From the Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California.
Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine, Stanford, California.
Anesth Analg. 2020 Dec;131(6):1815-1826. doi: 10.1213/ANE.0000000000005012.
Performing key actions efficiently during crises can determine clinical outcomes, yet even expert clinicians omit key actions. Simulation-based studies of crises show that correct performance of key actions dramatically increases when emergency manuals (EMs) are used. Despite widespread dissemination of EMs, there is a need to understand in clinical contexts, when, how, and how often EMs are used and not used, along with perceived impacts.
We conducted interviews with the anesthesia professionals involved in perioperative crises, identified with criterion-based sampling, occurring between October 2014 and May 2016 at 2 large academic medical centers with a history of EM training and implementation. Our convergent, mixed-methods study of the interview data extracted quantitative counts and qualitative themes of EM use and nonuse during clinical crises.
Interviews with 53 anesthesia professionals yielded 80 descriptions of applicable clinical crises, with varying durations and event types. Of 69 unique patients whose cases involved crises, the EM was used during 37 (54%; 95% confidence interval [CI], 41-66). Impacts on clinician team members included decreased stress for individual anesthesia professionals (95%), enabled teamwork (73%), and calmed atmosphere (46%). Impacts on delivery of patient care included specific action improvements, including catching errors of omission, for example, turning off anesthetic during cardiac arrest, only after EM use (59%); process improvements, for example, double-checking all actions were completed (41%); and impediments (0%). In 8% of crises, EM use was associated with potential distractions, although none were perceived to harm delivery of patient care. For 32 EM nonuses (46%; 95% CI, 34-59), participants self-identified errors of omission or delays in key actions (56%), all key actions performed (13%), and crisis too brief for EM to be used (31%).
This study provides evidence that EMs in operating rooms are being used during many applicable crises and that clinicians perceive EM use to add value. The reported negative effects were minimal and potentially offset by positive effects.
在危机中高效执行关键操作可以决定临床结果，但即使是经验丰富的临床医生也会遗漏关键操作。基于模拟的危机研究表明，使用急救手册（EMs）可显著提高正确执行关键操作的比例。尽管 EMs 已经广泛传播，但仍需要了解在临床环境中何时、如何以及频率使用和不使用 EMs，以及感知到的影响。
我们对参与围手术期危机的麻醉专业人员进行了访谈，这些人员是通过基于标准的抽样在 2014 年 10 月至 2016 年 5 月期间在 2 家具有 EMs 培训和实施历史的大型学术医疗中心中确定的。我们对访谈数据进行了收敛性、混合方法研究，提取了临床危机期间使用和不使用 EMs 的定量计数和定性主题。
对 53 名麻醉专业人员的访谈产生了 80 种不同的临床危机描述，其持续时间和事件类型各不相同。在涉及危机的 69 名独特患者中，有 37 名（54%；95%置信区间[CI]，41-66）在危机期间使用了 EM。对临床医生团队成员的影响包括降低个体麻醉专业人员的压力（95%）、促进团队合作（73%）和缓解气氛（46%）。对患者护理的影响包括具体行动的改进，例如，在心脏骤停期间关闭麻醉，仅在使用 EM 后才能避免遗漏（59%）；流程改进，例如，检查所有操作是否完成（41%）；以及障碍（0%）。在 8%的危机中，使用 EM 与潜在的干扰有关，尽管没有人认为这会对患者护理的提供造成伤害。对于 32 次 EM 不使用（46%；95%CI，34-59），参与者自行确定了遗漏或延迟关键操作的错误（56%），所有关键操作均已执行（13%），且危机太短暂而无法使用 EM（31%）。
本研究提供了证据表明，手术室中的 EMs 在许多适用的危机中得到了使用，并且临床医生认为使用 EMs 具有价值。报告的负面影响很小，并且可能被积极影响所抵消。
