Pilots use checklists. Anesthesiologists do not use them as much, if at all. Is there evidence to show that when they are used, the performance of individuals and teams is improved? Are there recommendations as to how such checklists or cognitive aids can be tested and improved?
Dr. Stuart Marshall, 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, reviewed 22 cognitive aids that were evaluated in 23 studies. His findings appear in the article titled “The Use of Cognitive Aids During Emergencies in Anesthesia: A Review of the Literature” that was published in this month’s edition of Anesthesia & Analgesia.
Seven of 22 cognitive aids were developed to help in a variety of anesthetic crises. The rest deal with specific crises such as cardiac arrest or airway emergency. Thirteen cognitive aids were based on national guidelines. The cognitive aids took the form of handbooks, cards, posters, or computerized systems.
Surveys, simulation studies, and case reports have been used to evaluate system success. Evaluation of cognitive aids has focused on frequency of use and awareness of the aids by physicians in the clinical workspace. Several studies have assessed whether their use improved patient outcome. In 10 of 13 studies, technical performance including airway management and malignant hyperthermia management suggested improvement, whereas in two studies there was no improvement in outcome. In one study involving a personal digital assistant, the time to diagnose and intervene during an emergency took longer. In one retrospective study, the authors felt that had a cognitive aid been used, 60% of incidents could have been resolved in less than a minute.
Training in the use of cognitive aids has varied between no training and allowing study participants to familiarize themselves with the aids. Team functioning has been studied in only four studies and the usefulness of such aids for teams has been mixed.
Within the field of medicine, the need for checklists is not unique to anesthesiologists. For example, Dr. Atul Gawande, a surgeon, describes in his 2009 book, The Checklist Manifesto, how a checklist can prevent potentially fatal mistakes. Some anesthesiologists liken the conduct of anesthesia to flying an airplane. Pilots accept the use of cognitive aids. It is curious why those same anesthesiologists have not adopted the practices of pilots. Pulse oximetry, for example, has been accepted with little evidence to show that its use improves outcome. The question of why checklists have not been similarly adopted could again be asked given that there is evidence to show that their use improves outcome.