It Is Time to Use Checklists for Anesthesia Emergencies: Simulation Is the Vehicle for Testing and Learning

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The use of simulation to improve medical training and patient safety has been growing in popularity. Many fully functional health care simulation centers now operate in the United States and throughout the world. Simulation is widely viewed as an important tool for a broad spectrum of education, training, and patient safety applications and particularly for the teaching and study of rare crisis events. However, simulation can also be used to evaluate new patient safety interventions, such as checklists. Many industries, such as the airline industry, manufacturing, food inspection, and pharmaceutical industries, have been using checklists for decades, especially as processes become more complex and the number of routine tasks required exceeds what can realistically be remembered, even by experts.1,2 Unfortunately, the health care industry has been a late adopter of checklists despite the complex and unpredictable situations often faced in the field. Checklists were initially introduced in anesthesia in the 1980s,3 although it took more than 10 years for checklists to be introduced in other clinical care areas.2 In a relatively short time, the reduction in process variability provided by checklists has led to improved outcomes and reduced incidence of central line infections,4,5 ventilator management, and end of life care.6,7
Despite improved patient outcomes resulting from using checklists in general, there is much more to learn about how to develop them, how to use them, and how to train clinicians to use them effectively for managing emergencies.8 In the case of rare clinical emergencies, such as local anesthesia systemic toxicity (LAST), it is likely impossible to become proficient with the use of checklists in an actual clinical setting. Simulation is the obvious vehicle for training. We see an excellent example of that in a study by Neal et al in this issue of Regional Anesthesia and Pain Medicine.9 Their study evaluated the use of the American Society of Regional Anesthesia’s (ASRA’s) checklist for managing LAST to improve trainees’ technical and nontechnical performance during a simulated LAST crisis event. We learn from this report that there is still much work required to optimize the use of checklists, in anesthesia and elsewhere, and to educate and train practitioners so that checklists are accepted as the cultural norm. Neal et al have demonstrated the usefulness of simulation for this purpose.
The authors randomized trainees who were managing a simulated LAST crisis to either receive the checklist to use during the simulation or not to receive the checklist. They found that trainees who were given the checklist as an aid completed substantially more medical management tasks correctly than those who did not have the checklist. Furthermore, the checklist subjects scored higher in their overall crises management behaviors. These findings are consistent with a very recent study that shows improved adherence to critical management steps with the use of checklists during simulated crisis situations in the operating room.8
Neal et al illustrate that checklists can improve performance in the management of LAST. Without the checklist, performance was surprisingly poor; on average, the nonchecklist group completed only 8 of 21 essential tasks for management of a LAST crisis. Yet, even with the checklist, performance was not ideal; the checklist group, on average, performed only 16 of 21 essential tasks. Further deliberate practice,10 ideally with the use of simulation, is clearly required to improve performance.
Perhaps a more striking finding in this study is that unless it was not reported, none of the 13 trainees in the nonchecklist group asked for a checklist. Each trainee had received the ASRA practice advisory 4 weeks before the study commenced, albeit “without fanfare.

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