Cognitive aids have been present in the non-medical industry for a long time. For instance, the aviation industry has been using cognitive aids since 1930. The reasoning behind it was that experts in aviation safety considered that even highly experienced and trained pilots may need more than their memory to fly an aircraft safely.

In Medicine, cognitive aids also enhance clinical decision-making and treatment planning, especially during medical crises.  Time and resources are limited in a crisis, and even experienced providers may need help retrieving information from long-term memory during high-stress situations. The impact of stressful situations on human memory makes cognitive errors more frequent in the intraoperative setting, especially when the events are uncommon. Cognitive aids can therefore provide a helpful tool to minimise errors.

Unlike protocols or guidelines that describe extensively the state of knowledge and detailed sequences of actions, cognitive aids should be simple and easy to use during emergencies.

Studies on simulation training have shown that surgical teams perform better when crisis manuals are used. Then, many institutions and anaesthesia scientific societies recommend using cognitive aids in the operating room. The SENSAR (Spanish System of Safety Notification in Anesthesiology and Resuscitation) developed the Crisis Manual for Anesthesia and Critical Care. However, there needs to be data about implementing the SENSAR crisis manual. Here, we aim to evaluate the role of the SENSAR crisis manual in the clinical practice of different groups of anesthesiologists.

We conducted an anonymous 5-minute survey.  Participants were anesthesiologist consultants from our institution and different institutions in Spain attending a continuing medical education course and residents of anaesthesia from our institution and other regional institutions.  The survey completion was understood as consent to participate in the study. This research was conducted by the Helsinki Declaration.

The survey explored the following topics: awareness of cognitive aids in the operating room, usefulness, who should be the appropriate person to read the mental aid, and example of crises when participants used cognitive aids during the last month.

We collected a total of 115 surveys. A high percentage of anesthesiologists and residents -76.5% and 89%, respectively- reported they knew the concept of cognitive aids.  However, just one-third were aware of the location of cognitive aids in the operating room.  The location and accessibility of cognitive aids are essential factors in enhancing their use. Cognitive aids should be located in a visible, agreed place inside the operating room to be immediately available during the crisis.

To boost the use of cognitive aids, it is also essential that the team perceive them as useful. Most participants agreed that cognitive aids may be helpful in crisis management, even for experienced anesthesiologists. However, 44% of participants were not sure or believed cognitive aids could be a waste of time during crisis resolution. Indeed, if cognitive aids are used at the wrong time, for instance, during cardiac arrest with insufficient clinicians, they could be counterproductive. However, when used at the appropriate time and manner, crisis manuals can be helpful for decision-making and checking for all the necessary steps during a crisis, especially when critical events are not frequent.

Regarding the experience with cognitive aids during the previous month of the survey. Only 12 anesthesiologists (13% of participants) referred to have experienced a critical event during the last month. Cognitive aids were used only in three cases and were helpful in two. Although the number of participants in the survey is limited and the period considered for critical events presentation was probably too short, cognitive aids are far from being used. Only 25% of those facing a crisis used a crisis manual. We consider that active training in cognitive aids is required for their implementation. Simulation scenarios, including cognitive aids, may reinforce their use in actual clinical practice. The mere presence of cognitive aids does not ensure they would be consulted or it would be done correctly. The slight use of crisis manuals in clinical practice has been related to poor knowledge of cognitive aids and the lack of training. Simulation-based training in crisis management, including cognitive aids, is believed to be the most efficacious method. Even previous orientation to mental aid increases the likelihood of its use. The use of cognitive aids has also been reported in the absence of a crisis as a way of training, teaching, or debriefing after a critical event.

There were various opinions regarding who should read the crisis manual during the critical event. Most participants believe that the team leader in a crisis should refrain from reading the cognitive aid themselves. Burden et al. showed that teams that defined the role of a manual reader during a simulated crisis improved their performance during crisis resolution. It would be necessary to study this reader’s role in clinical practice and determine who could assume this role. The usefulness of cognitive aids in crisis management has been widely recognised in simulation settings. The question is whether implementing cognitive aids in clinical practice can change crisis management and whether this change improves patient outcomes.

Written by the Barcelona team

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