable format.
First, we rounded out the list of topics to include other anesthesia challenges, such as hypotension, hypoxemia, massive blood loss, and transfusion reactions. To standardize the format, we looked to the aviation literature, and the suggestions that were included in Atul Gawande’s text, The Checklist Manifesto. The internet already had advice available, now incorporated into the ProjectCheck website (http://www.projectcheck.org/checklist-for-checklists.html), but we were also fortunate to have a local resource- Dan Boorman of the Boeing Company, who develops checklists for their airplanes. He was generous with general advice, and soon we had a binder of one-page action oriented checklists/algorithms.
We chose a 3-ring red binder format, recognizing that these algorithms are subject to updates, and we wanted the option to change one page at a time. We also thought it would be useful to take out the relevant page in an emergency. We elected to have the basic steps on the front side, trying to keep to the “seven simple items” from aviation, and additional/supplemental information on the back of each page. We placed one copy of the book in the top drawer of each anesthesia machine, but realized that actual use would require more training, and even a cultural change like the surgical checklist evoked.
To increase awareness of the checklists, and to validate them, we organized multidisciplinary simulation with OR and PACU nurses, using the LAST and the MH checklists to start. We quickly learned that a team leaded, and perhaps a separate “reader” were helpful. We found the original pages were confusing, and modified them accordingly. Our simulation of LAST was especially helpful in showing how important it was to distinguish this resuscitation from standard ACLS protocols. It was also obvious in both these protocols that inclusion of multiple team members was essential. We have continued to use the pathways as templates for simulation with nursing teams in the OR.
Revisions were inevitable. When the Boston group published their simulation-tested checklists, we added some items to our own. We have recently revised the format of the book to make the index more clear, with colored tabs imitating the textual presentation by Borshoff (Borshoff DC. The Anaesthetic Crisis Manual). This also involved laminating the sheets (like the Stanford model) to make them fit better, and to avoid spills. We have added new ASA algorithms for OR Fire and Difficult Airway (February 2013 issue of Anesthesiology journal) as well as the new ACLS protocols, and incorporated our Blood Bank’s Massive Transfusion protocol. We have learned that implementation requires both broad administrative support and at least one local “champion” who makes sure the lists are updated and simulations occur on a regular basis. We are fortunate that the Director of Perioperative Services is an anesthesiologist who was on the original team and is fully supportive, as is the OR Nursing Educator. One of the anesthesia staff and one of the anesthesia technicians have remained the “day-to-day” champions ensuring that the books remain in the anesthesia carts, and are actually looked at by the staff when discussing potential management of an emergency.
Although it was a bit of work, we feel we currently have a functioning set of manuals, partly local creation, and partly adoption of several national algorithms and protocols. It was possible in a mid-size hospital with just local staff and routine administrative support (and a friendly FedEx copy shop!). We recognize the ongoing challenge is to ensure that the manuals move beyond simulation, and are actually used in an emergency situation. Changing that behavior will be more challenging than adopting the surgical checklist, but ultimately is the right thing!