Simulation-Based Trial of Surgical-Crisis Checklists

Department of Health Policy and Management, Harvard School of Public Health, Boston, MA, USA.
New England Journal of Medicine (Impact Factor: 55.87). 01/2013; 368(3):246-53. DOI: 10.1056/NEJMsa1204720
Source: PubMed


Operating-room crises (e.g., cardiac arrest and massive hemorrhage) are common events in large hospitals but can be rare for individual clinicians. Successful management is difficult and complex. We sought to evaluate a tool to improve adherence to evidence-based best practices during such events.
Operating-room teams from three institutions (one academic medical center and two community hospitals) participated in a series of surgical-crisis scenarios in a simulated operating room. Each team was randomly assigned to manage half the scenarios with a set of crisis checklists and the remaining scenarios from memory alone. The primary outcome measure was failure to adhere to critical processes of care. Participants were also surveyed regarding their perceptions of the usefulness and clinical relevance of the checklists.
A total of 17 operating-room teams participated in 106 simulated surgical-crisis scenarios. Failure to adhere to lifesaving processes of care was less common during simulations when checklists were available (6% of steps missed when checklists were available vs. 23% when they were unavailable, P<0.001). The results were similar in a multivariate model that accounted for clustering within teams, with adjustment for institution, scenario, and learning and fatigue effects (adjusted relative risk, 0.28; 95% confidence interval, 0.18 to 0.42; P<0.001). Every team performed better when the crisis checklists were available than when they were not. A total of 97% of the participants reported that if one of these crises occurred while they were undergoing an operation, they would want the checklist used.
In a high-fidelity simulation study, checklist use was associated with significant improvement in the management of operating-room crises. These findings suggest that checklists for use during operating-room crises have the potential to improve surgical care. (Funded by the Agency for Healthcare Research and Quality.).

35 Reads
  • Source
    • "There is no evidence to show whether the use of a pocket guide increases the quality of resuscitation. However, one study recommends the use of a pocket guide in preoperative evaluation [10] and recently the use of a set of crisis checklists significantly improved the management of simulated operating-room crises suggesting possible improvement of surgical care [33]. Since we found that the overall adherence to the guidelines is fairly low, the use of pocket guides or checklists during advanced life support might be a suitable way to improve performance with the aim to improve survival after cardiac arrest. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Purpose: Austrian out-of-hospital emergency physicians (OOHEP) undergo mandatory biannual emergency physician refresher courses to maintain their licence. The purpose of this study was to compare different reported emergency skills and knowledge, recommended by the European Resuscitation Council (ERC) guidelines, between OOHEP who work regularly at an out-of-hospital emergency service and those who do not currently work as OOHEP but are licenced. We obtained data from 854 participants from 19 refresher courses. Demographics, questions about their practice and multiple-choice questions about ALS-knowledge were answered and analysed. We particularly explored the application of therapeutic hypothermia, intraosseous access, pocket guide use and knowledge about the participants' defibrillator in use. A multivariate logistic regression analysed differences between both groups of OOHEP. Age, gender, years of clinical experience, ERC-ALS provider course attendance and the self-reported number of resuscitations were control variables. Licenced OOHEP who are currently employed in emergency service are significantly more likely to initiate intraosseous access (OR = 4.013, p < 0.01), they initiate mild-therapeutic hypothermia after successful resuscitation (OR = 2.550, p < 0.01) more often, and knowledge about the used defibrillator was higher (OR = 2.292, p < 0.01). No difference was found for the use of pocket guides.OOHEP who have attended an ERC-ALS provider course since 2005 have initiated more mild therapeutic hypothermia after successful resuscitation (OR = 1.670, p <0.05) as well as participants who resuscitated within the last year (OR = 2.324, p < 0.01), while older OOHEP initiated mild therapeutic hypothermia less often, measured per year of age (OR = 0.913, p <0.01). Licenced and employed OOHEP implement ERC guidelines better into clinical practice, but more training on life-saving rescue techniques needs to be done to improve knowledge and to raise these rates of application.
    Scandinavian Journal of Trauma Resuscitation and Emergency Medicine 01/2014; 22(1):9. DOI:10.1186/1757-7241-22-9 · 2.03 Impact Factor
  • Source
    • "Simulations were successfully used as a research tool to evaluate variations in the retention of knowledge and skills over time (Smith et al. 2008 ), in the appropriate time intervals for refresher trainings (Woollard et al. 2006 ), and in alternative training devices to enhance retention (Spooner et al. 2007 ). Arriaga et al. ( 2013 ) investigated operating room teams working in a series of surgical crisis scenarios in a simulated operating room. Each team was randomly assigned to manage half the scenarios with a set of crisis checklists and the remaining scenarios from memory alone. "
    [Show abstract] [Hide abstract]
    ABSTRACT: An overview is presented of the strengths and limitations of simulation learning, with a particular focus on simulation learning in medicine and health care. We present what simulation learning is about and what the main components of simulations are. The most important theoretical approaches are reviewed which were developed in order to explain why simulation learning is effective. The most prominent best-practice examples of simulation learning applications are presented, and a short overview on research fi ndings concerning simulation learning is given.
    International Handbook of Research in Professional and Practice-based Learning, Edited by S. Billett, C. Harteis, H. Gruber, 01/2014: chapter Simulation learning: pages 673-98; Springer, Heidelberg., ISBN: 978-94-017-8901-1
    • "By adopting a systematic framework, the extraneous load of checking can be reduced, allowing trainees to focus on finding mistakes. Often, these frameworks are organized into checklists , which have helped physicians reduce error in a variety of contexts (Wolff et al. 2004; Haynes et al. 2009; Winters et al. 2009; Ely et al. 2011; Arriaga et al. 2013; Sibbald et al. 2013). Many checklists focus on the key variables involved in a diagnostic or management decision (Hales et al. 2008). "
    [Show abstract] [Hide abstract]
    ABSTRACT: Background: Checking diagnostic and management decisions can help reduce medical error, however, little literature explores how this is best taught. Aims: To provide practical advice to direct teaching practices. Methods: The authors conducted a literature review using Medline and PsychInfo using search terms: check or checklist and medical error or diagnostic error, supplemented by a manual search through cited literature. Conclusion: Twelve tips for teaching how to check diagnostic and management decisions are presented.
    Medical Teacher 11/2013; 36(2). DOI:10.3109/0142159X.2013.847910 · 1.68 Impact Factor
Show more