Marjorie P. Stiegler

Cognitive processes in anesthesiology decision making

The quality and safety of health care are under increasing scrutiny. Recent studies suggest that medical errors, practice variability, and guideline noncompliance are common, and that cognitive error contributes significantly to delayed or incorrect diagnoses. These observations have increased interest in understanding decision-making psychology.Many nonrational (i.e., not purely based in statistics) cognitive factors influence medical decisions and may lead to error. The most well-studied include heuristics, preferences for certainty, overconfidence, affective (emotional) influences, memory distortions, bias, and social forces such as fairness or blame.Although the extent to which such cognitive processes play a role in anesthesia practice is unknown, anesthesia care frequently requires rapid, complex decisions that are most susceptible to decision errors. This review will examine current theories of human decision behavior, identify effects of nonrational cognitive processes on decision making, describe characteristic anesthesia decisions in this context, and suggest strategies to improve decision making.

Decision-making and safety in anesthesiology.

Purpose of review Anesthesiologists work in a complex environment that is intolerant of errors. Cognitive errors, or errors in thought processes, are mistakes that a clinician makes despite ‘knowing better’. Several new studies provide a better understanding of how to manage risk while making better decisions. Recent findings Heuristics, or mental shortcuts, allow physicians to make decisions quickly and efficiently but may be responsible for errors in diagnosis and treatment. Using simple ‘decision-making checklists’ can help healthcare providers to make the correct decisions by monitoring their own thought processes. Anesthesiologists can adopt risk assessment tools that were originally developed for use by pilots to determine the hazards associated with a particular clinical management strategy. Summary Effective decision-making and risk management reduce the risk of adverse events in the operating room. This article proposes several new decision-making and risk assessment tools for use in the operating room.

Decision-making and cognitive strategies.

“I think, therefore I am” - Rene Descartes“He who knows most, knows best how little he knows.” - Thomas JeffersonThe past decade has seen a considerable increase in interest in understanding the cognitive underpinnings of medical decision making in dynamic acute care arenas. Errors caused by faulty

Effect of a Cognitive Aid on Adherence to Perioperative Assessment and Management Guidelines for the Cardiac Evaluation of Noncardiac Surgical Patients

Background:The 2007 American College of Cardiologists/American Heart Association Guidelines on Perioperative Cardiac Evaluation and Care for Noncardiac Surgery is the standard for perioperative cardiac evaluation. Recent work has shown that residents and anesthesiologists do not apply these guidelines when tested. This research hypothesized that a decision support tool would improve adherence to this consensus guideline. Methods:Anesthesiology residents at four training programs participated in an unblinded, prospective, randomized, cross-over trial in which they completed two tests covering clinical scenarios. One quiz was completed from memory and one with the aid of an electronic decision support tool. Performance was evaluated by overall score (% correct), number of incorrect answers with possibly increased cost or risk of care, and the amount of time required to complete the quizzes both with and without the cognitive aid. The primary outcome was the proportion of correct responses attributable to the use of the decision support tool. Results:All anesthesiology residents at four institutions were recruited and 111 residents participated. Use of the decision support tool resulted in a 25% improvement in adherence to guidelines compared with memory alone (P < 0.0001), and participants made 77% fewer incorrect responses that would have resulted in increased costs. Use of the tool was associated with a 3.4-min increase in time to complete the test (P < 0.001). Conclusions:Use of an electronic decision support tool significantly improved adherence to the guidelines as compared with memory alone. The decision support tool also prevented inappropriate management steps possibly associated with increased healthcare costs.

Local anesthetic systemic toxicity after combined psoas compartment-sciatic nerve block: analysis of decision factors and diagnostic delay.

987 April 2014 H IP fractures are common in elderly individuals, accounting for the majority of fracture-related medical care costs and mortality in patients over the age of 50 yr.1 In the United States, the age-standardized annual incidence of hip fractures is estimated to be 150 to 250 per 100,000 per year, with higher rates observed in women.2 Affected patients often present with multiple comorbidities, posing significant challenges to the anesthesiologist. Peripheral nerve blocks have gained popularity for anesthetic management of procedures involving the lower extremity, both as a complement to general anesthesia and as an alternative to neuraxial anesthesia. Combined psoas compartment–sciatic nerve block (CPCSNB) is a technique used to provide adequate surgical anesthesia to the ipsilateral lower extremity during operative repair of hip fracture.3,4 CPCSNB is theoretically associated with less of the sympathetic blockade and vasodilatation characteristic of neuraxial anesthesia and has successfully been performed in patients with severe aortic stenosis.5 Despite these advantages, CPCSNB is not without risk. The psoas compartment is formed by the psoas muscle, the anterior fascia of the psoas muscle, and the quadratus lumborum posteriorly; it contains the lumbar plexus (ventral rami of L1–4) and is the desired distribution of local anesthetic spread.6 Epidural spread has been reported after psoas compartment blockade, with an incidence of up to 27% in adults and 92% in children depending on the approach used.7–10 Auroy et al.,11 in a major survey of regional anesthesia complications in France, reported one case of cardiac arrest, one case of seizure, and two cases of respiratory failure associated with cephalad diffusion of local anesthetic in the epidural or intrathecal space during psoas compartment blockade. The possibility of intravascular injection or systemic absorption from the epidural venous plexus places the patients at risk for local anesthetic systemic toxicity (LAST). We report a case of LAST after CPCSNB in an elderly patient presenting for operative repair of a hip fracture. The time to onset of LAST signs and symptoms was prolonged, and patient-specific factors confounded the diagnosis. Delayed diagnosis and treatment may have contributed to the patient’s eventual adverse outcome. We discuss the cognitive factors contributing to a delay in LAST diagnosis, with an emphasis on broadly applicable principles of clinical decision making and diagnostic error. A brief review of LAST clinical presentation and treatment is also presented.

A Smartphone-based Decision Support Tool Improves Test Performance Concerning Application of the Guidelines for Managing Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy.

Background:The American Society of Regional Anesthesia and Pain Medicine (ASRA) consensus statement on regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy is the standard for evaluation and management of these patients. The authors hypothesized that an electronic decision support tool (eDST) would improve test performance compared with native physician behavior concerning the application of this guideline. Methods:Anesthesiology trainees and faculty at 8 institutions participated in a prospective, randomized trial in which they completed a 20-question test involving clinical scenarios related to the ASRA guidelines. The eDST group completed the test using an iOS app programmed to contain decision logic and content of the ASRA guidelines. The control group completed the test by using any resource in addition to the app. A generalized linear mixed-effects model was used to examine the effect of the intervention. Results:After obtaining institutional review board’s approval and informed consent, 259 participants were enrolled and randomized (eDST = 122; control = 137). The mean score was 92.4 ± 6.6% in the eDST group and 68.0 ± 15.8% in the control group (P < 0.001). eDST use increased the odds of selecting correct answers (7.8; 95% CI, 5.7 to 10.7). Most control group participants (63%) used some cognitive aid during the test, and they scored higher than those who tested from memory alone (76 ± 15% vs. 57 ± 18%, P < 0.001). There was no difference in time to completion of the test (P = 0.15) and no effect of training level (P = 0.56). Conclusions:eDST use improved application of the ASRA guidelines compared with the native clinician behavior in a testing environment.

What I Learned About Adverse Events From Captain Sully: It’s Not What You Think

This is not a piece about how medicine should take a cue from aviation and incorporate simulations into training. It is not about how medicine should learn from aviation and develop emergency checklists and algorithms. It is not about how medicine should learn from aviation and promote blame-free error reporting. No, it is not even about how medicine should learn from aviation and incorporate briefings, debriefings, and safety language models. Medicine safety culture is experiencing a bit of “aviation fatigue,” and it is often noted that patients are not airplanes. Patients are not airplanes, it is true. But humans are human whether they be pilots, physicians, or patients. And so when folks say a key difference between aviation and medicine is that the pilot goes down with the plane, I beg to differ. The well-being of physicians is directly tied to the well-being of their patients. Earlier last year, I had the pleasure of speaking on the phone with Captain Chesley (Sully) B. Sullenberger III of the now-famous Miracle on the Hudson landing of US Airways Flight 1549 (May 2014). As nearly everyone knows, Captain Sully’s aircraft hit some birds shortly after takeoff, causing the plane to lose power in both engines. Some incredible emergency management ensued, with practically perfect execution by the captain, first officer, cabin crew, and air traffic control. The aircraft touched down in the middle of the Hudson River, close to rescuers, and no one was killed or critically injured. There was no glaring error, no misstep, no panic. By all accounts, this was an incredible save. So why did Captain Sully tell me they “all had PTSD for several months” thereafter? Why, if Captain Sully’s years of experience had all been a cumulative preparation for this most unlikely event, and if he did just about everything right (and quickly), could he not sleep or concentrate for three months? Why did he need medications to control his racing heart and high blood pressure? Why could he not return to the skies for nearly half a year? First Officer Jeff Skiles experienced similar aftermath, according to Sully. According to testimony before Congress, even the air traffic controller Patrick Harten had to be removed immediately from duty and was unable to return to work for about a month and reported only beginning to feel good about that event a full year later. Mr Harten says, “It may sound strange, but for me the hardest part of the event was when it was over. During the event I was hyperfocused ... but when it was over, it hit me hard.”1 Captain Sully shared this sentiment, telling me that he felt in control during the event, and in shock immediately afterward, and the total impact took some time to process. The flight crew also took time away, and one flight crew member with 38 years of experience never returned. I was surprised to know that after a hugely successful demonstration of teamwork and skill, and a landmark safety save, all of the parties involved were so adversely affected. And I was impressed when Captain Sully told me that a coordinated and supportive debriefing was arranged within 24 hours for their flight team and family members, with the purpose of preparing them for emotions and physical responses they might have, and normalizing the post-event experience and timeline for emotional recovery. And then I realized, this is one thing we haven’t yet learned from aviation. No one would have considered pulling Sully or Skiles or the flight crew members out of the river and asking them to head back to La Guardia and fly another leg. Yet in medicine, physicians are generally expected to continue caring for patients, sometimes without even a brief period of time to reflect or regroup. Patients suffer cardiac or respiratory arrests and other emergencies—they even sometimes die—in our operating rooms. And yet many of us feel pressure to get the next case going without delay. This may represent either explicit external pressure from administrators or other team members, internal pressure on ourselves to not appear vulnerable or weak, or a combination. People are different, of course, and not everyone will feel that their care and judgment for subsequent patients are affected by having been part of an emergency just moments before. Some will be impaired and know it, but be powerless to get relief from duty. Some will be impaired but not realize it, and trudge along like good soldiers. Some may truly not be affected at all. But we have some data that physicians and nurses are indeed adversely affected by the emotional turmoil of participating in emergencies, whether the outcome is good or bad, and whether mistakes are made or the execution is perfect. Physicians are twice as likely to kill themselves as the general population,2 and, at least among anesthesiologists, the impact of perioperative critical events is both powerful and lasting. According to one study of anesthesiology physicians, being involved in a perioperative death or similar event caused up to 70% of those surveyed to have symptoms consistent with posttraumatic stress disorder and two-thirds to say that they believed their ability to provide safe patient care subsequently was compromised.3 The impact was so great in fact that nearly 20% said they never A PIECE OF MY MIND

Review of crisis resource management (CRM) principles in the setting of intraoperative malignant hyperthermia.

The practice of medicine is characterized by routine and typical cases whose management usually goes according to plan. However, the occasional case does arise which involves rare catastrophic emergencies, such as intraoperative malignant hyperthermia (MH), which require a comprehensive, coordinated, and resource-intensive treatment plan. Physicians are expected to provide expert quality care for routine, typical cases, but is it reasonable to expect the same standard of expertise and comprehensive management when the emergency involves a rare entity? Although physicians would like to say yes to this question, the reality is that no physician will ever amass the amount of experience in patient care needed to truly qualify as an expert in the management of a rare emergency entity, such as MH. However, physicians can become expert in the global process of managing emergencies by using the principles of crisis resource management (CRM). In this article, we review the key concepts of CRM, using a real life example of a team who utilized CRM principles to successfully manage an intraoperative MH crisis, despite there being no one on the team who had ever previously encountered a true MH crisis.

Catastrophic Events in the Perioperative Setting: A Survey of U.S. Anesthesiologists

Catastrophic events in the perioperative period can adversely impact the wellbeing of the healthcare workers involved. These second victims may experience symptoms including depression, isolation and loss of confidence related to the event. A limited amount of published research suggests those who receive formal support (e.g. departmental debriefing) may have an improved recovery experience. This cross-sectional study was conducted to assess the proportion of U.S. anesthesiologists who have experienced catastrophic perioperative events and bring into focus the association between event details, respondent characteristics and utilization of formal support with recovery time. Additionally, we aimed to ascertain the current state of post-event formal support and opinions for ideal event handling across the anesthesiology practice. A seventeen-question survey was distributed to 5,000 attending anesthesiologist members of the American Society of Anesthesiologists (ASA). 289 responses were received. 85% report having experienced a catastrophic event; greater than 80% of those involved a death. 42% took a few days or less to recover yet 24% took a year or more. 31% had department debriefing and 25% had multidisciplinary debriefing. No association between gender, practice setting, years of experience and recovery time was detected. Comments revealed highly individualized recovery experiences and heterogeneity in processes for post-event debrief. Regarding current, institutional practice: 56% report there is no departmental debriefing team and 16% do not know if such a team exists. 49% feel debriefing should be mandatory. Comments reflect a variety of opinions regarding ideal support. Resources that address the complexities of the recovery experience should be thoughtfully developed and made available to those who may benefit from them.

Clinical error management.

The operating room is a complex environment in which even seemingly insignificant errors can have potentially life-threatening consequences. Ad hoc interprofessional teams with varying levels of training care for patients with multiple comorbidities while they are subjected to a range of physiologic stresses and surgical insults. Patient care in the operating room is a dynamic interaction that requires cooperation among team members and reliance upon sophisticated technology. All members must manage large quantities of rapidly changing information and, ideally, share these data with the rest of the team in an explicit, timely, and contextualized manner. It is, therefore, not surprising that the operating room is home to a large number of adverse events. Schimpff has identified 6 characteristics unique to the perioperative environment that predispose to an error. First, he describes the operating room as a “high-velocity” environment, and as hospitals increasingly rely on surgical volume as a mainstay of economic enterprise, production pressure may increase the likelihood that an error can occur. Second, the patient is usually asleep or sedated and, therefore, cannot be an advocate for his or her own safety (eg, by warning of a drug allergy or by complaining about a pressure point). Third, although there are multiple people working together in the operating room, they rarely function as a true team: each person shares a workspace and overlapping goals, but each has his or her distinct role and works independently. Fourth, in contrast to other safety cultures,