A crisis is defined as a time-sensitive situation in which intervention must occur rapidly in order to change the patient’s clinical course. In such cases, it is vital that the patient care team comes together to deliver comprehensive and rapid care to avoid worsening outcomes for both mother and fetus. While the patient case above was one of maternal cardiac arrest, there are many obstetric crises that occur which have specific treatments to hopefully avoid the outcome of cardiopulmonary arrest.
Anesthesia care frequently requires rapid, complex decisions that are most susceptible to decision errors (36), and while we may each build our own expertise in certain areas, no anesthesiologist is expert at managing all aspects of all critical events. Moreover, stressful situations have been shown to negatively impact multiple aspects of human memory, including retrieval of inert knowledge, working memory for calculations, and prospective memory for future tasks (37). This underscores the importance of identifying and reliably training with additional rapidly-accessible tools such as cognitive aids.
Cognitive aids are prompts designed to help users complete a task or series of tasks. They may take the form of posters, flowcharts, checklists, or even mnemonics. It has been suggested that the use of cognitive aids improves performance and patient outcomes during anesthetic emergencies (38). Previous research has shown that the presence of a cognitive aid can improve performance in the simulated management of a rare, high-stakes scenario such as maternal cardiac arrest and malignant hyperthermia (39). A cognitive aid would theoretically guide clinicians under stressful situations through a sequence of complex steps and prevent them from omitting key actions (40). It is important to promote throughout each organization’s culture that the use of these aids is meant to be viewed as a sign of strength and wisdom instead of a sign of weakness and lack of intelligence (41).
Cognitive aids form one component of the larger picture of crisis resource management, which includes other important items such as cross-monitoring, clear and effective communication, mobilizing and managing resources, establishing role clarity, and calling for help early (42). Checklists and similar algorithmic cognitive aids are increasingly popular as decision support tools for critical events. Use of such aids may be effective in promoting better decisions and mitigating the influence of nonrational cognitive factors such as bias.
Simulation studies suggest checklists may help medical teams perform optimally during emergencies (43); however, periodic training is necessary in order to familiarize health care provider teams with their use (44). Incomplete or misleading cognitive aids (such as inaccurate or poorly designed aids), or incorrect use of cognitive aids, may distract clinicians and lead to worse performance than without them (45). It has also been suggested that the introduction of an unfamiliar cognitive aid may lead to a reduction in the volume of communication within the team (46) , especially when a code leader attempts to read a cognitive aid and subsequently becomes task saturated by trying to perform too many simultaneous actions. Therefore, it has been recommended that a code leader designate a team member to serve as the “reader” of the cognitive aid during crises so that interventions from the checklist can be read aloud and cross-checked (47).
The critical determinants to enable the successful development and use of cognitive aids include 1) accurate content, 2) user-friendly design, 3) iterative testing using simulation, 4) repeated familiarization and training, 5) accessibility, and 6) the use of a reader (48). There is a need for larger prospective trials of the effect of aids on task completion, practitioners’ team behaviors, and overall team functioning.
As a separate exercise, we invite you to create your own personal version of a cognitive aid for a specific obstetric crisis. Is there already an existing cognitive aid for that particular obstetric crisis? If so, how does yours compare? If no cognitive aid exists, consider turning your work into a publication to better serve our community of providers.
- Stiegler et al Anesthesiology 2014
- Goldhaber-Fiebert and Howard A&A 2013
- Marshall et al A&A 2013
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- Gaba A&A November 2013
- Gaba DM, Fish KJ, Howard SK, Burden A. Chapter 2: Principles of crisis resource management. In: Crisis Management in Anesthesiology, 2nd ed. Saunders, 2014.
- Marshall et al A&A 2013 and Berkenstadt et al.
- Goldhaber-Fiebert and Howard, Marshall et al A&A 2013
- Marshall A&A 2013
- Burden et al
- Burden et al 2012
- Goldharber-Fiebert and Howard A&A 2013