Advertisement

Fundamentals of Managing the Operative Catastrophe

  • Idalid Franco
  • David L. Hepner
  • William R. Berry
  • Alexander F. Arriaga
Chapter

Abstract

Operative catastrophes are low-frequency events that require rapid and coordinated management under stressful conditions. Although these events may be rare at the individual provider level, they can be a common occurrence when viewed in aggregate in large medical centers. As the surgical volume worldwide continues to grow, it is of critical importance in surgical management that we turn our attention to mechanisms of preventing and addressing potentially catastrophic events, such as through the use of structured cognitive aids including crisis checklists and emergency manuals.

Keywords

Operative catastrophes Emergency manuals Crisis checklists Cognitive aids Crisis/crew resource management 

Notes

Acknowledgment

This work is supported by grants from the University of Pennsylvania, McCabe Fund, and Bach Fund. The authors would like to thank Maryann Henry, CRNA, MS, and Carlene McLaughlin, CRNA, MSN, PhD, for their review of the work and their efforts to advance the principles of crisis management and patient safety. The views expressed in this article are those of the authors and do not necessarily represent the official views of supporting entities.

Suggested Reading

  1. Babcock WW. Resuscitation during anesthesia. Anesth Analg. 1924;3(6):208–13.CrossRefGoogle Scholar
  2. Link MS, Berkow LC, Kudenchuk PJ, Halperin HR, Hess EP, Moitra VK, Neumar RW, O’Neil BJ, Paxton JH, Silvers SM, White RD. Part 7: adult advanced cardiovascular life support. Circulation. 2015;132(18 suppl 2):S444–64.CrossRefPubMedGoogle Scholar
  3. Arriaga AF, Bader AM, Wong JM, Lipsitz SR, Berry WR, Ziewacz JE, Hepner DL, Boorman DJ, Pozner CN, Smink DS, Gawande AA. Simulation-based trial of surgical-crisis checklists. N Engl J Med. 2013;368(3):246–53.CrossRefPubMedGoogle Scholar
  4. Goldhaber-Fiebert SN, Pollock J, Howard SK, Merrell SB. Emergency manual uses during actual critical events and changes in safety culture from the perspective of anesthesia residents: a pilot study. Anesth Analg. 2016;123(3):641–9.CrossRefPubMedGoogle Scholar
  5. Bhatti NI. Chapter 6: surgical management of the difficult adult airway. In: Flint PW, et al., editors. Cummings otolaryngology. 6th ed. Philadelphia: Elsevier Saunders; 2014.Google Scholar

References

  1. 1.
    Charuluxananan S, Suraseranivongse S, Jantorn P, Sriraj W, Chanchayanon T, Tanudsintum S, Kusumaphanyo C, Suratsunya T, Poajanasupawun S, Klanarong S, Pulnitiporn A. Multicentered study of model of anesthesia related adverse events in Thailand by incident report (The Thai anesthesia incidents monitoring study): results. J Med Assoc Thai. 2008;91(7):1011.PubMedGoogle Scholar
  2. 2.
    Ziewacz JE, Arriaga AF, Bader AM, Berry WR, Edmondson L, Wong JM, Lipsitz SR, Hepner DL, Peyre S, Nelson S, Boorman DJ. Crisis checklists for the operating room: development and pilot testing. J Am Coll Surg. 2011;213(2):212–7.CrossRefPubMedGoogle Scholar
  3. 3.
    Arriaga AF, Bader AM, Wong JM, Lipsitz SR, Berry WR, Ziewacz JE, Hepner DL, Boorman DJ, Pozner CN, Smink DS, Gawande AA. Simulation-based trial of surgical-crisis checklists. N Engl J Med. 2013;368(3):246–53.CrossRefPubMedGoogle Scholar
  4. 4.
    Goldhaber-Fiebert SN, Pollock J, Howard SK, Merrell SB. Emergency manual uses during actual critical events and changes in safety culture from the perspective of anesthesia residents: a pilot study. Anesth Analg. 2016;123(3):641–9.CrossRefPubMedGoogle Scholar
  5. 5.
    Burden AR, Carr ZJ, Staman GW, Littman JJ, Torjman MC. Does every code need a “reader?” improvement of rare event management with a cognitive aid “reader” during a simulated emergency: a pilot study. Simul Healthc. 2012;7(1):1–9.CrossRefPubMedGoogle Scholar
  6. 6.
    McEvoy MD, Hand WR, Stoll WD, Furse CM, Nietert PJ. Adherence to guidelines for the management of local anesthetic systemic toxicity is improved by an electronic decision support tool and designated ‘reader’. Reg Anesth Pain Med. 2014;39(4):299.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Neumar RW, Otto CW, Link MS, Kronick SL, Shuster M, Callaway CW, Kudenchuk PJ, Ornato JP, McNally B, Silvers SM, Passman RS. Part 8: adult advanced cardiovascular life support. Circulation. 2010;122(18 suppl 3):S729–67.CrossRefPubMedGoogle Scholar
  8. 8.
    Link MS, Berkow LC, Kudenchuk PJ, Halperin HR, Hess EP, Moitra VK, Neumar RW, O’Neil BJ, Paxton JH, Silvers SM, White RD. Part 7: adult advanced cardiovascular life support. Circulation. 2015;132(18 suppl 2):S444–64.CrossRefPubMedGoogle Scholar
  9. 9.
    Brown TB, Dias JA, Saini D, Shah RC, Cofield SS, Terndrup TE, Kaslow RA, Waterbor JW. Relationship between knowledge of cardiopulmonary resuscitation guidelines and performance. Resuscitation. 2006;69(2):253–61.CrossRefPubMedGoogle Scholar
  10. 10.
    Semeraro F, Signore L, Cerchiari EL. Retention of CPR performance in anaesthetists. Resuscitation. 2006;68(1):101–8.CrossRefPubMedGoogle Scholar
  11. 11.
    Kurrck MM, Devitc JH, Cohen M. Cardiac arrest in the OR: how are our ACLS skills? Can J Anaesth. 1998;45(2):130.CrossRefGoogle Scholar
  12. 12.
    Yang CW, Yen ZS, McGowan JE, Chen HC, Chiang WC, Mancini ME, Soar J, Lai MS, Ma MH. A systematic review of retention of adult advanced life support knowledge and skills in healthcare providers. Resuscitation. 2012;83(9):1055–60.CrossRefPubMedGoogle Scholar
  13. 13.
    Operating Room Crisis Checklists. Ariadne Labs, Brigham and Women’s Hospital, and Harvard School of Public Health; 2013 (Revised July 2016). http://www.emergencymanuals.org/free-tools.html.
  14. 14.
    Babcock WW. Resuscitation during anesthesia. Anesth Analg. 1924;3(6):208–13.CrossRefGoogle Scholar
  15. 15.
    Mitka M. Peter J. Safar, MD: “father of CPR,” innovator, teacher, humanist. JAMA. 2003;289(19):2485–6.CrossRefPubMedGoogle Scholar
  16. 16.
    Lavonas EJ, Drennan IR, Gabrielli A, Heffner AC, Hoyte CO, Orkin AM, Sawyer KN, Donnino MW. Part 10: special circumstances of resuscitation. Circulation. 2015;132(18 suppl 2):S501–18.CrossRefPubMedGoogle Scholar
  17. 17.
    Apfelbaum JL, Hagberg CA, Caplan RA, Blitt CD, Connis RT, Nickinovich DG, Benumof JL, Berry FA, Bode RH, Cheney FW, Guidry OF. Practice guidelines for management of the difficult airway an updated report by the American society of anesthesiologists task force on management of the difficult airway. Anesth. 2013;118(2):251–70.CrossRefGoogle Scholar
  18. 18.
    Frerk C, Mitchell VS, McNarry AF, Mendonca C, Bhagrath R, Patel A, O’sullivan EP, Woodall NM, Ahmad I. Difficult airway society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth. 2015;115(6):827–48.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Flint PW, Haughey BH, Robbins KT, Thomas JR, Niparko JK, Lund VJ, Lesperance MM. Cummings otolaryngology-head and neck surgery. Amsterdam: Elsevier Health Sciences; 2014.Google Scholar
  20. 20.
    Fasting S, Gisvold SE. Serious intraoperative problems—a five-year review of 83,844 anesthetics. Can J Anesth. 2002;49(6):545–53.CrossRefPubMedGoogle Scholar
  21. 21.
    Irita K, Kawashima Y, Iwao Y, Seo N, Tsuzaki K, Morita K, Obara H. Annual mortality and morbidity in operating rooms during 2002 and summary of morbidity and mortality between 1999 and 2002 in Japan: a brief review. Masui. 2004;53(3):320–35.PubMedGoogle Scholar
  22. 22.
    Walls RM, Murphy MF, editors. Manual of emergency airway management. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2013.Google Scholar
  23. 23.
    Morris RW, Watterson LM, Westhorpe RN, Webb RK. Crisis management during anaesthesia: hypotension. Qual Saf Health Care. 2005;14(3):e11.CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Szekely SM, Runciman WB, Webb RK, Ludbrook GL. Crisis management during anaesthesia: desaturation. Qual Saf Health Care. 2005;14(3):e6.CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Stanford Anesthesia Cognitive Aid Group.1 Emergency Manual: Cognitive aids for perioperative critical events. See http://emergencymanual.stanford.edu for latest version. Creative Commons BY-NC-ND. 2016 (Version 3) (http://creativecommons.org/licenses/by-nc-nd/3.0/legalcode).
  26. 26.
    Hepner DL, Arriaga AF, Cooper JB, Goldhaber-Fiebert S, Gaba DM, Berry WR, Boorman DJ, Bader AM. Clinical concepts and commentary: operating room crisis checklists and emergency manuals. Anesthesiology. 2017;127(2):384–92.CrossRefPubMedGoogle Scholar
  27. 27.
    Krombach JW, Edwards WA, Marks JD, Radke OC. Checklists and other cognitive aids for emergency and routine anesthesia care-a survey on the perception of anesthesia providers from a large academic US institution. Anesth Pain Med. 2015;5(4):e26300.CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Neily J, DeRosier JM, Mills PD, Bishop MJ, Weeks WB, Bagian JP. Awareness and use of a cognitive aid for anesthesiology. Jt Comm J Qual Patient Saf. 2007;33(8):502–11.CrossRefPubMedGoogle Scholar
  29. 29.
    Szabo A, August DA, Klainer S, Miller AD, Kaye AD, Raemer DB, Urman RD. The use of emergency manuals in perioperative crisis management: a cautious approach. J Med Pract Manage. 2014;30:8–12.Google Scholar
  30. 30.
    Cima RR, Deschamps C. Role of the surgeon in quality and safety in the operating room environment. Gen Thorac Cardiovasc Surg. 2013;61(1):1–8.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Idalid Franco
    • 1
  • David L. Hepner
    • 2
    • 3
  • William R. Berry
    • 3
    • 4
    • 5
  • Alexander F. Arriaga
    • 2
    • 6
  1. 1.Harvard Medical SchoolBostonUSA
  2. 2.Department of Anesthesiology, Perioperative and Pain MedicineHarvard Medical School, Brigham and Women’s HospitalBostonUSA
  3. 3.Ariadne LabsBostonUSA
  4. 4.Center for Surgery and Public HealthBostonUSA
  5. 5.Department of Health Policy and ManagementHarvard School of Public HealthBostonUSA
  6. 6.Department of Anesthesiology and Critical CareUniversity of Pennsylvania Health SystemPhiladelphiaUSA

Personalised recommendations