Emergency manuals as cognitive aids: from simulations to clinical implementations and uses (Goldhaber-Fiebert)

There is a mountain of published literature on optimal management for many operating room crises, such as local anaesthetic systemic toxicity or cardiac arrhythmias. But despite this, even expert clinicians frequently omit or delay key actions, with detrimental impacts on patient morbidity and mortality.446,447 In the decade since the 2010 Helsinki Declaration on Patient Safety in Anaesthesiology, great strides have been made in the arena of cognitive aids to enable healthcare teams to deliver better care to our patients, during and peri-crisis. One of the first actions of the EBA/ESA Helsinki Declaration Implementation Task Force was to produce and promote a series of Crisis Checklists. Building upon the WHO Surgical Safety Checklist for normal workflow, which was highlighted in Helsinki,392,393 multiple groups globally have worked on emergency manuals, including development, simulation testing, clinical implementation studies and training resources. Examples include ‘The Anaesthetic Crisis Manual’ by David Borshoff, the ESA Quick Reference Handbook (http://html.esahq.org/patientsafetykit/resources/checklists.html), and Guidelines for crises in anaesthesia https://anaesthetists.org/Portals/0/PDFs/QRH/QRH_complete_August_2019.pdf?ver=2019-08-23-113330-550. Others are Ariadne Labs Crisis Checklists (https://www.ariadnelabs.org/areas-of-work/surgery-or-crisis-checklists/), Society for Pediatric Anesthesia Critical Events Checklists (https://www.pedsanesthesia.org/critical-events-checklist/) and the Stanford Emergency Manual (https://emergencymanual.stanford.edu/).

Other articles provide a history of the development of emergency manuals as patient safety tools and a conceptual framework for going from simulation-based evidence to clinical implementation and use (Fig. 7).448,449 This work is a continuation of a previous publication in Anesthesiology Clinics (the author retained copyright of that text and gave permission to EJA to use those parts). The Emergency Manuals Implementation Collaborative (EMIC) provides a central repository, including links to many cost-free downloadable tools and an adaptable implementation toolkit at www.emergencymanuals.org.

Fig 7: Four vital elements for implementing emergency manuals ©S. Goldhaber-Fiebert and S. Howard, 2012; reprinted with permission.


Emergency manuals are context-relevant sets of cognitive aids that are intended to provide professionals with key information for managing rare crises.

Synonyms and related terms are ‘Crisis Checklists’, ‘Emergency Checklists’ and ‘Cognitive Aids’. The latter is a much broader term for any resource that enhances cognition, decision-making, or delivery of current best practices. This term is also often used to describe tools for crises specifically. To differentiate from normal workflow cognitive aids, throughout this article the term ‘Emergency Manual’ is used, except when referring generically to any of these as ‘tools’ or when describing a specific study with its own terminology. The synonyms above are also commonly used in the literature.

Simulation: proof of concept, stress, teamwork, design testing and immersive training

In multiple simulation-based studies, correct performance of key actions during crises dramatically increased when emergency manuals were used.450–452 One of the most impactful and widely cited simulation studies examined interprofessional operating room teams managing eight different operating room crises.450 Each team served as its own control, randomly assigned to half of the events with, and half without crisis checklists. Participants were familiarised with the crisis checklist concept and format, though not the specific study events. A comparison between the simulated operating rooms with and without check lists, showed that fewer key management steps were omitted when check lists were used: 6 vs. 23%, respectively, signifying considerable improvement in crisis event management when using a checklist. Similar results have recently been shown in a large simulation-based study of surgical ward teams managing deteriorating postoperative patients (10 vs. 33%).453

Why are these tools so helpful, even for experienced clinicians? Stress reduction and enabling teamwork are both relevant mechanisms, as well as the broad benefits of cognitive aids detailed previously that include directly helping to prevent omissions in medical management.271,446,454 Across diverse safety-critical industries including health care, there is mounting evidence that even when they ‘know’ what to do, stress causes well trained professionals to omit key actions, to narrow their thinking, and to diverge from optimal management: emergency manuals serve as a powerful antidote.455,456

Simulation provides a powerful technique for training with emergency manuals: it is a laboratory in which to study their effectiveness, and a safe setting to test the usability of their design features.312 One of the most impactful ways of enabling effective clinical use of emergency manuals is engaging clinicians immersively, demonstrating both the rationale of why to use emergency manuals and the practical details of when and how to use them, and, conversely, when clinicians are not familiar with emergency manuals they rarely use them, even if available.448,457 A simulation-based study showed the power of a ‘reader’ reading out the steps aloud, and, dynamically interacting with the leader: this has led to read aloud steps, leading to exploratory work regarding a clinical reader role.458–461

Enabling tools

Emergency manuals are intended as both educational and clinical tools. They represent highly condensed repositories of practical knowledge that must be carefully and iteratively designed and that require training to enable effective use under conditions of significant pressure.312,448,462–464

Emergency manuals are intended to be symbiotic adjuncts, rather than replacements, for good preparation, teamwork and clinical judgment. Emergency manual use should never precede necessary immediate actions such as chest compressions for a pulseless patient. Their intended use begins only once resources allow – either sufficient help is available for synchronous use from the beginning of a crisis, or initial clinical actions are already underway.

Effective team co-ordination and NTS are crucial to providing effective patient care and decreasing failure of rescue events.448,465 Increasingly, studies in both simulation and clinical settings are finding that emergency manual use improves team co-ordination and decision making.461,466,467 Within CRM, cognitive aids, including emergency manuals are one of multiple constructs which interact synergistically, all helping healthcare teams to provide better patient care (Fig. 8).446,448,468 In addition to helping surgical teams and their patients, the concept of emergency manuals has spread to other settings, such as Labour and Delivery wards.469

Fig 8: Crisis resource management skills, including ‘Use cognitive aids’. ©2008 S. Goldhaber-Fiebert, K. McCowan, K. Harrelson, R. Fanning, S. Howard, D. Gaba; reprinted with permission.

Dissemination, clinical implementations and uses

Since the EMIC began in 2012, there has been broad dissemination of multiple tools globally. Conservative estimates are that more than half a million clinicians have downloaded various English-language tools or their translations (data from EMIC members), including robust data from Chinese translations.470 Many clinicians stated they shared the tools widely with colleagues at their local institutions, implying even broader dissemination. These tools seem to be filling a need, with active interest in the concept from clinicians, though downloading is only one initial step towards clinical use. Building on simulation-based evidence of positive impacts, early implementations of emergency manuals spread the concept in clinical contexts and sought to understand questions including awareness (that the tool was available), range of clinical uses and usefulness.

In survey studies, clinicians reported significant numbers of emergency manual clinical uses (though none yet with denominators of applicable crises), and stated that emergency manual use during crises helped teams deliver better care to their patients and, when asked, none expressed distraction from patient care nor negative impacts.470–472 Given that crises occur infrequently, the patterns of use necessarily differ from normal workflow tools such as the Surgical Safety Checklist: there is the added challenge that not only do clinicians need to familiarise themselves ahead of time with the why, the when and the how to effectively use emergency manuals, but also the clinicians must remember to trigger the emergency manual use during a stressful crisis. Of note, across the studies above, the vast majority of clinicians who used an emergency manual during a crisis had prior exposure and familiarity with the tool, as well as an increased intent to use emergency manuals when applicable in future. This demonstrated a ‘use begets use’ feedback loop, with a positive reinforcement value of experiential use.

Changing clinical culture from ‘you should know and remember everything’, towards ‘it’s smart to use cognitive aids to help you provide better patient care’, ensuring accessibility and familiarity with the manuals, empowering multiple team members to suggest emergency manual use, and incorporating immersive training, were among significant themes of successful emergency manual implementations.459,471,473–475

As more institutions are pursuing emergency manual implementation, a common question is how to implement this effectively. A study of 368 clinicians across the United States found multiple controllable factors to support success.474 Success was correlated with the number of implementation steps they took, with a dose–response relationship, and leadership support was key. Training mattered, with interprofessional and immersive drills particularly impactful. Local customisation also helped, at a minimum for phone numbers and conformity with local policies. Simply hanging copies in the operating room rarely has much impact during stressful crises. This national survey work led also to develop an implementation toolkit, including a roadmap, training resources and common challenges. The toolkit is available cost-free from the AHRQ and the EMIC (www.emergencymanuals.org).

There are multiple case reports describing early emergency manual use during clinical crises, with both geographic and event diversity, and a case study including interviews with all team members.461,476–478 While many biases exist for single cases, the combination of case reports and large surveys reinforces the fact that these tools are being used clinically, with clinicians perceiving helpful impacts in at least some circumstances. This underscores the need for more formal mixed-methods research on clinical implementation and use of emergency manuals.

As discussed further elsewhere, implementing emergency manuals shares with other complex, socially adaptive, processes the need to influence frontline clinicians’ knowledge, attitudes and behaviours, and requires local adaptation and multiple coordinated approaches.479,480 The vital prework is to agree locally on the problem as well as the need and potential for improvement. In this case, the problem and a potential solution are well represented in the simulation literature described above. There was a large gap between evidence-based literature and the management of stressful crises, and increasing clinical emergency manual use is helping to decrease that gap.


In the past decade since publication of the Helsinki Declaration on Patient Safety in Anaesthesiology, emergency manuals have been shown to enable healthcare teams to deliver better care to our patients, during and peri-crisis. Building upon initial simulation-based evidence of emergency manual efficacy, there has been widespread interest and with global dissemination, increasing clinical implementations. In early studies of peri-operative clinical implementations, emergency manual use showed positive engagement from clinicians and also a promise of improving care in clinical settings, with further work needed to fully assess their effectiveness across diverse clinical contexts. There is active spread of the concept and content development within other contexts, such as surgical wards and labour and delivery units.

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