Medical emergencies present a significant cognitive challenge to the clinician. Multiple causes must be considered and rapidly managed; the consequences of missing a step can be catastrophic. Emergencies in the prehospital setting present the clinician not only with limited time, but also limited space, equipment, and communication.
Aviators have made use of checklists for years to minimize the impact of cognitive errors. Physicians have historically spurned checklists, usually citing their ability to remember an extensive and esoteric differential for just about any physiologic abnormality. Most steps in crisis management, however, are simple enough to be easy to forget under pressure: it doesn’t matter if a clinician can calculate the patient’s shunt fraction if they’ve forgotten to check if the oxygen is connected.
Checklists have made their way into a few areas in medicine already. Pre-op checklists have already significantly improved outcomes at minimal cost.1 Many centres use a checklist for RSI, and operating theatre emergency checklists appear beneficial in simulation trials.2,3 UK HEMS have produced a series of crash cards for emergency situations, but overall the use of emergency checklists in the prehospital setting seems quite limited.
We have produced a series of ‘challenge-response’ emergency checklists. After an emergency is declared, a crew member will read each management step (the challenge) to the clinician, and the clinician will confirm its completion (the response).
Our aim is not to replace a clinician’s judgement, but to reduce the likelihood a management step is missed, and, more importantly, to reduce a clinician’s cognitive burden so challenging steps can be more efficiently completed.
Attached below is our Hypoxia emergency checklist. We’re up to 15 emergency checklists and 4 checklists for standard procedures. We’ve trialled them extensively in a simulated setting at the base, and they’re headed for operational use soon. They’re going to appear in a hard copy format in the helicopter, as well as on the brand new Auckland HEMS app.
The preliminary hard copy format:
In-situ checklist testing:
We’d love to hear comments and suggestions – we’re looking to improve these on an ongoing basis. Post any thoughts below or email me directly at firstname.lastname@example.org
1. Haynes AB. Weiser TG. Berry WR. Lipsitz SR. Breizat AS. Dellinger EP. Herbosa T. Joseph S. Kibatala PL. Lapitan MCM. Merry AF. Moorthy K. Reznick RK. Taylor B. Gawande AA. A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. New England Journal of Medicine. 2009 Jan 29; 360(5):491-9.
2. Arriaga AF, Bader AM, Wong JM, Lipsitz SR, Berry WR, Ziewacz JE, Hepner DL, Boorman DJ, Pozner CN, Smink DS, Gawande AA. Simulation-Based Trial of Surgical-Crisis Checklists New England Journal Of Medicine 2013;368:246-53.
3. Ziewacz JE, Arriaga AF, Bader AM, Berry WR, Edmondson L, Wong JM, Lipsitz SR, Hepner DL, Peyre S, Nelson S, Boorman DJ, Smink DS, Ashley SW, Gawande AA. Crisis Checklists for the Operating Room: Development and Pilot Testing Journal of the American College of Surgeons. Aug 2011; 213(2): 212-217.
No secret that I am a fan of CLs (per #smaccGOLD debate and the checklist posts on kidocs.org)..and intuitively seems sensible to use for troubleshooting in PHEC as we do in OT
In the spirit of FOAMed, will the other CLs/action cards be availabel for download and sharing outside of the Auckland HEMs community and app?
I am probably idealistic, but see the benefit of these not just for individual sevices, but for sharing between other agencies who care for the same patient – whether the small rural clinician who is sending a patient, or for the receiving ED.
Lessons of PHEC apply to both…sharing resources can help bring quality care, out there
good stuff Robert! I wish you and the service well in this endeavour.
In my service we have just implemented a prehosp RSI checklist. I suspect it will not make a significant difference when I examine our performance data but I am willing to be proved wrong!
The issue with prehosp checklists for doctors is that if you are not performing at a high level of success already then its uncertain if a checklist alone is going to make a difference. The key is the training as you point out. If the CL allows you to train better, then that must be good , regardless of anything else.
There is this oft purported benefit of prehospital checklists improving team work. This maybe true but here is the paradox. Humans are social creatures and can work in small groups, but perform best when there is a good team leader in charge. A checklist is not a surrogate team leader.
We tried to propose a ventilated patient checklist a while ago and our nurses basically opposed it , saying if the retrieval doctor needs a checklist then they did not think that instills a lot of confidence in the team. They said from their viewpoint they rather have a doctor who knows what they are doing than knowing how to use a checklist.
A bit unfair but so is human nature.
Just one thing about using aviation comparison with medicine. Whilst this is oft touted, i think this really needs to be challenged. Patients are not aircraft and doctors are not pilots.
Pilots are legally mandated to utilise checklists..its even programmed into their electronic flight computers!
If we truly think medical checklists are so good then why arent we proposing they are also legally mandatory? The simple answer is that the aviation and medicine analogy is flwawed
anyway all the best with your project!
“We tried to propose a ventilated patient checklist a while ago and our nurses basically opposed it , saying if the retrieval doctor needs a checklist then they did not think that instills a lot of confidence in the team. They said from their viewpoint they rather have a doctor who knows what they are doing than knowing how to use a checklist.
A bit unfair but so is human nature.”
How about a doctor that knows what they are doing AND knows how to use a checklist?
To me this anecdote highlights cultural inertia in medicine, i.e. the perception that cognitive aids like checklists are a sign of weakness (lack of knowledge/skill/leadership etc). I believe this perception needs to change – checklists are simply another tool in a clinician’s toolkit, and it is up to each individual/service/department to decide whether/how/when a checklist would be helpful.
If there is one thing that aviation has taught us, it is that the human brain is fallible, and that even “experts” make significant errors and omissions, especially in times of crisis. A checklist is simply one of many ways of preventing error.
KIdocs – the app will be live on the app store soon – watch this space!
Thanks for the comments guys!
Many thanks for making time to engage with Auckland HEMS on this patient safety initiative.
1. Above is a source of inspiration for our service. Dr. Gawande and his cadre are at the vanguard of patient safety.
2. The Norwegians aren’t far behind:
Innovation is one element of success; implementation is another core element. This article emphasizes the importance of end-users ‘the sharp end’ being involved throughout the checklist development process. We are fortunate to have input into this checklist from our pilots, crewmen, paramedics and doctors. Even our CEO (who is also a pilot) have shared their experiences.
3. We are keen to share our Emergency Medical challenge-and-response checklist with the Prehospital and Retrieval Medicine community. They are still undergoing simulation-based usability testing. Stay tuned…