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Evaluating perceived barriers to cognitive aid use among anesthesia providers during malignant hyperthermia, myocardial ischemia, and unanticipated difficult airway

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Evaluating perceived barriers to cognitive aid use among anesthesia providers during malignant hyperthermia, myocardial ischemia, and unanticipated difficult airway

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Content PERCEIVED BARRIERS TO COGNITIVE AID USE

EVALUATING PERCEIVED BARRIERS TO COGNITIVE AID USE
AMONG ANESTHESIA PROVIDERS DURING MALIGNANT HYPERTHERMIA,
MYOCARDIAL ISCHEMIA, AND UNANTICIPATED DIFFICULT AIRWAY
by
Hanna Paik

A Doctoral Capstone Presented to the
FACULTY OF THE USC KECK SCHOOL OF MEDICINE
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the Requirements for the Degree
DOCTOR OF NURSE ANESTHESIA PRACTICE

May 2021

PERCEIVED BARRIERS TO COGNITIVE AID USE ii

The following manuscript was contributed to in equal parts by
Nicole Arsenis, Timur Kitaev & Hanna Paik.

PERCEIVED BARRIERS TO COGNITIVE AID USE iii

Dedication

We dedicate our work to our doctoral colleagues at the University of Southern California Nurse
Anesthesia Program. We are grateful for their support and camaraderie throughout the program.
We also dedicate our work to our families for their endless love and support.

PERCEIVED BARRIERS TO COGNITIVE AID USE iv

Acknowledgements

We would like to express our deepest appreciation to our committee chair, Dr. Charlotte Garcia,
and committee members, Dr. Elizabeth Bamgbose and Dr. Jeffrey Darna, for their unwavering
support throughout the doctoral capstone process. We would also like to sincerely thank our
biostatistician, Dr. Amanda Goodrich, for conducting the statistical analysis and her continued
guidance throughout the data interpretation and presentation process. Lastly, we would like to
thank our librarian, Hannah Schilperoort, at the Norris Medical Library, for her help throughout
our literature search. Thank you to all for encouraging us and believing in us throughout this
time of immense learning and growth.

PERCEIVED BARRIERS TO COGNITIVE AID USE v

Table of Contents
Dedication ...................................................................................................................................... iii

Acknowledgements ........................................................................................................................ iv

List of Tables ................................................................................................................................. vi

Abstract ......................................................................................................................................... vii

Chapter 1 ......................................................................................................................................... 1
Introduction ................................................................................................................................. 1
Research Question & Aim .......................................................................................................... 2
Specific Aims .......................................................................................................................... 2
Background & Significance ........................................................................................................ 3

Chapter 2 ......................................................................................................................................... 6
Literature Review........................................................................................................................ 6
Efficacy of Cognitive Aid Use ................................................................................................ 6
Evidence Against the Efficacy of Cognitive Aid Use ............................................................ 8
Barriers to Cognitive Aid Use............................................................................................... 10

Chapter 3 ....................................................................................................................................... 13
Methodology ............................................................................................................................. 13

Chapter 4 ....................................................................................................................................... 14
Results ....................................................................................................................................... 14
Quantitative Response Analysis ........................................................................................... 14
Qualitative Response Analysis ............................................................................................. 17

Chapter 5 ....................................................................................................................................... 20
Discussion and Conclusion ....................................................................................................... 20
Recommendations for Future Research ................................................................................ 23

References ..................................................................................................................................... 26

Tables ............................................................................................................................................ 32
Appendices .................................................................................................................................... 44
Appendix A: Gap analysis on the use of cognitive aids in OR among anesthesia providers ....... 44
Appendix B: SWOT analysis on the use of cognitive aids in OR among anesthesia providers ... 45
Appendix C: PRISMA Flow Diagram .......................................................................................... 46
Appendix D: Survey ..................................................................................................................... 47
Appendix E: iStar Approval.......................................................................................................... 53

PERCEIVED BARRIERS TO COGNITIVE AID USE vi

List of Tables
Table Page
1 Demographic Data of the Participants ................................................................................ 32
2 EM and Reader Utilization/Barriers to Using EM Step by Step ........................................ 33
3 General Barriers to EM Use During MH, MI and/or UDA Stratified by Location
(LAC+USC Medical Center vs. Keck Hospital of USC), Type of Provider (MD vs.
CRNA) and Years of Experience (Less Than 10 Years of Experience vs. More
Than 10 Years of Experience) ........................................................................................ 34
4 MH and Barriers to EM Use Stratified by Location (LAC+USC Medical Center vs.
Keck Hospital of USC), Type of Provider (MD vs. CRNA) and Years of Experience
(Less Than 10 Years of Experience vs. More than 10 Years of Experience) ................. 35
5 MI and Barriers to EM use Stratified by Location (LAC+USC Medical Center vs.
Keck Hospital of USC), Type of Provider (MD vs. CRNA) and Years of Experience
(Less Than 10 Years of Experience vs. More Than 10 Years of Experience)................ 36
6 UDA and Barriers to EM use Stratified by Location (LAC+USC Medical Center vs.
Keck Hospital of USC), Type of Provider (MD vs. CRNA) and Years of Experience
(Less Than 10 Years of Experience vs. More Than 10 Years of Experience)............... 37
7 Potential EM Utilization During MH, MI, UDA, Stratified by Years of Experience
(Less Than or Equal to Five Years vs. More Than Six Years) ...................................... 38
8 EM Awareness, Training, Access and Departmental Support and Perceived Competence
Stratified by Location (LAC+USC Medical Center vs. Keck Hospital of USC),
Type of Provider (MD vs. CRNA) and Years of Experience (Less Than 10 Years of
Experience vs. More Than 10 Years of Experience) ...................................................... 39
9 Procedural Timeout Stratified by Location (LAC+USC Medical Center vs. Keck
Hospital of USC), Type of Provider (MD vs. CRNA) and Years of Experience
(Less Than 10 Years of Experience vs. More Than 10 Years of Experience)................ 41
10 Barriers to EM Use During MH, MI and UDA Stratified by Perceived Importance of
Procedural Time Out (Neutral/Important vs. Very Important) ....................................... 42
11 Perceived Competence vs. Barriers to EM Use .................................................................. 43

PERCEIVED BARRIERS TO COGNITIVE AID USE vii

Abstract
Background: A cognitive aid is defined by the Stanford Anesthesia Cognitive Aid Group as a
visual in any form intended to enhance cognition and improve adherence to medical best
practices. While the efficacy of cognitive aid use during simulated, intraoperative emergencies is
well supported in the current literature, their use in anesthesia practice remains limited.
Aim: The aim of this doctoral capstone paper is to investigate perceived barriers to cognitive aid
use in the operating room among anesthesia providers during various emergency situations.
Methodology: An anonymous survey was disseminated to 149 certified registered nurse
anesthetists and anesthesiologists at two large academic institutions to explore actual and
potential barriers that preclude cognitive aid use during three specific intraoperative
emergencies: malignant hyperthermia, myocardial ischemia, and unanticipated difficult airway.
Results: The survey was completed by 35 anesthesia providers. The three most frequently
reported perceived barriers to cognitive aid use for all three emergency scenarios were: (a) would
have distracted/delayed patient care, (b) did not know a cognitive aid was available, and (c) not
enough help in the room (nobody available as the reader).
Conclusion: While the current literature vastly supports the use of cognitive aids during
simulated, intraoperative emergency scenarios, studies investigating their use in practice is
limited. Our survey identified barriers to cognitive aid use in three specific emergency situations.
Future research should focus on interdisciplinary cognitive aid training, access to cognitive aids,
and use of a reader.
Keywords: cognitive aid, emergency manual, checklist, anesthesia, critical event, emergency
situation, barriers
PERCEIVED BARRIERS TO COGNITIVE AID USE 1

Chapter 1
Introduction
There is an ongoing discussion in anesthesia practice literature regarding the
implementation of cognitive aids during emergency situations (Gleich et al., 2018). A cognitive
aid is defined as a visual resource in any form that is intended to enhance cognition and improve
adherence to medical best practices (Stanford Medicine, 2018). Cognitive aids exist in various
forms such as checklists, emergency manuals, and algorithms; these terms will be used
interchangeably throughout this paper.
Numerous studies have demonstrated an appreciable potential for cognitive aid use to
improve patient safety and adherence to evidence-based guidelines in anesthesia practice during
intraoperative emergencies when cognitive load is increased (Isaak & Stiegler, 2015). Cognitive
load theory postulates that intrinsic, extraneous, and germane cognitive loads are additive and
have the ability to overwhelm the capacity of working memory (Kirschner et al., 2009). Working
memory can actively process two to three pieces of new information simultaneously. Cognitive
aids help decrease the anesthesia provider’s cognitive load during crisis management or times of
high stress within the perioperative area. The visual aids help diminish extraneous load such that
working memory is not overcome when cognitive load is high. Repeated use of cognitive aids
and checklists facilitate the development of schema, whereby information can be automated, and
easily recalled when necessary. Practice, and deliberate practice, ensures that key information
becomes automated, much like that of domain experts who can recall information with limited
effort (Merriënboer & Sweller, 2010).
While the efficacy of cognitive aid use during simulated, intraoperative emergencies is
well-supported in the current literature, their use in anesthesia practice is not widespread
PERCEIVED BARRIERS TO COGNITIVE AID USE 2

(Agarwala et al., 2019). Further exploration and identification of the barriers precluding
cognitive aid use during intraoperative emergencies may help improve patient safety in the
operating room (OR).
Research Question & Aim
The PICO (population, intervention, comparison, outcome) question guiding this
investigation is: What are the perceived barriers to cognitive aid use in the OR among anesthesia
providers during various emergency situations? A SWOT (strengths, weaknesses, opportunities,
and threats) and gap analysis were used as frameworks which guided a needs assessment to
further investigate the inconsistent use of cognitive aids by anesthesia providers during
emergencies in the OR. The gap analysis (see Appendix A) outlines the problem, evidence-based
practice, and goals. The SWOT analysis (see Appendix B) outlines the strengths, weaknesses,
opportunities, and threats with the use of cognitive aids in the OR among anesthesia providers.
Specific Aims
1. Utilize the SWOT and gap analysis framework to further investigate the inconsistent use
of cognitive aids by anesthesia providers during emergencies in the OR.
2. Distribute an anonymous survey to certified registered nurse anesthetists (CRNAs) and
anesthesiologists at two large medical academic institutions to explore the barriers of
cognitive aid use during three specific emergencies: malignant hyperthermia (MH),
myocardial ischemia (MI), and unanticipated difficult airway (UDA).
3. Analyze the data collected and formulate a set of recommendations, offering solutions to
overcome barriers to cognitive aid use in anesthesia emergencies.
PERCEIVED BARRIERS TO COGNITIVE AID USE 3

Background & Significance
High reliability organizations, defined as organizations that make few mistakes over long
periods of time in spite of operating in complex and hazardous environments, such as the
aviation industry, have utilized cognitive aids before their application into medicine (Baker et al.,
2006). The first aviation checklist was introduced after the crash of a Boeing B-17 aircraft in
1935 (Gawande, 2014). From 1959 to 2015, aircraft accident rates declined from 50 per
1,000,000 departures to 2 per 1,000,000 departures (Statistical Summary of Commercial Jet
Airplane Accidents, 2016). From 1950 to 2010, the rate of fatal accidents per 1,000,000
departures in the United States decreased from 2.5 to zero (Garrison & Levinson, 2006; Savage,
2013). As a result, checklists have been deemed indispensable tools in promoting airline safety
(Turner & Huntley, 1991). Dr. David Gaba, Dr. Kevin Fish, and Dr. Steven Howard recognized
the significant impact of checklists promoting airline safety and adapted the aviation industry’s
crew resource management into anesthesiology between 1989 and 1990, naming it Anesthesia
Crisis Resource Management (ACRM) (Gaba et al., 1994). ACRM went on to provide the
foundation for the development of the Stanford Emergency Manual in 2013 (Stanford Cognitive
Aid Group, n.d.).
While managing anesthesia emergencies, there is an increased risk for error due to
practice variability between different providers, external distractions, elevated stress levels, and
task interruptions (Lelaidier et al., 2017). The mortality rate within 48 hours of surgery due to
anesthetic complications is estimated to be 0.033% in the United States (Whitlock et al., 2015).
However, adverse events related to anesthesia complications were most recently reported at 4.8%
(Liau et al., 2014).
PERCEIVED BARRIERS TO COGNITIVE AID USE 4

Cognitive aids have been shown to improve both the technical and/or non-technical
performance of anesthesia providers during the management of various simulated intraoperative
medical crises including but not limited to MH (Hardy et al., 2018; Lelaidier et al., 2017;
Ziewacz et al., 2011), anaphylactic shock (Lelaidier et al., 2017; Ziewacz et al., 2011), cardiac
arrest, air embolism (Ziewacz et al., 2011), local anesthetic systemic toxicity (LAST) (Lelaidier
et al., 2017; McEvoy et al., 2014), severe gynecological transurethral resection of the prostate
(TURP) syndrome (St. Pierre et al., 2017a), and intraoperative ST-elevation myocardial
infarction (STEMI) during caesarean section (St. Pierre et al., 2017b). Despite the large body of
evidence supporting use of cognitive aids, there is a literature gap describing consistent use of
cognitive aids in emergencies for real time patient care.
Few studies demonstrate the implementation of cognitive aids among anesthesia
providers in the OR and their impact on cognitive aid utilization. Agarwala et al. (2019)
investigated the use of an emergency manual six months after implementation at a large
academic institution and found that 67% of anesthesia providers reported using the manual.
Among these providers, 24.1% used the manual for clinical care, 9.2% used the manual during a
critical event, and the remainder used it for individual review, group education, or phone number
reference. In another study, six months after cognitive aid booklets were distributed to Veterans
Health Administration facilities, 87% of the respondents were aware of the cognitive aid, 50% of
the anesthesia providers reported using the cognitive aid for reference, and 6.7% reported using
the cognitive aid during a critical event (Neily et al., 2007). In a pilot study, 15 months after
implementing cognitive aids at Stanford, 45.2% of anesthesia providers reported using the
cognitive aid at least once during a critical event, and 11.9% reported using the cognitive aid
greater than or equal to three times during a critical event (Goldhaber-Fiebert et al., 2016).
PERCEIVED BARRIERS TO COGNITIVE AID USE 5

However, the potential positive impact of cognitive aid use on patient care is limited by the lack
of successful implementation into organizationally complex work environments.

PERCEIVED BARRIERS TO COGNITIVE AID USE 6

Chapter 2
Literature Review
Efficacy of Cognitive Aid Use
In 2018, Hardy et al. measured the technical and non-technical performance of 24
anesthesiologists in a simulated MH scenario with a print-based checklist. They were divided
into two groups; a checklist and control group. The anesthesiologists who used the cognitive aid
had increased speed of care (15.7 minutes vs. 22.4 minutes for the control group) and better
adherence to the French Society of Anesthesia and Intensive Care (SFAR) guidelines for patients
presenting with MH (24/30 vs. 18/30 for the control group). The anesthesiologists who used the
cognitive aid also demonstrated improved non-technical skills (56.5/60 vs. 48.5/60 for the
control group) measured by the Anesthetists’ Non-Technical Skills evaluation tool, which
evaluates task management, teamwork, situation awareness, and team management (Flin et al.,
2010). The researchers noted that their study was not designed to assess how the
anesthesiologists used the checklist. They observed that the anesthesiologists most often did not
use the cognitive aid in a strict chronological fashion, but rather used it as a reassurance tool for
accuracy.
Lelaidier et al. (2017) measured the technical and non-technical performance of 52
anesthesia residents in five different simulated anesthesia or intensive care emergencies with a
hand-held digital cognitive aid. Each resident participated in two different scenarios, with and
without the cognitive aid. The average technical performance (on a scale of 0-100%), measured
by adherence to SFAR or the European Society of Cardiology guidelines, was greater in the
cognitive aid group (81.6%) compared to the control group (58.6%). Improved adherence to
these guidelines occurred in all scenarios (severe hyperkalemia, anaphylactic shock, LAST, and
PERCEIVED BARRIERS TO COGNITIVE AID USE 7

MH) except for the cardiac arrest with ventricular fibrillation scenario. The residents who used
the cognitive aid also demonstrated improved non-technical skills (33.7 vs. 30.9 points)
measured by the Ottawa Global Rating Scale on a scale of 7-42 points. The Ottawa Global
Rating Scale (OGRS) is a measuring tool that provides a seven-point Likert scale for
performance in five categories of crisis resource management and provides an overall
performance score (Kim et al., 2009). The response process, content validity, relationship to
variable of training, and internal structure were validated within the OGRS. In the cognitive aid
group, overall performance, leadership, problem solving, and resource-using were improved. Of
note, the electronic cognitive aid was designed so that the residents were required to read each
chronological step before moving onto the next step.
Several other studies support the efficacy of cognitive aid use during simulated
intraoperative emergencies. McEvoy et al. (2014) found that using a cognitive aid with a reader
improved adherence to guidelines by anesthesia residents during management of LAST. St.
Pierre et al. (2017a) showed that using cognitive aids improved the performance of anesthesia
teams consisting of a consultant anesthetist, anesthetic nurse, and anesthetic trainees, during
management of TURP syndrome. St. Pierre et al. (2017b) showed that using cognitive aids
improved the performance of anesthesia teams consisting of a consultant anesthetist, anesthetic
nurse, and anesthetic trainees, during management of STEMI during caesarean section. Ziewacz
et al. (2011) found that during the management of eight emergency scenarios with two teams
consisting of a surgical attending, surgical resident, anesthesia attending, anesthesia resident, and
a circulating nurse and/or surgical technologist, the rate of failure of adhere to critical
management steps decreased from a failure rate of 24% without the cognitive aid to a failure rate
of 4% with the cognitive aid. The emergency scenarios consisted of air embolism, anaphylaxis,
PERCEIVED BARRIERS TO COGNITIVE AID USE 8

unstable bradycardia, unstable tachycardia, asystole, cardiac arrest with ventricular fibrillation,
hemorrhage, and MH.
Evidence Against the Efficacy of Cognitive Aid Use
Despite an extensive literature search, only two studies demonstrated inconclusive results
when comparing crisis management with cognitive aid use vs. recollection and training alone.
Coopmans & Biddle (2008) introduced a cognitive aid in the form of computer assisted decision
making (cognitive aidDM) via a personal digital assistant. The study yielded mixed results in a
simulation lab when comparing management of two different clinical scenarios with and without
the use of a cognitive aidDM. The authors acknowledged the study had a small sample size (4
participants and 2 clinical scenarios) which limits generalizability and inferential analysis. The
experience level of the participants was not disclosed, limiting the interpretation and
generalizability of the results.
Bould et al. (2009) studied the effects of a neonatal resuscitation algorithm on anesthesia
residents’ adherence to the appropriate steps in neonatal resuscitation. The participants used a
previously validated 15-step checklist and were evaluated on successful and timely completion.
The study found no statistically significant difference between the control and intervention group
when performing neonatal resuscitation. The authors acknowledged the intervention group
performed better than the control group by performing one extra checklist task correctly.
However, the authors’ decision to look for a large effect size a priori prevented this difference
from being statistically significant as the study was underpowered to detect a small effect with
16 subjects in each group. After the study was completed, an expert neonatologist and neonatal
resuscitation program (NRP) instructor, who observed the performances of both groups, stated
PERCEIVED BARRIERS TO COGNITIVE AID USE 9

none of the participants would have passed the NRP test necessary for certification. In a post
study survey, 29% of the intervention group members reported they did not need a cognitive aid.
Barriers to Cognitive Aid Use
Goldhaber-Fiebert et al. (2016) conducted a cross-sectional mixed methods pilot study at
Stanford University Medical Center assessing anesthesia residents’ perception of emergency
manual use during crisis scenarios via a pre- and post-implementation survey. Residents at the
institution were already familiar with the emergency manual and its use was encouraged during
simulation activities at the time of the initial survey. Implementation of emergency manuals
included providing leadership support, increasing emergency manuals accessibility in all ORs
and training interdisciplinary OR staff. A subsequent post intervention survey with 11 additional
questions exploring emergency manual training efficacy, barriers to emergency manual use,
types of emergency manual use and use of emergency manual during actual critical events, was
sent out to a new cohort of anesthesia residents 15 months after clinical implementation of
emergency manuals. Response rates between the pre- and post-implementation groups were
similar at 51.5% and 56.8%, respectively. In the post-implementation group, 45.2% of
respondents reported using an emergency manual for at least one critical clinical event, and
11.9% used the emergency manual at least three times; no data was available on use of
emergency manual for the pre-implementation group to compare how the emergency manual
implementation impacted emergency manual use. Post-implementation data showed critical care
event simulation (95.2%) and self-review of emergency manual (73.8%) positively influenced
use of emergency manual while the top two barriers to its use was the fast pace of the OR
(40.5%) and not having enough people in the room to help read the manual (23.8%). Qualitative
survey results showed that barriers to emergency manual use included: limited time, challenges
PERCEIVED BARRIERS TO COGNITIVE AID USE 10

with who and how the manual should be read, recall failure of manual availability, and
acceptance of emergency manual use during critical events.
Krombach et al. (2015) conducted a survey of anesthesia providers at a single, large
academic United States institution examining opinions regarding healthcare cognitive aids for
both routine use and crisis management. The sample consisted of anesthesia providers, including
full time faculty, fellows, residents, interns, and CRNAs with varying years of experience
(n=214). The majority of providers in all experience levels accepted the use of emergency
manuals for emergency situations in anesthesia care. Survey results showed 34% agreed or
strongly agreed that they felt competent to deal with emergency situations based on memory and
experience alone. More than two thirds of all providers with less than two years of experience
(n=47) reported that they did not feel confident dealing with emergency situations based only on
memory and experience. The belief that checklists might significantly delay patient care was
shared by 31% of providers and 27% were concerned about distracting patient care. The survey
indicated that cognitive aids that are easy to use and are well integrated into the anesthesia
workspace would facilitate use.
Alidina et al. (2018), explored organizational context and implementation process as
factors influencing cognitive aid use during OR crises. Individuals who downloaded the Ariadne
Labs OR Crisis Checklist were invited to complete a survey that explored facilitators and barriers
to successful implementation of the checklist. The measure for successful cognitive aid
implementation was reported regular cognitive aid use during clinical events, which included
emergency drills, complex case preparations, critical event debriefing, and educational review.
The authors excluded surveys completed by participants outside of the United States, those who
downloaded the cognitive aid stating no intention of using it in the OR, and those who stated that
PERCEIVED BARRIERS TO COGNITIVE AID USE 11

they were in the process of implementing the cognitive aid at their institution. The final sample
size meeting inclusion criteria was 368 respondents out of the 1796 surveys collected. Although
the role of the participants downloading the survey was unclear, the majority (85%) were
anesthesia providers, who worked for facility/university or physician-owned practice (57.3%)
and had 20 or more years of experience (53.8%). Facilities with fewer ORs reported more
successful implementation (81.1%) than facilities with at least 30 ORs (59.5%) and there was no
significant relationship with teaching status (presence of anesthesia or surgical residents), facility
type (hospital or ambulatory surgical center) and successful implementation. Provider resistance
to using cognitive aids (p<0.0001), absence of implementation champion (p=0.0126) and
unsatisfactory content of design of the tool (p=0.0112) were associated with less successful
implementation of the cognitive aid. Additionally, those who were less successful with
implementation were associated with the perception that there was little impact from introducing
the tool in the OR (p<0.0001).

PERCEIVED BARRIERS TO COGNITIVE AID USE 12

Chapter 3
Methodology
The proposed research question guided a literature review. The databases accessed were
PubMed, Embase, and Google Scholar. A total of 218 articles were identified with a database
search using the following keywords: barriers, cognitive aid, emergency manual, checklist,
anesthesia, anesthetist, crisis, perception, OR, surgery, perioperative, and implementation.
Inclusion criteria consisted of studies published in English within the past 15 years, and
cognitive aid use for anesthesia specific emergencies in both simulated and real-time situations.
Studies exclusively involving cognitive aids for non-emergency situations (such as routine
checklists) were excluded from the literature review. After review, 11 articles met the inclusion
criteria (see Appendix C for PRISMA Flow Diagram).
To further inform the research question, perceived barriers to cognitive aid use during
intraoperative emergencies, the authors created a survey (see Appendix D) to investigate
perceived barriers to cognitive aid use during intraoperative emergencies. With permission, three
survey questions were adapted from Krombach et al. (2015). The remaining questions were
finalized after consulting with a PhD prepared committee member and an expert biostatistician.
Demographic information included anesthesia providers’ location of practice, professional role
(CRNA or anesthesiologist) and years of clinical experience. The survey was created and
distributed on REDCap; it included 33 multiple choice questions and one open ended question.
Due to the utilization of branching logic, the greatest number of questions a participant could
answer was 34 questions, and the fewest number of questions a participant could answer was 16
questions.
The study was approved by the University of Southern California Institutional
PERCEIVED BARRIERS TO COGNITIVE AID USE 13

Review Board (proposal #HS-19-00769) (see Appendix E). The survey link was emailed to a
total of 149 CRNAs and anesthesiologists at two large medical academic institutions: Keck
Hospital of USC, and Los Angeles County and University of Southern California (LAC+USC)
Medical Center. Completion of the survey indicated consent to participate in this study. To
protect confidentiality of the study participants, data was collected under a unique identifier and
no personal information was collected from respondents. No financial incentives were provided
for completing the survey. Reminder emails were sent at one-week intervals with a total survey
period of three weeks. At the closure of the survey, data was downloaded from the REDCap
website and quantitative data was statistically analyzed and interpreted with a biostatistician
utilizing Stata Statistical Software: Release 15 College Station, TX (StataCorp, LLC.).
Qualitative data from the one open response question was analyzed by the authors using thematic
analysis.

PERCEIVED BARRIERS TO COGNITIVE AID USE 14

Chapter 4
Results
All survey questions were stratified by practice setting, type of anesthesia provider, years
of experience, perception of procedural time out and perceived competence of a provider to
manage an emergency anesthesia situation without any lapses based on memory and experience
only. Multiple choice questions where the subject could only select one answer were compared
between levels of each group using Pearson chi-square tests, or Fisher's exact tests when the
sample sizes were too small (expected values were < 5 for 20% or more of the cells). For
questions in which multiple answers were allowed, z-tests for proportions were used to compare
percentages between levels of each group.
Among the 149 anesthesia providers who received the survey, 35 total responses were
collected (Table 1). Nine respondents reported using an emergency manual (n=8 used it for a
single event and n=1 used it for all three events) (Table 2). Among the 70 separate emergency
situations reported, UDA was encountered by 32 out of 35 anesthesia providers, MI was
encountered by 26 out of 35 providers, and MH was encountered by 12 out of 35 providers.
Quantitative Response Analysis
Perceived Barriers to Emergency Manual Use During MH, MI, and UDA. All 35
respondents (whether they encountered the three emergencies in the OR or not) were asked what
they believed served as barriers to emergency manual use during MH, MI and UDA. The three
most frequently reported perceived barriers to cognitive aid use for all three emergency scenarios
(from most to least frequent) were: (a) would have distracted/delayed patient care, (b) did not
know an emergency manual was available, and (c) and not enough help in the room (nobody
available as the reader) (Table 3). Overall, 8% of respondents reported that the manual was too
PERCEIVED BARRIERS TO COGNITIVE AID USE 15

difficult to use, and 6% reported a lack of support from the department regarding the use of an
emergency manual.
During actual intraoperative emergencies in which an emergency manual was used, a
reader was utilized only 36% of the time (Table 2). A reader was utilized 50% of the time during
management of MH, 0% of the time during management of MI, and 50% of the time during
management of UDA.
Barriers to Emergency Manual Use During MH. Among anesthesia providers who
encountered MH, 50% used an emergency manual during the crisis but 89% responded they
would use an emergency manual if they were to encounter it in the future. Those who
encountered MH but did not use an emergency manual to manage the emergency reported that
the most frequently encountered barriers to its use were: (a) did not know an emergency manual
was available, (b) did not see a need for it, and (c) would have distracted or delayed patient care.
Due to the small sample size, no statistical significance was found when data was stratified into
location, type of provider, and years of experience (Table 4).
Barriers to Emergency Manual Use During MI. Among anesthesia providers who
encountered MI, 12% used an emergency manual during the crisis but 61% responded they
would use an emergency manual if they were to encounter it in the future. Those who
encountered MI but did not use an emergency manual to manage the emergency reported the
most frequently encountered barriers to its use were: a) did not know an emergency manual was
available (11/23), b) did not see a need for it (9/23), and c) did not think to consult an emergency
manual under stress, and would have distracted or delayed patient care (both 4/23). Compared to
25% of providers from LAC+USC Medical Center not knowing an emergency manual was
PERCEIVED BARRIERS TO COGNITIVE AID USE 16

available during their encounter with MI, 73% of providers from Keck Hospital of USC were not
aware of emergency manual availability (p=0.002) (Table 5).
Barriers to Emergency Manual Use During UDA. While UDA was the most
frequently encountered intraoperative emergency, 6% of anesthesia providers who encountered
UDA used an emergency manual during the crisis, the least among the three scenarios (Table 2).
However, 25% of all providers responded they would use an emergency manual if they were to
encounter it in the future (Table 7). Those who encountered UDA but did not use an emergency
manual to manage the emergency reported that the most frequently encountered barriers to its
use were: a) did not see a need for it, b) would have distracted or delayed patient care, and c) did
not know an emergency manual was available (Table 6). A majority of providers (8/9) who used
an emergency manual to manage actual intraoperative emergencies (MH, MI, and UDA) were
those with six or more years of experience; only one out of the nine providers had less than six
years of experience (Table 7). Interestingly, among anesthesia providers who had six or more
years of experience, 38% reported they would use an emergency manual to manage UDA while
none of the anesthesia providers who had less than six years of experience reported they would
use an emergency manual to manage UDA (p=0.02).
Emergency Manual Awareness and Training. Five of the 35 anesthesia providers had
never heard of an emergency manual designed to manage OR crises (n=4 Keck Hospital of USC,
n=1 LAC+USC Medical Center, p>0.05) (Table 8). Four out of the five providers who reported
they did not know about the emergency manual were those who had more than 10 years of
experience (p>0.05). While 54% of those surveyed received some sort of emergency manual
training at their facility, 26% of anesthesia providers used an emergency manual during an
emergency situation (Table 2).
PERCEIVED BARRIERS TO COGNITIVE AID USE 17

Perception of Importance of Procedural Time Out and Cognitive Aid Use. While
91% of anesthesia providers reported that they consider routine cognitive aid use during
procedural time out in the OR important or very important, cognitive aid use in emergency
situations was not widespread (Table 9). Of those who thought that procedural timeout was very
important, 63% did not know that an emergency manual was available when they encountered
MI (p=0.03), and 25% did not see a need for it (p=0.04) (Table 10). No other statistically
significant data was found when barriers to emergency manual use was stratified by response to
perceived importance of procedural timeout, and therefore no correlations can be made regarding
perception of importance of procedural timeout and perception of importance of cognitive aid
use during emergency situations.
Perception of Competence and Its Impact on Emergency Manual Use. When
providers were asked whether they thought they can deal with emergency situations without any
lapses based on memory and experience alone, 54% disagreed or completely disagreed. There
were no statistical differences between locations, type of provider, or years of experience
(p>0.05) (Table 8). Those who did not feel like they could manage an emergency by memory
alone also reported that the cognitive aid would distract or delay patient care (p=0.03) (Table
11).
Qualitative Response Analysis
When asked to describe barriers to emergency manual use that were not mentioned in the
survey, qualitative analysis of anesthesia providers’ responses revealed several themes pointing
to personal experiences anesthesia providers had with barriers to cognitive aid use.
Emergency Manuals for Rarely Encountered Crises. One of the primary themes
precluding cognitive aid use by anesthesia providers in the clinical setting was the selective
PERCEIVED BARRIERS TO COGNITIVE AID USE 18

application of emergency manuals to rarely encountered crises. Providers stated to “use it
(emergency manual) when needed,” “manuals are great for circumstances that are rarely
encountered (MH, LAST),” and “MH has a poster which is very useful in a step by step
manner.” Additionally, “some (emergencies) are much less common (MH/LAST) and include
doses of meds we don’t give often. For these the emergency manual is useful...because nobody
sees them regularly enough to be an expert in them beyond an algorithm.”
Lack of Emergency Manual Training. Another common theme precluding emergency
manual use in the clinical setting was the lack of emergency manual training. Providers reported
“no continued education or training for emergency situations, no simulation exercises for
situations that are infrequently encountered… no designated group providing continuing
education or inservices.” Additionally, providers stated “if we don’t practice emergency
scenarios with the manual, we won’t remember to use it as a reference” and that “there seems to
be an issue with translating the knowledge regarding manual use from the training environment
to the actual patient care environment, most likely because of the infrequency of training such
that a schema is never developed.”
Crisis Management Based on Memory and Training Only. Several responders also
felt that providers should know how to manage situations based on memory, training, and
experience. One provider stated
I’m thoroughly opposed to using them (emergency manuals) in things like difficult
airway because people turn on their protocol and turn off their brain. There are
many options for difficult airways that are not in the protocol. Protocols bring the
weak up to an average level of care, but they devalue those who think at a higher
level.
PERCEIVED BARRIERS TO COGNITIVE AID USE 19

Another provider stated, “I was fully prepared to treat the patients, I had reviewed the manual
previously... I’ve memorized the algorithm completely.” Finally, a separate provider stated that
an emergency manual is a “helpful tool for situations where one is uncertain of what to do in an
emergency... but I knew what the next steps were as soon as I encountered them.”
Pace of the OR. The pace of events contributed as a barrier to emergency manual use as
providers stated that “people just do not think to use it (emergency manual) in emergencies and
only remember it (emergency manual) in retrospect,” they “lack understanding of tunnel vision,”
and “(there is) too much going on.” Providers also cited cultural barriers such as “ego” and
“cultural norms dictate practice - if a supervising anesthesia provider does not use the manual
then the trainees won’t use it.” Finally, some providers “have never seen one (an emergency
manual),” don’t know “how to access it,” and have a “lack of understanding of the importance of
emergency manuals in crisis situations.”

PERCEIVED BARRIERS TO COGNITIVE AID USE 20

Chapter 5
Discussion and Conclusion
The results of this study emphasize the sentiment that emergency manuals potentially
delay patient care. This finding is consistent with the study by Goldhaber-Fiebert et al. (2016)
which found the most frequently cited barrier to be that events in the operating room happen too
quickly. However, these statements contrast with other research data. Hardy et al. (2018) found
that the initial dose of dantrolene was administered significantly faster during MH crisis in the
checklist group and Lipps et al. (2017) found that the decision and initiation of pacing and
administration of atropine during intraoperative third degree heart block was faster in the
cognitive aid group, although the timing of atropine administration was not statistically
significant in this sample. Among the other simulated crisis studies cited, there were no
appreciable time differences to treatment between cognitive aid and control groups.
Additional recurrent barriers identified by our survey results include lack of awareness of
emergency manual availability and insufficient help to facilitate emergency manual use.
Similarly, Goldhaber-Fiebert et al. (2016) found insufficient help as the second most frequently
cited barrier to emergency manual use. However, our data contrasts with the study conducted by
Krombach et al. (2015) which found that checklist design and departmental endorsement are two
of the top five factors that promote checklist use. Our findings suggest that neither poor
emergency manual design, nor lack of departmental support were significant factors preventing
emergency manual use.
The results from our study demonstrate that a likely contributor to anesthesia providers’
lack of awareness and utility of cognitive aids is little or no training provided at the institution.
Among providers from Keck Hospital of USC, 93% reported that they never received emergency
PERCEIVED BARRIERS TO COGNITIVE AID USE 21

manual training. However, a discrepancy remains that two providers reported Keck Hospital of
USC offers training during new hire orientation, and one provider reported Keck Hospital of
USC offers annual training, even though all three providers said they never received training
themselves. Additionally, 34% of total respondents did not know how to access an emergency
manual intraoperatively, and 20% did not know that they had one available. A majority of these
anesthesia providers were from Keck Hospital of USC (p<0.001). Of note, a hard copy of the
Stanford Emergency Manual is available in every OR at LAC+USC Medical Center but not at
Keck Hospital of USC; however, a digital copy of the emergency manual is accessible online. At
both institutions, anesthesiologists were more likely to be unaware that an emergency manual
was available compared to CRNAs (p=0.02).
Clark & Estes (2008) assert that a performance gap has three causes: providers’
knowledge and skills, their motivation, and organizational barriers. Our research indicates that
there may be different levels of motivation among anesthesia providers using a cognitive aid for
different types of emergencies. Of the 35 respondents, 90% stated they would use a cognitive aid
for MH, 61% stated they would use a cognitive aid for MI, and 25% stated they would use a
cognitive aid for UDA. These results suggest that anesthesia providers are more likely to use
cognitive aids for MH, a rare emergency that requires specific interventions, and less likely to
use a cognitive aid for UDA, possibly because they feel they should be able to manage this
emergency by memory alone as a trained airway expert.
In both institutions, training with deliberate practice is inconsistent, which has prevented
the mastery of cognitive aid use. Deliberate practice is identified as specialized training designed
to enhance performance of a task through systematic practice with feedback, problem solving,
evaluation, and repeat performance (Ericsson, 2008). Gaps identified by providers in this study
PERCEIVED BARRIERS TO COGNITIVE AID USE 22

lend to knowledge, skill, and organizational barriers. We recommend a future gap analysis to be
conducted at both institutions to identify specific causes that may be inhibiting cognitive aid use.
The literature indicates the vast benefits of simulation education to enhance learning of checklist
use. Indeed, studies of checklist use during emergency situations have brought to light the
limitations of working memory and the effects of extraneous load in the use of cognitive aids in
high stress situations.
Among the subgroup of providers who experienced one or more of the three emergency
scenarios (MH, MI, and UDA) and did not use an emergency manual to manage their most
recent encounter of the scenario(s), the most frequently reported barriers (from most to least
frequent), were that they (a) did not see a need for it, (b) did not know an emergency manual was
available, and (c) would have distracted/delayed patient care. The top cited barrier of this
subgroup is particularly interesting when considering the majority of providers we surveyed do
not believe they can manage an anesthesia emergency without any lapses based on memory and
experience only. Krombach et al. (2015) found a similar discrepancy in the results of their
survey, where 96% of anesthesia providers stated they would use a crisis manual checklist if
available, but greater than one third of them either agree or strongly agree that they can manage
these crises using solely their memory and experience. The authors attribute this to a discrepancy
between the anesthesia provider’s understanding that cognitive aids are necessary, and the
culture within healthcare that good providers must perform tasks by memory.
Limitations
There are several limitations to the survey. The sample size was small with 35
participants from two academic institutions. Survey results may be limited by the lack of
exposure to, and limited reported occurrence of emergency situations in the OR. Additionally,
PERCEIVED BARRIERS TO COGNITIVE AID USE 23

because the survey was reliant on self-report of these events, the results may not be a true
reflection of what actually occurs in the OR. Unfortunately, there is no way to verify the veracity
of participant responses without actual observation, although the use of an electronic emergency
manual may allow researchers to track its use and provide useful data. Lastly, the survey
participants may be subject to selection bias because those who feel strongly about cognitive aids
(either positively or negatively) may be more likely to complete the survey.
Recommendations for Future Research
Based on our study findings, we identify three areas of future research to overcome the
barriers that inhibit cognitive aid use during intraoperative emergencies. One potential area of
future research is how to motivate academic medical centers to provide interdisciplinary
cognitive aid training for trainees and licensed providers. It is worth exploring whether consistent
cognitive aid training programs can translate the studied benefits of increased treatment accuracy
and efficiency into practice by shifting the current views held by providers that emergency
manuals distract and/or delay patient care. We recommend institutions conduct research utilizing
in situ simulation, meaning that the simulation experience occurs within the actual operating
room environment with the multidisciplinary team, using a portable high-fidelity manikin.
Research shows the benefits of in situ simulation in improving team processes and identifying
systems gaps, however there is a paucity of simulation studies that evaluate the use of cognitive
aids or checklists in the perioperative environment. McEnvoy et al. (2014) studied the use of an
electronic decision support tool with a designated reader compared to the control (memory
alone) in the management of a high-fidelity in situ simulation of LAST in the post-anesthesia
care unit (PACU). The participants included a PACU nurse, anesthesiology residents, and a
standardized actor who arrived at the scene when help was called for to act as the reader. The
PERCEIVED BARRIERS TO COGNITIVE AID USE 24

cognitive aid group demonstrated improved adherence to guidelines in LAST management. This
evidence shows promise that incorporating cognitive aid use into an in situ, simulated,
interdisciplinary training, has the potential to improve patient care outcomes. More research is
needed to evaluate how in situ training may improve cognitive aid use in practice. We
recommend the multidisciplinary team to include surgeons, nurses, anesthesia providers,
technicians, assistants, and outlying services as indicated. By doing this, actions such as finding
where the emergency manual is kept and choosing the best person to read the emergency manual,
can be experienced within the real OR environment.
A second potential area of future research would include identification of ways to
increase provider access to cognitive aids during intraoperative crises. The Health Information
Technology for Economic and Clinical Health (HITECH) Act was signed into law on February
17, 2009 requiring meaningful use of technology into healthcare (HHS Office of the Secretary &
Office for Civil Rights, 2017). The authors believe this presents a strong opportunity to increase
access and integrate emergency manuals into electronic healthcare programs, as they become
universally adopted in the United States. Lelaidier et al. (2017) found that electronic cognitive
aids are an efficacious tool to enhance provider performance during intraoperative crises. With
increased use of health information technology, and supportive findings in the literature, a
further inquiry into digital cognitive aids is warranted as a means to increase access and
integration into the clinical setting.
Finally, a third area of future research would involve evaluation of how to effectively
facilitate a reader in order for the anesthesia provider to have adequate support during a crisis
scenario. McEvoy et al. (2014) found that utilizing a reader led to near perfect guideline
adherence during simulated intraoperative crisis. However, Marshall (2016) states that neither
PERCEIVED BARRIERS TO COGNITIVE AID USE 25

the team structure nor who is most suited to be the reader have been established, citing resource
variability among different locations. Most recently, Huang et al. (2019) conducted a survey that
suggested the senior physician is the preferred reader during an anesthesia crisis. Perhaps
identifying how the emergency manual can be accessed, and designating an appropriate reader
during surgical time out, can establish roles and expectations appropriate for a specific institution
to successfully prepare the perioperative team for emergencies.
While the current literature vastly supports the use of cognitive aids during simulated,
intraoperative emergency scenarios, studies investigating their use in practice is limited. Our
survey identified barriers to cognitive aid use in three specific emergency situations.

PERCEIVED BARRIERS TO COGNITIVE AID USE 26

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Table 1

Demographic Data of the Participants

Demographic data N (%)
Title

MD 10 (29)
CRNA 25 (71)
Years of experience
≤ 10 years 17 (49)
10+ years 18 (51)
Location

LAC+USC Medical Center 21 (60)
Keck Hospital of USC 14 (40)
Note: MD, physician anesthesiologist; CRNA, certified
registered nurse anesthetist; LAC+USC, Los Angeles
County and University of Southern California.
PERCEIVED BARRIERS TO COGNITIVE AID USE 33

Table 2

EM and Reader Utilization/Barriers to Using EM Step by Step

Survey Question Total
N (%)
MH
N (%)

MI
N (%)
UDA
N (%)
During your most recent encounter of this emergency situation in the OR, was an EM used?
Yes 11 (15.7) 6 (50.0) 3 (11.5) 2 (6.2)
No 59 (84.3) 6 (50.0) 23 (88.5) 30 (93.8)
Was there a reader during utilization of the EM to manage this emergency situation?
Yes 4 (36.4) 3 (50.0) 0 1 (50.0)
No 7 (63.6) 3 (50.0) 3 (100.0) 1(50.0)
While managing this emergency situation, the EM was
Followed step by step 3 (27.2) 3 (50.0) 0 0
Used as a reference intermittently 8 (72.7) 3 (50.0) 3 (100.0) 2 (100.0)
If the EM was not followed step by step, please select all the reasons that apply
Events in the OR happened too quickly 7 (87.5) 3 (100.0) 3 (100.0) 1 (50.0)
The EM is too difficult to use (too long, poorly designed, etc.) 0 0 0 0
I didn’t know how to use it because I never received EM training 0 0 0 0
Lack of institutional support 1 (12.5) 0 0 1 (50.0)
It would have distracted or delayed patient care 5 (62.5) 1 (33.3) 3 (100.0) 1 (50.0)
Not enough help in the room (nobody available as reader) 0 0 0 0
Anesthesia providers should be able to manage these situations by memory alone 1 (12.5) 0 0 1 (50.0)
Note: EM, emergency manual; OR, Operating Room; MH, malignant hyperthermia; MI, myocardial ischemia; UDA, unanticipated difficult airway.

PERCEIVED BARRIERS TO COGNITIVE AID USE 34

Table 3

General Barriers to EM Use During MH, MI and/or UDA Stratified by Location (LAC+USC Medical Center vs. Keck Hospital of USC), Type of Provider (MD vs. CRNA) and Years of Experience (Less
Than 10 Years of Experience vs. More Than 10 Years of Experience

Survey Question Total
N (%)

LAC+USC
Medical
Center
N (%)
Keck
Hospital
of USC
N (%)
P-valueA MD
N (%)
CRNA
N (%)
P-valueB ≤ 10
Working
years
N (%)
10+
Working
years
N (%)
P-valueC
N=35 N=21 N=14 N=10 N=25 N=17 N=18
Please select all the reasons you believe serve as barriers to EM use during MH, MI, and/or UDA.
I did not know an EM was available 14 (38.9) 3 (14.3) 11 (78.6) <0.001 7 (70.0) 7 (28.0) 0.02 5 (29.4) 9 (50.0) 0.21
I didn’t see a need for it 6 (16.7) 5 (23.8) 1 (7.1) 0.20 4 (40.0) 2 (8.0) 0.02 3 (17.6) 3 (16.7) 0.94
I didn’t think to consult an EM under stress 9 (25.0) 7 (33.3) 2 (14.3) 0.21 3 (30.0) 6 (24.0) 0.71 5 (29.4) 4 (22.2) 0.63
I couldn't readily access the EM 8 (22.2) 5 (23.8) 3 (21.4) 0.87 2 (20.0) 6 (24.0) 0.80 3 (17.6) 5 (27.8) 0.47
The EM was too difficult to use (too long, poorly designed, etc.)
3 (8.3) 2 (9.5) 1 (7.1) 0.81 1 (10.0) 2 (8.0) 0.85 1 (5.9) 2 (11.1) 0.58
I didn't know how to use it because I never received EM training 4 (11.1) 3 (14.3) 1 (7.1) 0.52 3 (30.0) 1 (4.0) 0.03 0 4 (22.2) 0.04
Lack of institutional support 7 (19.4) 4 (19.0) 3 (21.4) 0.86 1 (10.0) 6 (24.0) 0.35 4 (23.5) 3 (16.7) 0.62
Would have distracted/delayed patient care 17 (47.2) 13 (61.9) 4 (28.6) 0.05 6 (60.0) 11 (44.0) 0.39 10 (58.8) 7 (38.9) 0.24
Not enough help in the room (nobody available as reader) 13 (36.1) 11 (52.4) 2 (14.3) 0.02 4 (40.0) 9 (36.0) 0.82 6 (35.3) 7 (38.9) 0.83
Anesthesia providers should be able to manage these situations by
memory alone
9 (25.0) 8 (38.1) 1 (7.1) 0.04 3 (30.0) 6 (24.0) 0.71 7 (41.2) 2 (11.1) 0.04
Note. EM, emergency manual; MH, malignant hyperthermia; MI, myocardial ischemia; UDA, unanticipated difficult airway; LAC+USC, Los Angeles County + University of Southern California; MD,
physician anesthesiologist; CRNA, certified registered nurse anesthetist.
A P-value from Z-test of proportions comparing LAC+USC Medical Center vs. Keck Hospital of USC. B P-value from Z-test of proportions comparing MD vs. CRNA. C P-value from Z-test of
proportions comparing providers having less than 10 years of experience vs. providers having more than 10 years of experience.
. P-values are missing due to very small sample sizes.
PERCEIVED BARRIERS TO COGNITIVE AID USE 35

Table 4

MH and Barriers to EM Use Stratified by Location (LAC+USC Medical Center vs. Keck Hospital of USC), Type of Provider (MD vs. CRNA) and Years of Experience (Less Than 10 Years of Experience
vs. More Than 10 Years of Experience)

Survey Question Total
N (%)

LAC+USC
Medical
Center
N (%)
Keck
Hospital of
USC
N (%)
P-valueA MD
N (%)
CRNA
N (%)
P-valueB ≤ 10
Working
years
N (%)
10+
Working
years
N (%)
P-valueC
N=6 N=3 N=3 N=3 N=3 N=3 N=3
If an EM was not used to manage this emergency situation, please select reason
I did not know an EM was available 3 (50.0) 2 (66.7) 1 (33.3) 0.41 2 (66.7) 1 (33.3) 0.41 1 (33.3) 2 (66.7) 0.41
I didn’t see a need for it 2 (66.7) 1 (33.3) 1 (33.3) > 0.99 1 (33.3) 1 (33.3) > 0.99 1 (33.3) 1 (33.3) > 0.99
I didn’t think to consult an EM under stress 0 0 0 . 0 0 . 0 0 .
I couldn't readily access the EM 0 0 0 . 0 0 . 0 0 .
The EM was too difficult to use (too long, poorly designed, etc.) 0 0 0 . 0 0 . 0 0 .
I didn't know how to use it because I never received EM training 0 0 0 . 0 0 . 0 0 .
Lack of institutional support 1 (33.3) 0 1 (33.3) 0.27 0 1 (33.3) 0.27 1 (33.3) 0 0.27
Would have distracted/delayed patient care 2 (66.7) 2 (66.7) 0 0.08 1 (33.3) 1 (33.3) > 0.99 1 (33.3) 1 (33.3) > 0.99
Not enough help in the room (nobody available as reader) 0 0 0 . 0 0 . 0 0 .
Anesthesia providers should be able to manage these situations by
memory alone
0 0 0 . 0 0 . 0 0 .
Note: MH, malignant hyperthermia; EM, emergency manual; LAC+USC, Los Angeles County + University of Southern California; MD, physician anesthesiologist; CRNA, certified registered nurse
anesthetist.
A P-value from Z-test of proportions comparing LAC+USC Medical Center vs. Keck Hospital of USC. B P-value from Z-test of proportions comparing MD vs. CRNA. C P-value from Z-test of
proportions comparing providers having less than 10 years of experience vs. providers having more than 10 years of experience.
. P-values are missing due to very small sample sizes.
PERCEIVED BARRIERS TO COGNITIVE AID USE 36

Table 5
MI and Barriers to EM use Stratified by Location (LAC+USC Medical Center vs. Keck Hospital of USC), Type of Provider (MD vs. CRNA) and Years of Experience (Less Than 10 Years of Experience
vs. More Than 10 Years of Experience)

Survey Question Total
N (%)

LAC+USC
Medical
Center
N (%)
Keck
Hospital of
USC
N (%)
P-valueA MD
N (%)
CRNA
N (%)
P-valueB ≤ 10
working
years
N (%)
10+
working
years
N (%)
P-valueC
N=23 N=12 N=11 N=7 N=16 N=9 N=14
If an EM was not used to manage this emergency situation, please select reason:
I did not know an EM was available 11 (47.8) 3 (25.0) 8 (72.7) 0.02 3 (42.9) 8 (50.0) 0.75 4 (44.4) 7 (50.0) 0.79
I didn’t see a need for it 9 (39.1) 5 (41.7) 4 (36.4) 0.79 4 (57.1) 5 (31.3) 0.24 4 (44.4) 5 (35.7) 0.68
I didn’t think to consult an EM under stress 4 (17.4) 2 (16.7) 2 (18.2) 0.92 1 (14.3) 3 (18.8) 0.79 1 (11.1) 3 (21.4) 0.52
I couldn't readily access the EM 2 (8.7) 0 2 (18.2) 0.12 0 2 (12.5) 0.33 1 (11.1) 1 (7.1) 0.74
The EM was too difficult to use (too long, poorly designed, etc.) 1 (4.3) 1 (8.3) 0 0.33 0 1 (6.3) 0.50 0 1 (7.1) 0.41
I didn't know how to use it because I never received EM training 1 (4.3) 0 1 (9.1) 0.29 0 1 (6.3) 0.50 0 1 (7.1) 0.41
Lack of institutional support 1 (4.3) 1 (8.3) 0 0.33 0 1 (6.3) 0.50 1 (11.1) 0 0.20
Would have distracted/delayed patient care 4 (17.4) 3 (25.0) 1 (9.1) 0.32 3 (42.9) 1 (6.3) 0.003 2 (22.2) 2 (14.3) 0.63
Not enough help in the room (nobody available as reader) 2 (8.7) 2 (16.7) 0 0.16 0 2 (12.5) 0.33 1 (11.1) 1 (7.1) 0.74
Anesthesia providers should be able to manage these situations by
memory alone
0 0 0 . 0 0 . 0 0 .
Note: MI, myocardial ischemia; EM, emergency manual; LAC+USC, Los Angeles County + University of Southern California; MD, physician anesthesiologist; CRNA, certified registered nurse
anesthetist.
A P-value from Z-test of proportions comparing LAC+USC Medical Center vs. Keck Hospital of USC. B P-value from Z-test of proportions comparing MD vs. CRNA. C P-value from Z-test of
proportions comparing providers having less than 10 years of experience vs. providers having more than 10 years of experience.
. P-values are missing due to very small sample sizes.

PERCEIVED BARRIERS TO COGNITIVE AID USE 37

Table 6
UDA and Barriers to EM Use Stratified by Location (LAC+USC Medical Center vs. Keck Hospital of USC), Type of Provider (MD vs. CRNA) and Years of Experience (Less Than 10 Years of
Experience vs. More Than 10 Years of Experience)

Survey Question Total
N (%)

LAC+USC
Medical
Center
N (%)
Keck
Hospital
of USC
N (%)
P-valueA MD
N (%)
CRNA
N (%)
P-valueB ≤ 10
Working
years
N (%)
10+
Working
years
N (%)
P-
valueC
N=30 N=17 N=13 N=9 N=21 N=13 N=17
If an EM was not used to manage this emergency situation, please select reason:
I did not know an EM was available 8 (26.7) 2 (11.8) 6 (46.2) 0.03 1 (11.1) 7 (33.3) 0.21 1 (7.7) 7 (41.2) 0.04
I didn’t see a need for it 16 (53.3) 9 (52.9) 7 (53.8) 0.96 6 (66.7) 10 (47.6) 0.34 6 (46.2) 10 (58.8) 0.52
I didn’t think to consult an EM under stress 1 (3.3) 1 (5.9) 0 0.37 1 (11.1) 0 0.12 0 1 (5.9) 0.37
I couldn't readily access the EM 3 (10.0) 0 3 (23.1) 0.04 1 (11.1) 2 (9.5) 0.89 2 (15.4) 1 (5.9) 0.39
The EM was too difficult to use (too long, poorly designed, etc.) 0 0 0 0 0 . 0 0 .
I didn't know how to use it because I never received EM training 2 (6.7) 1 (5.9) 1 (7.7) 0.84 1 (11.1) 1 (4.8) 0.53 0 2 (11.8) 0.20
Lack of institutional support 1 (3.3) 0 1 (7.7) 0.24 0 1 (4.8) 0.30 1 (7.7) 0 0.24
Would have distracted/delayed patient care 9 (30.0) 7 (41.2) 2 (15.4) 0.13 4 (44.4) 5 (23.8) 0.26 5 (38.5) 4 (23.5) 0.37
Not enough help in the room (nobody available as reader) 5 (16.7) 4 (23.5) 1 (7.7) 0.25 1 (11.1) 4 (19.0) 0.59 3 (23.1) 2 (11.8) 0.41
Anesthesia providers should be able to manage these situations
by memory alone
5 (16.7) 3 (17.6) 2 (15.4) 0.87 2 (22.2) 3 (14.3) 0.59 4 (30.8) 1 (5.9) 0.07
Note. UDA, unanticipated difficult airway; EM, emergency manual; LAC+USC, Los Angeles County + University of Southern California; MD, physician anesthesiologist; CRNA, certified registered
nurse anesthetist.
A P-value from Z-test of proportions comparing LAC+USC Medical Center vs. Keck Hospital of USC. B P-value from Z-test of proportions comparing MD vs. CRNA. C P-value from Z-test of
proportions comparing less than 10 years of experience vs. more than 10 years of experience.
. P-values are missing due to very small sample sizes.

PERCEIVED BARRIERS TO COGNITIVE AID USE 38

Table 7

Potential EM Utilization During MH, MI, and UDA, Stratified by Years of Experience (Less Than or Equal to Five Years vs. More Than Six Years)

Survey Question N (%) ≤ 5 Working years
N (%)
6+ Working
years
N (%)
P-valueA
I would use an EM if I were to encounter: (please select all that apply)
MH 32 (88.9) 10 (90.9) 22 (91.7) 0.94
MI 22 (61.1) 8 (72.7) 14 (58.3) 0.41
UDA 9 (25.0) 0 9 (37.5) 0.02
None of the above 3 (8.3) 1 (9.1) 2 (8.3) 0.94
During your most recent encounter of this emergency situation in the OR, was an EM used? (Yes)
MH 6 (50) 1 (25) 5 (62.5) 0.55
MI 3 (11.5) 0 3 (14.3) > 0.99
UDA 2 (6.2) 0 2 (8.7) > 0.99
Note: EM, emergency manual; MH, malignant hyperthermia; MI, myocardial ischemia; UDA, unanticipated difficult airway.

PERCEIVED BARRIERS TO COGNITIVE AID USE 39

Table 8

EM Awareness, Training, Access and Departmental Support and Perceived Competence Stratified by Location (LAC+USC Medical Center vs. Keck Medical Center), Type of Provider (MD vs. CRNA)
and Years of Experience (Less Than 10 Years of Experience vs. More Than 10 Years of Experience)

Survey Question Total
N (%)

LAC+USC
Medical
Center
N (%)
Keck
Hospital of
USC
N (%)
P-valueA MD
N (%)
CRNA
N (%)
P-valueB ≤ 10
Working
years
N (%)
10+
Working
years
N (%)
P-valueC
Have you heard of an EM designed to manage operating room crises?
Yes 30 (85.7) 20 (95.2) 10 (71.4)
0.13
7 (70.0) 23 (92.0)
0.13
16 (94.1) 14 (77.8)
0.17
No 5 (14.3) 1 (4.8) 4 (28.6) 3 (30.0) 2 (8.0) 1 (5.9) 4 (22.2)
Have you received any training about the use of EM at your facility? (i.e. Webinar, In-person class, Handout, In service, other.)
Yes 19 (54.3) 19 (90.5) 0
< 0.001
2 (20.0) 17 (68.0)
0.02
10 (58.8) 9 (50.0)
0.59 No 13 (37.1) 0 13 (92.9) 6 (60.0) 7 (28.0) 5 (29.4) 8 (44.4)
I don't know if we have one 3 (8.6) 2 (9.5) 1 (7.1) 2 (20.0) 1 (4.0) 5 (29.4) 1 (5.6)
When does your department offer EM training?
During new hire orientation only 13 (37.1) 11 (52.4) 2 (14.3)
< 0.001
3 (30.0) 6 (60.0)
0.54
7 (41.2) 6 (33.3)
0.40
Every 6 months 1 (2.9) 1 (4.8) 0 0 1 (4.0) 0 1 (5.6)
Annually 7 (20.0) 6 (28.6) 1 (7.1) 1 (10.0) 6 (24.0) 5 (29.4) 2 (11.1)
Every 2 years 1 (2.9) 1 (4.8) 0 0 1 (4.0) 0 1 (5.6)
There are no training opportunities in my department 13 (37.1) 2 (9.5) 11 (78.6) 6 (60.0) 7 (28.0) 5 (29.4) 8 (44.4)
Do you know how to access an EM intraoperatively?
Yes 23 (65.7) 20 (95.2) 3 (21.4)
0.002
5 (50.0) 18 (72.0)
0.29
13 (76.5) 10 (55.6)
0.13 No 5 (14.3) 0 5 (35.7) 3 (30.0) 2 (8.0) 3 (17.6) 2 (11.1)
I don't know if we have one 7 (20.0) 1 (4.8) 6 (42.9) 2 (20.0) 5 (20.0) 1 (5.9) 6 (33.3)
How supportive is your department in using an EM?
Not supportive at all 2 (5.7) 1 (4.8) 1 (7.1) 0.32 0 2 (8.0) 0.07 0 2 (11.1) 0.63
PERCEIVED BARRIERS TO COGNITIVE AID USE 40

Minimally supportive 5 (14.3) 2 (9.5) 3 (21.4) 2 (20.0) 3 (12.0) 3 (17.6) 2 (11.1)
Neutral 11 (31.4) 5 (23.8) 6 (42.9) 5 (50.0) 6 (24.0) 6 (35.3) 5 (27.8)
Supportive 14 (40.0) 10 (47.6) 4 (28.6) 1 (10.0) 13 (52.0) 7 (41.2) 7 (38.9)
Very supportive 3 (8.6) 3 (14.3) 0 2 (20.0) 1 (4.0) 1 (5.9) 2 (11.1)
I feel competent that I can always deal with an emergency anesthesia situation (i.e. airway fire, cardiac arrest, MH, etc.) without any lapses based on memory and experience only.
Completely disagree 5 (14.3) 3 (14.3) 2 (14.3)
0.70
1 (10.0) 4 (16.0)
> 0.99
2 (11.8) 3 (16.7)
0.87
Somewhat disagree 14 (40.0) 10 (47.6) 4 (28.6) 4 (40.0) 10 (40.0) 7 (41.2) 7 (38.9)
Neutral 1 (2.9) 0 1 (7.1) 0 1 (4.0) 1 (5.9) 0
Somewhat agree 13 (37.1) 7 (33.3) 6 (42.9) 4 (40) 9 (36.0) 6 (35.3) 7 (38.9)
Completely agree 2 (5.7) 1 (4.8) 1 (7.1) 1 (10) 1 (4.0) 1 (5.9) 1 (5.6)
Note. EM, emergency manual; LAC+USC, Los Angeles County + University of Southern California; MD, physician anesthesiologist; CRNA, certified registered nurse anesthetist; MH, malignant
hyperthermia.
A P-value from Fisher's exact chi-square comparing LAC+USC Medical Center vs. Keck Hospital of USC. B P-value from Fisher's exact chi-square comparing MD vs. CRNA. C P-value from Fisher's
exact chi-square comparing providers having less than 10 years of experience vs. providers having more than 10 years of experience.

PERCEIVED BARRIERS TO COGNITIVE AID USE 41

Table 9

Procedural Timeout Stratified by Location (LAC+USC Medical Center vs. Keck Hospital of USC), Type of Provider (MD vs. CRNA) and Years of Experience (Less Than 10 Years of Experience vs.
More Than 10 Years of Experience)

Survey Question Total
N (%)

LAC+USC
Medical
Center
N (%)
Keck
Hospital of
USC
N (%)
P-valueA MD
N (%)
CRNA
N (%)
P-valueB ≤ 10
Working
years
N (%)
10+
Working
years
N (%)
P-valueC
I consider procedural time out in the OR
Neutral 3 (8.6) 2 (9.5) 1 (7.1)
0.99
2 (20.0) 1 (4.0)
0.11
2 (11.8) 1 (5.6)
0.79 Important 6 (17.1) 4 (19.0) 2 (14.3) 0 6 (24.0) 3 (17.6) 3 (16.7)
Very important 26 (74.3) 15 (71.4) 11 (78.6) 8 (80.0) 18 (72.0) 12 (70.6) 14 (77.8)
Note: LAC+USC, Los Angeles County + University of Southern California; MD, physician anesthesiologist; CRNA, certified registered nurse anesthetist; OR, operating room.
A P-value from Fisher's exact chi-square comparing LAC+USC Medical Center vs. Keck Hospital of USC. B P-value from Fisher's exact chi-square comparing MD vs. CRNA. C P-value from Fisher's
exact chi-square comparing providers having less than 10 years of experience vs. providers having more than 10 years of experience.

PERCEIVED BARRIERS TO COGNITIVE AID USE 42

Table 10

Barriers to EM Use During MH, MI and UDA Stratified by Perceived Importance of Procedural Time Out (Neutral/Important vs. Very Important)
Survey Question MH MI UDA
Total
N (%)
Neutral /
important
Very
important
P-valueA Total
N (%)
Neutral /
important
Very
important
P-valueB Total
N (%)
Neutral /
important
Very
important
P-valueC
If an EM was not used to manage this emergency situation, please select reason (select all that apply)
I did not know an EM was available 3 (50.0) 0 3 (75.0) . 11 (47.8) 1 (14.3) 10 (62.5) 0.03 8 (26.7) 1 (14.3) 7 (30.4) 0.40
I didn't see a need for it 2 (66.7) 1 (50.0) 1 (25.0) . 9 (39.1) 5 (71.4) 4 (25.0) 0.04 16 (53.3) 4 (57.1) 12 (52.2) 0.82
I didn't think to consult an EM under stress 0 0 0 . 4 (17.4) 0 4 (25.0) 0.15 1 (3.3) 0 1 (4.3) 0.58
I couldn't readily access the EM 0 0 0 . 2 (8.7) 0 2 (12.5) 0.33 3 (10.0) 0 3 (13.0) 0.31
The EM was too difficult to use (too long, poorly
designed, etc.)
0 0 0 . 1 (4.3) 0 1 (6.3) 0.50 0 0 0 .
I didn't know how to use it because I never received
EM training
0 0 0 . 1 (4.3) 1 (14.3) 0 0.12 2 (6.7) 1 (14.3) 1 (4.3) 0.35
Lack of institutional support 1 (33.3) 1 (50.0) 0 . 1 (4.3) 0 1 (6.3) 0.50 1 (3.3) 0 1 (4.3) 0.58
Would have distracted/delayed patient care 2 (66.7) 1 (50.0) 1 (25.0) . 4 (17.4) 2 (28.6) 2 (12.5) 0.35 9 (30.0) 2 (28.6) 7 (30.4) 0.93
Not enough help in the room (nobody available as reader) 0 0 0 . 2 (8.7) 1 (14.3) 1 (6.3) 0.53 5 (16.7) 1 (14.3) 4 (17.4) 0.85
Anesthesia providers should be able to manage these
situations by memory alone
0 0 0 . 0 0 0 . 5 (16.7) 0 5 (21.7) 0.18
Note: EM, emergency manual; MH, malignant hyperthermia; MI, myocardial ischemia; UDA, unanticipated difficult airway.
A P-value from Z-test of proportions comparing perceived importance of procedural time out as neutral/important vs. very important and barriers to EM use during MH. B P-value from Z-test of
proportions comparing perceived importance of procedural time out as neutral/important vs. very important and barriers to EM use during MI. C P-value from Z-test of proportions comparing perceived
importance of procedural time out as neutral/important vs. very important and barriers to EM use during UDA.
. P-values are missing due to very small sample sizes.

PERCEIVED BARRIERS TO COGNITIVE AID USE 43

Table 11
Perceived Competence vs. Barriers to EM Use
Survey Question I feel competent that I can always deal with an emergency anesthesia
situation (i.e. airway fire, cardiac arrest, MH, etc.) without any lapses based
on memory and experience only.
Total
N (%)

Agree Disagree P-valueA
N=35 N=19 N=16
Please select all the reasons you believe serve as barriers to EM use during MH, MI, and/or UDA.
I did not know an EM was available 14 (38.9) 8 (42.1) 6 (37.5) 0.78
I didn’t see a need for it 6 (16.7) 3 (15.8) 3 (18.8) 0.82
I didn’t think to consult an EM under stress 9 (25.0) 6 (31.6) 3 (18.8) 0.39
I couldn't readily access the EM 8 (22.2) 5 (26.3) 3 (18.8) 0.50
The EM was too difficult to use (too long, poorly designed, etc.) 3 (8.3) 1 (5.3) 2 (12.5) 0.45
I didn't know how to use it because I never received EM training 4 (11.1) 2 (10.5) 2 (12.5) 0.85
Lack of institutional support 7 (19.4) 5 (26.3) 2 (12.5) 0.31
Would have distracted/delayed patient care 17 (47.2) 6 (31.6) 11 (68.8) 0.03
Not enough help in the room (nobody available as reader) 13 (36.1) 8 (42.1) 5 (31.2) 0.51
Anesthesia providers should be able to manage these situations by memory alone 9 (25.0) 5 (26.3) 4 (25.0) 0.93
Note: MH, malignant hyperthermia; EM, emergency manual; MI, myocardial ischemia; UDA, unanticipated difficult airway.
A P-value from Z test of proportions comparing those who felt competent to always deal with an emergency situation based on memory and experience alone vs. those who did not feel competent to deal
with an emergency situation based on memory and experience alone.
PERCEIVED BARRIERS TO COGNITIVE AID USE 44

Appendix A
Gap analysis on the use of cognitive aids in OR among anesthesia providers

PERCEIVED BARRIERS TO COGNITIVE AID USE 45

Appendix B
SWOT analysis on the use of cognitive aids in OR among anesthesia providers

PERCEIVED BARRIERS TO COGNITIVE AID USE 46

Appendix C
PRISMA Flow Diagram

Appendix D
Survey

Records identified through database
searching
(n = 218)
Databases: Pubmed, Google Scholar, Embase
Keywords: barriers, cognitive aid, emergency
manual, checklist, anesthesia, anesthetist, crisis,
perception, OR, surgery, perioperative, and
implementation

Additional records identified through
reference lists
(n = 8)
Records after duplicates removed
(n = 206)
Records screened
(n = 206)
Records excluded with reasons:
did not meet inclusion criteria
(n = 150)
Full-text articles assessed for
eligibility
(n = 56)
Full-text articles excluded with
reasons: did not meet inclusion
criteria
n = 53)
Articles that met inclusion
criteria (addressing barriers
to cognitive aid use)
(n = 3)
Because of small n, inclusion
criteria expanded to include:
evidence supporting and
against efficacy of cognitive
aid use (same databases and
keywords used)
(n = 8)
Total articles included in
literature review
(n = 11)
PERCEIVED BARRIERS TO COGNITIVE AID USE 47

Appendix D
Survey

Use of Emergency Manuals at LAC + USC / Keck Hospital Survey

1. I practice at
a. LAC+USC Medical Center
b. Keck Medical Center

2. I am a(n)
a. MD (Physician Anesthesiologist)
b. CRNA

3. I have been a licensed anesthesia practitioner for
a. < 2 years
b. 2 - 5 years
c. 6 - 10 years
d. 11 - 20 years
e. > 20 years
4. I consider a procedural time out in the OR:
a. Not important at all
b. Low importance
c. Neutral
d. Important
e. Very important

5. Have you heard of an emergency manual designed to manage operating room
crises?
a. Yes
b. No

6. Have you received any training about the use of emergency manuals at your
Facility? (ie Webinar, In-person class, Handout, In service, other.)
a. Yes
b. No
c. I don’t know

7. When does your department offer emergency manual training?
a. During new hire orientation only
b. Every 3 months
c. Every 6 months
d. Annually
e. Every 2 years
f. There are no training opportunities in my department
PERCEIVED BARRIERS TO COGNITIVE AID USE 48

8. Do you know how to access an emergency manual intraoperatively?
a. Yes
b. No
c. I don’t know if we have one

9. How supportive is your department in using an emergency manual:
a. Not supportive at all
b. Minimally supportive
c. Neutral
d. Supportive
e. Very supportive

10. “I feel competent that I can always deal with an emergency anesthesia situation
(ie airway fire, cardiac arrest, malignant hyperthermia etc.) without any lapses
based on my memory and experience only.”
a. Completely disagree
b. Somewhat disagree
c. Neutral
d. Somewhat agree
e. Completely agree

11. Have you encountered Malignant Hyperthermia in the OR?
a. Yes
b. No

11a. [Branching Logic, if yes for #11] How long ago did you encounter Malignant
Hyperthermia?
a. Within the last year
b. Within the last 1-5 years
c. More than 5 years ago

11b. [Branching Logic, if yes for #11] During your most recent encounter of
Malignant Hyperthermia in the OR, was an emergency manual used?
a. Yes
b. No

11c. [Branching Logic, if yes for #11 and no for 11b.] If an emergency manual was
not used for Malignant Hyperthermia, please select reason:
a. I didn’t know if an emergency manual was available
b. I didn’t see a need for it
c. I didn’t think to consult an emergency manual under stress
d. I couldn’t readily access the emergency manual
e. The emergency manual was too difficult to use (too long, poorly designed, etc.)
f. I didn’t know how to use it because I never received emergency manual training
g. Lack of institutional support
PERCEIVED BARRIERS TO COGNITIVE AID USE 49

h. Would have distracted/delayed patient care
d. Not enough help in the room (nobody available as reader)
e. Anesthesia providers should be able to manage these situations by memory
alone

11d. [Branching Logic, if yes for #11 and yes for 11b.] A reader is defined as a
person in the OR who is responsible for reading the emergency manual aloud
during the crisis situation. Was there a reader during utilization of the emergency
manual to manage Malignant Hyperthermia?
a. Yes
b. No

11e. [Branching Logic, if yes for #11 and yes for 11b.] While managing Malignant
Hyperthermia, the emergency manual was:
a. Followed step by step
b. Used as a reference intermittently

11f. [Branching Logic, if yes for #11, yes for 11b., and used as a reference
intermittently for 11e.] If the emergency manual was not followed step by step,
please select all the reasons that apply
a. Events in the OR happened too quickly
b. The emergency manual is too difficult to use (too long, poorly designed, etc.)
c. I didn’t know how to use it because I never received emergency manual training
d. Lack of institutional support
e. It would have distracted or delayed patient care
f. Not enough help in the room (nobody available as reader)
g. Anesthesia providers should be able to manage these situations by memory alone

12. Have you encountered Myocardial Ischemia in the OR?
a. Yes
b. No

12a. [Branching Logic, if yes for #12] How long ago did you encounter Myocardial
Ischemia?
a. Within the last year
b. Within the last 1-5 years
c. More than 5 years ago

12b. [Branching Logic, if yes for #12] During your most recent encounter of
Myocardial Ischemia in the OR, was an emergency manual used?
a. Yes
b. No

12c. [Branching Logic, if yes for #12 and no for 12b.] If an emergency manual was
not used for Myocardial Ischemia, please select reason:
a. I didn’t know if an emergency manual was available
PERCEIVED BARRIERS TO COGNITIVE AID USE 50

b. I didn’t see a need for it
c. I didn’t think to consult an emergency manual under stress
d. I couldn’t readily access the emergency manual
e. The emergency manual was too difficult to use (too long, poorly designed, etc.)
f. I didn’t know how to use it because I never received emergency manual training
g. Lack of institutional support
h. Would have distracted/delayed patient care
i. Not enough help in the room (nobody available as reader)
j. Anesthesia providers should be able to manage these situations by memory alone

12d. [Branching Logic, if yes for #12 and yes for 12b.] A reader is defined as a
person in the OR who is responsible for reading the emergency manual aloud
during the crisis situation. Was there a reader during utilization of the emergency
manual to manage Myocardial Ischemia?
a. Yes
b. No

12e. [Branching Logic, if yes for #12 and yes for 12b.] While managing Myocardial
Ischemia, the emergency manual was:
a. Followed step by step
b. Used as a reference intermittently

12f. [Branching Logic, if yes for #12, yes for 12b., and used as a reference
intermittently for 12e.] If the emergency manual was not followed step by step,
please select all the reasons that apply
a. Events in the OR happened too quickly
b. The emergency manual is too difficult to use (too long, poorly designed, etc.)
c. I didn’t know how to use it because I never received emergency manual training
d. Lack of institutional support
e. It would have distracted or delayed patient care
f. Not enough help in the room (nobody available as reader)
g. Anesthesia providers should be able to manage these situations by memory alone

13. Have you encountered Unanticipated Difficult Airway in the OR?
a. Yes
b. No

13a. [Branching Logic, if yes for #13] How long ago did you encounter
Unanticipated Difficult Airway?
a. Within the last year
b. Within the last 1-5 years
c. More than 5 years ago

13b. [Branching Logic, if yes for #13] During your most recent encounter of
Unanticipated Difficult Airway in the OR, was an emergency manual used?
a. Yes
PERCEIVED BARRIERS TO COGNITIVE AID USE 51

b. No

13c. [Branching Logic, if yes for #13 and no for 13b.] If an emergency manual was
not used for Unanticipated Difficult Airway, please select reason:
a. I didn’t know an emergency manual was available
b. I didn’t see a need for it
c. I didn’t think to consult an emergency manual under stress
d. I couldn’t readily access the emergency manual
e. The emergency manual was too difficult to use (too long, poorly designed, etc.)
f. I didn’t know how to use it because I never received emergency manual training
g. Lack of institutional support
h. Would have distracted/delayed patient care
i. Not enough help in the room (nobody available as reader)
j. Anesthesia providers should be able to manage these situations by memory alone

13d. [Branching Logic, if yes for #13 and yes for 13b.] A reader is defined as a
person in the OR who is responsible for reading the emergency manual aloud
during the crisis situation. Was there a reader during utilization of the emergency
manual to manage Unanticipated Difficult Airway?
a. Yes
b. No

13e. [Branching Logic, if yes for #13 and yes for 13b.] While managing
Unanticipated Difficult Airway, the emergency manual was:
a. Followed step by step
b. Used as a reference intermittently

13f. [Branching Logic, if yes for #13, yes for 13b., and used as a reference
intermittently for 13e.] If the emergency manual was not followed step by step,
please select all the reasons that apply
a. Events in the OR happened too quickly
b. The emergency manual is too difficult to use (too long, poorly designed, etc.)
c. I didn’t know how to use it because I never received emergency manual training
d. Lack of institutional support
e. It would have distracted or delayed patient care
f. Not enough help in the room (nobody available as reader)
g. Anesthesia providers should be able to manage these situations by memory alone

14. I would use an emergency manual if I were to encounter (please select all that
apply)
a. Malignant hyperthermia
b. Myocardial infarction
c. Unanticipated difficult airway
d. None of the above

15. Please select all the reasons you believe serve as barriers to emergency manual use
PERCEIVED BARRIERS TO COGNITIVE AID USE 52

during Malignant Hyperthermia, Myocardial Ischemia, and/or Unanticipated
Difficult Airway.
a. I don’t know if an emergency manual is available
b. I don’t see a need for it
c. I don’t think to consult an emergency manual under stress
d. The emergency manual cannot be readily accessed
e. The emergency manual is too difficult to use (too long, poorly designed, etc.)
f. I never received emergency manual training so I don’t know how to use it
g. Lack of institutional support
h. Distracts or delays patient care
i. Not enough help in the room (nobody available as reader)
j. I should be able to manage these situations by memory

16. Please describe barriers to emergency manual use that you have encountered in
your clinical setting that were not mentioned in this survey
(Open Ended Response)

PERCEIVED BARRIERS TO COGNITIVE AID USE 53

Appendix E
iStar Approval

Abstract (if available)

Abstract Background: A cognitive aid is defined by the Stanford Anesthesia Cognitive Aid Group as a visual in any form intended to enhance cognition and improve adherence to medical best practices. While the efficacy of cognitive aid use during simulated, intraoperative emergencies is well supported in the current literature, their use in anesthesia practice remains limited. ❧ Aim: The aim of this doctoral capstone paper is to investigate perceived barriers to cognitive aid use in the operating room among anesthesia providers during various emergency situations. ❧ Methodology: An anonymous survey was disseminated to 149 certified registered nurse anesthetists and anesthesiologists at two large academic institutions to explore actual and potential barriers that preclude cognitive aid use during three specific intraoperative emergencies: malignant hyperthermia, myocardial ischemia, and unanticipated difficult airway. ❧ Results: The survey was completed by 35 anesthesia providers. The three most frequently reported perceived barriers to cognitive aid use for all three emergency scenarios were: (a) would have distracted/delayed patient care, (b) did not know a cognitive aid was available, and (c) not enough help in the room (nobody available as the reader). ❧ Conclusion: While the current literature vastly supports the use of cognitive aids during simulated, intraoperative emergency scenarios, studies investigating their use in practice is limited. Our survey identified barriers to cognitive aid use in three specific emergency situations. Future research should focus on interdisciplinary cognitive aid training, access to cognitive aids, and use of a reader.

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Asset Metadata

Creator Paik, Hanna (author)

Core Title Evaluating perceived barriers to cognitive aid use among anesthesia providers during malignant hyperthermia, myocardial ischemia, and unanticipated difficult airway

School Keck School of Medicine

Degree Doctor of Nurse Anesthesia Practice

Degree Program Nurse Anesthesiology

Publication Date 06/08/2020

Defense Date 06/08/2020

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag anesthesia,Barriers,checklist,cognitive aid,critical event,emergency manual,emergency situation,OAI-PMH Harvest

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Garcia, Charlotte (committee chair), Bamgbose, Elizabeth (committee member), Darna, Jeffrey (committee member)

Creator Email hpaik@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-316316

Unique identifier UC11663627

Identifier etd-PaikHanna-8574.pdf (filename),usctheses-c89-316316 (legacy record id)

Legacy Identifier etd-PaikHanna-8574.pdf

Dmrecord 316316

Document Type Capstone project

Rights Paik, Hanna

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA