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Emergency Manual Implementation in a Large Academic Anesthesia Practice

Strategy and Improvement in Performance on Critical Steps

Gleich, Stephen J., MD*; Pearson, Amy C. S., MD; Lindeen, Kevin C., CRNA, MNA*; Hofer, Ryan E., MD*; Gilkey, George D., MD*; Borst, Luann F., CRNA, MNA*; Haile, Dawit T., MD*; Martin, David P., MD, PhD*

doi: 10.1213/ANE.0000000000003578
Healthcare Economics, Policy, and Organization: Original Clinical Research Report

BACKGROUND: The use of cognitive aids, such as emergency manuals (EMs), improves team performance on critical steps during crisis events. In our large academic anesthesia practice, we sought to broadly implement an EM and subsequently evaluate team member performance on critical steps.

METHODS: We observed the phases of implementing an EM at a large academic anesthesia practice from 2013 to 2016, including the formation of the EM implementation team, identification of preferred EM characteristics, consideration of institution-specific factors, selection of the preferred EM, recognition of logistical barriers, and staff education. Utilization of the EM was tested in a regular clinical environment with all available resources using a standardized verbal simulation of 3 crisis events both preimplementation and 6 months postimplementation. Individual members of the anesthesia team were asked to verbalize interventions for specific crisis events over 60 seconds.

RESULTS: We introduced a customized version of the Stanford Emergency Manual on January 26, 2015. Fifty-nine total participants (equal proportion of anesthesiology attending physicians, resident physicians, certified registered nurse anesthetists, and student registered nurse anesthetist staff) were surveyed in the preimplementation phase and 60 in the 6-month postimplementation phase. In the postimplementation phase, a minority (41.7%) utilized the EM for the verbal-simulated crisis events. Those who used the EM performed better than those who did not (median 21.0 critical steps out of a possible 30 total steps [70.0%], interquartile range 19–25 vs 18.0 critical steps verbalized [60.0%], interquartile range 16–20; P < .001). Among all subjects, the median number of critical steps verbalized was 16 (53.3%) preimplementation and 19.5 critical steps (65.0%) postimplementation.

CONCLUSIONS: Implementation of an EM in a large academic anesthesia practice is not without challenges. While full integration of the EM was not achieved 6 months after implementation, verbalization of critical steps on 3 simulated crisis events improved when the EM was utilized.

From the *Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota

Department of Anesthesia, University of Iowa, Iowa City, Iowa.

Published ahead of print 8 May 2018.

Accepted for publication May 8, 2018.

Funding: None.

The authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website.

Reprints will not be available from the authors.

Address correspondence to Stephen J. Gleich, MD, Department of Anesthesiology and Pediatrics, Mayo Clinic, 200 1st St SW, Rochester, MN 55905. Address e-mail to

© 2019 International Anesthesia Research Society
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