The Use of Cognitive Aids During Emergencies in Anesthesia: A Review of the Literature

Marshall, Stuart MB, ChB, MHumanFact

Anesthesia & Analgesia:
doi: 10.1213/ANE.0b013e31829c397b
Patient Safety: Review Article

Cognitive aids are prompts designed to help users complete a task or series of tasks. They may take the form of posters, flowcharts, checklists, or even mnemonics. It has been suggested that the use of cognitive aids improves performance and patient outcomes during anesthetic emergencies; however, a systematic assessment of the evidence is lacking. The aim of this literature review was to determine (1) whether cognitive aids improve performance of individuals and teams and (2) whether recommendations can be made for future cognitive aid design, testing, and implementation. Medical, nursing, and psychology databases were searched using broad criteria to find cognitive aids that have been reported in the literature for use in anesthetic emergencies. The reference lists of the articles selected for review were also screened to identify additional studies. Selected articles that described the evaluation of cognitive aids used in anesthetic emergencies were reviewed to determine how the content of the aid was derived, how the design was evaluated, and the success of the aid in improving technical and team performance. The search yielded 22 cognitive aids developed to support clinicians during anesthetic emergencies that had been evaluated in 23 studies. Ten studies using simulation suggested that technical performance improves with the use of cognitive aids in some anesthetic emergencies such as malignant hyperthermia, cardiopulmonary resuscitation, and airway management. However, in 3 of the simulator-based evaluations, participants had either no improvement or took longer to diagnose and treat and made more incorrect diagnoses. Four studies investigated the effect of the aids on teamwork with differing conclusions. One study suggested improved participants’ coordination patterns and one found aids improved their decision-making scores, but 2 other studies indicated that there was no improvement and even provided evidence of reduced levels of team communication when teams used a cognitive aid in simulated conditions. The designs of cognitive aids were rarely considered. Education may compensate for a poorly designed aid, but only by ingraining correct actions for situations in which the aid provides little or no guidance. Cognitive aids should continue to be developed from established clinical guidelines where guidelines exist. They would also benefit from more extensive simulation-based usability testing before use. Further evidence is required to explore the effects of cognitive aids in anesthetic emergencies, how they affect team function, and their design considerations.

In Brief

Published ahead of print September 12, 2013

Author Information

From the Academic Board of Anaesthesia and Peri-operative Medicine, Monash University, Melbourne; Cognitive Engineering Research Group, School of Psychology, The University of Queensland, Brisbane; and Monash Simulation, Monash Medical Centre, Melbourne, Australia.

Accepted for publication April 15, 2013.

Published ahead of print September 12, 2013

Funding: The author has no competing interests to declare. All research was undertaken as part of a self-funded PhD thesis.

The author declares no conflicts of interest.

Reprints will not be available from the author.

Address correspondence to Stuart Marshall, MB, ChB, MHumanFact, Monash Simulation, Monash Medical Centre, Moorabbin Campus, 823–865 Centre Rd., East Bentleigh, Victoria 3165, Australia. Address e-mail to

© 2013 International Anesthesia Research Society