Updated OR Crisis Checklists Help Clinicians Rescue Patients from Critical Events

Surgical team working on a patient in operating theater

Boston, MA – Emergencies can occur unpredictably in surgery, from patient hemorrhage or cardiac arrest to the rare fire in the operating room (OR). Surgical teams must take quick action in these instances to avoid harm to their patients. The Ariadne Labs Operating Room Crisis Checklists were created to help surgical teams effectively manage the most dangerous OR emergencies. Now, Ariadne Labs is releasing updated crisis checklists to reflect the latest advancements in drugs, dosing, and patient safety.

“We know from clinicians around the country how valuable the OR Crisis Checklists have been. With these new updates, we stay at the forefront of patient safety,” said Dr. Alex Hannenberg, an anesthesiologist and Associate Faculty with the Safe Surgery Program at Ariadne Labs.

This compendium of 12 checklists provides clinicians step-by-step instructions for what to do in the case of dangerous OR events. It is a resource for clinicians to move efficiently and effectively to mitigate adverse occurrences.

The OR Crisis Checklists, which were compiled in 2011 and first revised in 2013, fit into Ariadne Labs’ broader mission to advance surgical safety around the world. While the WHO Surgical Safety Checklist is designed to prevent errors and their subsequent complications, the OR Crisis Checklists are about rescuing patients from potentially life-threatening situations and achieving a good outcome for the patient. Dr. Hannenberg, who led the recent update process with the Ariadne Labs team, sees these two tools as complementary, and points to hemorrhage as a good example of why this is so. “The Surgical Safety Checklist helps the OR team know that a patient is at increased risk for hemorrhage and allows them to prepare, and then the OR Crisis Checklists tell them what to do if and when a hemorrhage occurs,” he said.

The process to update the checklists was initiated to incorporate revisions to medical guidelines that reflect the most up-to-date guidance on how to manage emergencies in the operating room. “We know that OR emergencies are stressful situations for all involved,” said Dr. Hannenberg. “Studies show that people do not operate at their full capacity when stressed, and it can be easy for errors to occur. The OR Crisis Checklists are meant to mitigate these effects on the clinical team in order to provide the best, most complete care to the patient.”

Among other changes to support this aim, references to the hormone vasopressin, which can be used to raise blood pressure in the event of cardiac arrest, have been removed, leaving instructions related solely to the preferred agent, epinephrine. This change is in alignment with the newest guidelines from the American Heart Association. Clinical studies have shown that epinephrine and vasopressin are both effective for improving the likelihood of a return of spontaneous circulation during cardiac arrest, but there is no added benefit from administering both versus epinephrine alone. In order to simplify the process for clinicians, the American Heart Association removed vasopressin from the clinical guidelines.

In addition, the checklist now provides the epinephrine dilution calculations for quick reference in other scenarios. “Having to do math on the fly in an emergency is error prone,” Dr. Hannenberg said. “Adding the dilution instructions right on the page reduces the cognitive burden on the clinician in the moment.”

The process to update the checklists occurred over the course of six months and involved a detailed review of necessary changes and how to make them most readable. The strength of the tool is how usable it is under stressful circumstances, so there was focused scrutiny on the formatting details – font size, spacing, use of color – in order to maintain the tool’s usability.

Doctors reading medical documents of a patient before the surgery. Focus is on doctor with glasses.

“Crisis situations are not unique from a design perspective, but when seconds matter, extra care must be taken to ensure people can quickly find and act upon the right information,” said Chris Barnes, Principal at Emphatic Communications, who worked with the Ariadne Labs team to design the original and updated OR Crisis Checklists. To create a tool that is quickly intuitive, Barnes constructs visuals that direct a person’s attention from the most important information to the least. He creates an inventory of the various information to be included and then assigns a ranking to each by its relative importance. From there, all visual design decisions – from the organization of content on a screen or page down to the type size – are made to emphasize that prioritization.

Additionally, Barnes creates a unique set of characteristics for each type of information and applies that consistently throughout the tool. For example, information related to drug doses and treatment is always labeled in blue and located on the upper right portion of the page. A clinician knows to look for drug dosing information based on these characteristics on every page, regardless of the emergency OR event, because they “quickly learn and rely upon the ‘language’ of the visual design to navigate the tool,” Barnes said.

In addition to the team at Ariadne Labs, feedback was provided by the Emergency Manuals Implementation Collaborative (EMIC), a group of representatives from hospitals around the country devoted to promoting the integration of emergency tools and cognitive aids into OR practice.

“We want these tools to be a standard part of managing critical events in the OR. The first step in doing that is to make sure they have all the right information in a format that is easy to use under pressure,” Dr. Hannenberg noted.

The updated Operating Room Crisis Checklists are available on the Ariadne Labs and EMIC websites.

— By Margaret Ben-Or