• Sara N Goldhaber-Fiebert, Anna Frackman, Aalok V Agarwala, Allison Doney, and Pian-SmithMay C MMCMDepartment of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA. Electronic address: MPianSmith@mgh.harvard.edu..
• Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, 300 Pasteur Dr. Rm H3674, Stanford, CA 94305, USA. Electronic address: saragf@stanford.edu.
• J Clin Anesth. 2023 Aug 1; 87: 111111111111.

Study ObjectiveUse of cognitive aids during emergencies increases key actions and decreases omissions, both known to save lives. With little known about emergency manual (EM) clinical use, we aimed to help answer "Will EMs be used peri-crisis at a meaningful frequency?" and to explore clinical sustainment.DesignProspective, observational study.SettingOperating Rooms.PatientsAll patients undergoing anesthesia at a major academic medical center during the study periods; ∼75,000 cases.Intervention & MeasurementsTo understand the initial and sustainment phases of EM implementation, we placed a question regarding EM use at the end of every anesthetic case to prospectively measure EM use at: implementation, one-year later, and six years post-implementation.Main ResultsFor more than twenty-four thousand cases in each approximately 6-month study period, EMs were used peri-crisis (before, during or after a perioperative crisis) in 145 cases initially (0.55%; SE 0.045%), 42 cases one-year later (0.17%; SE 0.026%), and 57 cases (0.21%; SE 0.028%) six years post-implementation. Peri-crisis EM uses dropped 0.38% (97.5% CI: 0.26%, 0.49%) from initial to one-year post-implementation. After that, peri-crisis EM uses did not differ significantly from one-year to six years post-implementation, showing sustainment [increased 0.04% (97.5% CI: -0.05%, 0.12%)]. Among cases with cardiac arrest or CPR, as a subset proxy for relevant crises, EMs were used in 7/13 such cases initially (54%, SE 13.6%), 8/20 one-year later (40%; SE 10.9%) and 7/13 six years later (54%; SE 13.6%).ConclusionsAfter an initial expected drop, EM peri-crisis use six years post-implementation was: sustained without intensive additional efforts, averaged ∼10 times per month at a single institution, and was reported in more than half of cases with cardiac arrest or CPR. Peri-crisis use of EMs is appropriately rare, though for relevant crises can have substantial positive impacts as described in prior literature. The sustained use of EMs may be related to increasing cultural acceptance of EMs, as reflected in survey result trends and broader cognitive aid literature.Copyright © 2023. Published by Elsevier Inc.

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