Emergency Manual


How This Work Came to Be

Authored by Stanford Anesthesia Cognitive Aid Group (SACAG)

This Emergency Manual has a long history, evolving from decades of prior work on both Crisis Resource Management (CRM) concepts and cognitive aids for critical incidents. The 1994 book entitled Crisis Management in Anesthesiology by Dr. David Gaba, Dr. Steven Howard, and Dr. Kevin Fish provided the initial foundations for this project. Their simulation group has been involved in developing cognitive aids for operating rooms in the Palo Alto VA and then a national VA project, each with bulleted points for many critical events.

Observing that practitioners often miss key actions under stress, Drs. Harrison and Goldhaber-Fiebert along with Dr. Geoff Lighthall, Dr. Ruth Fanning, Dr. Howard, and Dr. Gaba developed several iterations of pocket cards for perioperative critical events, including some with rhythm strips, icons, and color design. In 2004, Dr. Larry Chu conceived of adapting crisis management cognitive aids to a more visually striking format for a new book he envisioned for today's highly-visual millennial learners. This became The Manual of Clinical Anesthesiology, published in 2011.

To create the current Emergency Manual, the Stanford Anesthesia Cognitive Aid Group was formed. All team members have had integral roles. Dr. Larry Chu, who directs the Stanford AIM (Anesthesia Informatics Management) lab, provided the new graphics and layout, applying his design skills and an understanding of user interface to make the content more easily usable. Drs. Sara Goldhaber-Fiebert, Kyle Harrison, Steven Howard, and David Gaba worked jointly to provide the content, including exact phrasing, ordering, and emphasis, as well as iterative simulation testing to revise both content and design elements.

Observing how cognitive aids are used by teams during hundreds of simulated crises has been crucial for pilot testing throughout. We hope that this Emergency Manual will support both education and patient safety efforts. Effective use has included pre-event review, post-event team debriefing, and ‘during’ critical event management – the latter particularly after adequate help has arrived or when the patient is sufficiently stable for a clinician to pause from acute care actions. We encourage the use of this Manual and welcome feedback from all practitioners.

Acknowledgments: For their extensive feedback, we deeply appreciate the faculty and residents at Stanford Hospital and VA Palo Alto anesthesia departments, especially Dr. Becky Wong. For their team effort in implementation for Stanford, we thank the entire OR leadership of nursing, surgery, technicians, and anesthesia, and in particular Diane Alejandro. We are grateful to our chair, Dr. Ron Pearl, whose support was critical to making this project a reality. The implementation of the Emergency Manual at Stanford has been facilitated by Amir Rubin, Dr. Bryan Bohman, Randy Cook, and Mary Lou Jackson among many others. We also thank Dr. Candace Pau and Vivek Mohta for their contributions in developing the Emergency Manual website.

Disclaimer: The material in this Manual is not intended to be a substitute for sound medical knowledge and training. Clinicians using this Manual should use their clinical judgment and decision making for patient management. Since treatment for the medical conditions described in this Manual can have variable presentations, departure from the information presented here is encouraged when appropriate.

Appropriate citation of this Emergency Manual:
Stanford Anesthesia Cognitive Aid Group*. Emergency Manual: Cognitive aids for perioperative critical events. See http://emergencymanual.stanford.edu for latest version. Creative Commons BY-NC-ND. 2014 (Version 2) (http://creativecommons.org/licenses/by-nc-nd/3.0/legalcode).
*Core contributors in random order: Howard SK, Chu LF, Goldhaber-Fiebert SN, Gaba DM, Harrison TK.

Attribution: Much of the work in this Anesthesia Emergency Manual was adapted from cognitive aids originally published in Appendix of Crisis Management Algorithms in Anesthesia in the Manual of Clinical Anesthesiology, edited by Larry Chu and Andrea Fuller, published by Lippincott Williams & Wilkins, 2011. The authors were*: Harrison TK, (21) Goldhaber-Fiebert SN (21), and Chu L (21), as well as on specific cognitive aids, contributions by: Lighthall G, (2), Howard S (1), and Mudumbai S (1)*First three authors listed in random order; # of cognitive aids contributed to in original publication listed parenthetically.

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