• Sara N Goldhaber-Fiebert, Sylvia Bereknyei Merrell, Aalok V Agarwala, Monica M De La Cruz, Jeffrey B Cooper, Steven K Howard, Steven M Asch, and David M Gaba.
• From the Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California.
• Anesth. Analg. 2020 Dec 1; 131 (6): 1815-1826.

BackgroundPerforming 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.MethodsWe 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.ResultsInterviews 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%).ConclusionsThis 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.

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