Runciman W B, Kluger M T, Morris R W, Paix A D, Watterson L M, Webb R K
Department of Anaesthesia and Intensive Care, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia.
Qual Saf Health Care. 2005 Jun;14(3):e1. doi: 10.1136/qshc.2002.004101.
All anaesthetists have to handle life threatening crises with little or no warning. However, some cognitive strategies and work practices that are appropriate for speed and efficiency under normal circumstances may become maladaptive in a crisis. It was judged in a previous study that the use of a structured "core" algorithm (based on the mnemonic COVER ABCD-A SWIFT CHECK) would diagnose and correct the problem in 60% of cases and provide a functional diagnosis in virtually all of the remaining 40%. It was recommended that specific sub-algorithms be developed for managing the problems underlying the remaining 40% of crises and assembled in an easy-to-use manual. Sub-algorithms were therefore developed for these problems so that they could be checked for applicability and validity against the first 4000 anaesthesia incidents reported to the Australian Incident Monitoring Study (AIMS).
The need for 24 specific sub-algorithms was identified. Teams of practising anaesthetists were assembled and sets of incidents relevant to each sub-algorithm were identified from the first 4000 reported to AIMS. Based largely on successful strategies identified in these reports, a set of 24 specific sub-algorithms was developed for trial against the 4000 AIMS reports and assembled into an easy-to-use manual. A process was developed for applying each component of the core algorithm COVER at one of four levels (scan-check-alert/ready-emergency) according to the degree of perceived urgency, and incorporated into the manual. The manual was disseminated at a World Congress and feedback was obtained.
Each of the 24 specific crisis management sub-algorithms was tested against the relevant incidents among the first 4000 reported to AIMS and compared with the actual management by the anaesthetist at the time. It was judged that, if the core algorithm had been correctly applied, the appropriate sub-algorithm would have been resolved better and/or faster in one in eight of all incidents, and would have been unlikely to have caused harm to any patient. The descriptions of the validation of each of the 24 sub-algorithms constitute the remaining 24 papers in this set. Feedback from five meetings each attended by 60-100 anaesthetists was then collated and is included.
The 24 sub-algorithms developed form the basis for developing a rational evidence-based approach to crisis management during anaesthesia. The COVER component has been found to be satisfactory in real life resuscitation situations and the sub-algorithms have been used successfully for several years. It would now be desirable for carefully designed simulator based studies, using naive trainees at the start of their training, to systematically examine the merits and demerits of various aspects of the sub-algorithms. It would seem prudent that these sub-algorithms be regarded, for the moment, as decision aids to support and back up clinicians' natural responses to a crisis when all is not progressing as expected.
所有麻醉医生都必须在几乎没有预警的情况下应对危及生命的危机。然而，一些在正常情况下适合提高速度和效率的认知策略及工作方法，在危机中可能会变得不适应。在之前的一项研究中判断，使用结构化的“核心”算法（基于助记符COVER ABCD-A SWIFT CHECK）可在60%的病例中诊断并纠正问题，在几乎其余40%的病例中提供功能性诊断。建议针对其余40%危机背后的问题开发特定的子算法，并汇编成一本便于使用的手册。因此针对这些问题开发了子算法，以便对照向澳大利亚事件监测研究（AIMS）报告的前4000例麻醉事件检查其适用性和有效性。
确定了24种特定子算法的需求。组建了由执业麻醉医生组成的团队，并从向AIMS报告的前4000例中识别出与每个子算法相关的事件集。主要基于这些报告中确定的成功策略，开发了一套24种特定子算法，用于对照4000份AIMS报告进行试验，并汇编成一本便于使用的手册。开发了一个流程，根据感知到的紧急程度在四个级别（扫描-检查-警报/准备-紧急）之一应用核心算法COVER的每个组件，并纳入手册。该手册在一次世界大会上分发并获得了反馈。
针对向AIMS报告的前4000例中的相关事件，对24种特定危机管理子算法中的每一种进行了测试，并与当时麻醉医生的实际处理情况进行了比较。判断得出，如果正确应用核心算法，在所有事件的八分之一中，相应的子算法本可以更好和/或更快地得到解决，并且不太可能对任何患者造成伤害。这24种子算法中每一种的验证描述构成了本系列其余的24篇论文。然后整理了来自五次会议的反馈，每次会议有60至100名麻醉医生参加，并包含在内。
所开发的24种子算法构成了制定麻醉期间基于合理证据的危机管理方法的基础。已发现COVER组件在实际复苏情况中令人满意，并且这些子算法已成功使用数年。现在希望通过精心设计的基于模拟器的研究，在培训开始时使用新手学员，系统地检查子算法各个方面的优缺点。目前将这些子算法视为决策辅助工具似乎是谨慎的，以在一切进展不如预期时支持并辅助临床医生对危机的自然反应。
