Qual Saf Health Care 2005 Runciman e1
Transcript of Qual Saf Health Care 2005 Runciman e1
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ORIGINAL ARTICLE
Crisis management during anaesthesia: the development ofan anaesthetic crisis management manual
W B Runciman, M T Kluger, R W Morris, A D Paix, L M Watterson, R K Webb. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
See end of article forauthors affiliations. . . . . . . . . . . . . . . . . . . . . . .
Correspondence to:Professor W B Runciman,President, AustralianPatient Safety Foundation,GPO Box 400, Adelaide,
South Australia 5001,Australia; [email protected]
Accepted 10 January 2005. . . . . . . . . . . . . . . . . . . . . . .
Qual Saf Health Care 2005;14:e1 (http://www.qshc.com/cgi/content/full/14/3/e1). doi: 10.1136/qshc.2002.004101
Background: All anaesthetists have to handle life threatening crises with little or no warning. However,some cognitive strategies and work practices that are appropriate for speed and efficiency under normalcircumstances may become maladaptive in a crisis. It was judged in a previous study that the use of astructured core algorithm (based on the mnemonic COVER ABCDA SWIFT CHECK) would diagnoseand correct the problem in 60% of cases and provide a functional diagnosis in virtually all of the remaining40%. It was recommended that specific sub-algorithms be developed for managing the problemsunderlying the remaining 40% of crises and assembled in an easy-to-use manual. Sub-algorithms weretherefore developed for these problems so that they could be checked for applicability and validity againstthe first 4000 anaesthesia incidents reported to the Australian Incident Monitoring Study (AIMS).Methods: The need for 24 specific sub-algorithms was identified. Teams of practising anaesthetists wereassembled and sets of incidents relevant to each sub-algorithm were identified from the first 4000 reportedto AIMS. Based largely on successful strategies identified in these reports, a set of 24 specific sub-
algorithms was developed for trial against the 4000 AIMS reports and assembled into an easy-to-usemanual. A process was developed for applying each component of the core algorithm COVER at one offour levels (scan-check-alert/ready-emergency) according to the degree of perceived urgency, andincorporated into the manual. The manual was disseminated at a World Congress and feedback wasobtained.Results: Each of the 24 specific crisis management sub-algorithms was tested against the relevant incidentsamong the first 4000 reported to AIMS and compared with the actual management by the anaesthetist atthe time. It was judged that, if the core algorithm had been correctly applied, the appropriate sub-algorithm would have been resolved better and/or faster in one in eight of all incidents, and would havebeen unlikely to have caused harm to any patient. The descriptions of the validation of each of the 24 sub-algorithms constitute the remaining 24 papers in this set. Feedback from five meetings each attended by60100 anaesthetists was then collated and is included.Conclusion: The 24 sub-algorithms developed form the basis for developing a rational evidence-basedapproach to crisis management during anaesthesia. The COVER component has been found to besatisfactory in real life resuscitation situations and the sub-algorithms have been used successfully for
several years. It would now be desirable for carefully designed simulator based studies, using naivetrainees at the start of their training, to systematically examine the merits and demerits of various aspects ofthe sub-algorithms. It would seem prudent that these sub-algorithms be regarded, for the moment, asdecision aids to support and back up clinicians natural responses to a crisis when all is not progressing asexpected.
All anaesthetists have to manage life threatening crises
which may arise with little or no warning.14 Indeed,
with a risky procedure in a sick patient, much of the
working day may be spent preventing and heading off
potential crises. Anaesthetists manage the vast majority of
these complex problems promptly and efficiently with skilled
pattern recognition and frequently practised clinical routines.
However, high profile cases documented in the lay press fromaround the world indicate that these patterns of response do
not always lead to the resolution of problems.5 Attention has
been focused worldwide on the safety of health care and the
ways in which it may be enhanced. Working groups from
several countries including the USA,6 UK,7 and Australia8
have produced documents outlining plans for improving the
safety of health care. This set of 25 articles outlines a
structured approach for when things are going wrong during
anaesthesia.932 Prevention is, of course, better than cure.
However, prevention (for example, appropriate preoperative
assessment, checking and planning) is not the intent of this
set of articles.
As indicated above, situations do arise during which
patient safety is compromised when the usual measures
have been or are being taken. This is the context in which an
incident report may be submitted. The Australian Incident
Monitoring Study (AIMS) was started in 1988.33 In 1993 a
symposium issue reviewing the first 2000 incidents was
published in the journal Anaesthesia and Intensive Care.34 The
symposium consisted of 30 papers looking at various aspectsof anaesthetic incidents. These included clinical crises and
adverse events (such as anaphylaxis, difficult intubation,
cardiac arrest, the wrong drug problem), assessments of the
applications and limitations of physiological monitors (for
example, the pulse oximeter, the electrocardiograph, the
capnograph), and an evaluation of the factors involved in the
generation and resolution of these incidents. In seven out of
every eight incidents which arose when patients were
breathing gas from an anaesthetic machine, the anaesthetists
involved recognised the problem and responded appropri-
ately.4 However, in one out of every eight it was considered by
an AIMS panel of reviewers that the application of a simple
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learned routine, properly applied, would have expedited the
diagnosis and/or led to an appropriate response more
rapidlyand often more effectively.4 This is because pre-
viously learned and intuitive strategies and work practices
which have evolved for speed and efficiency under normal
working conditions may fail to adjust in a crisis.35 Use of such
pre-compiled responses is consistent with the rapid
phase learned responses to some crises in aviation, nuclear
plant operation, community rescue organisations, and
military command, many of which are routinely tested in
simulation situations.
2
These findings suggested that there is a place for defaulting
to a simple structured routine when the anaesthetist is
uneasy that all may not be what it seems to be, when the
situation is deteriorating, or when an adverse outcome seems
likely. It is well recognised within the field of human error
and safety that the use of simple succinct guidelines and
protocols reduces the burden on the individuals involved and
allows their limited available cognitive resource to be used for
essential immediate tasks.36 37 Some of the principles under-
lying this structured approach have been dealt with in a
companion paper.35
THE COVERABCD A SWIFT CHECK COREAL GO RI TH M
After considering a number of alternatives, it was generallyagreed after a series of three meetings, each attended by 60
100 anaesthetists, that a core algorithm should form the
basis for the management of any crisis in which the
anaesthetist was uncertain of the exact cause or which was
not going exactly as expected.4 A common starting sequence
for all crises was thought to be essential because it was
recognised that it is very difficult to recover from a mind
set that a particular problem is being faced when, in fact,
the problem is a different one requiring a completely different
solution.
Such a core algorithm was devised based on the mnemonic
COVER ABCDA SWIFT CHECK which is suitable for use
when any patient is undergoing general or regional anaes-thesia. The original version, which was available on two sides
of a single laminated sheet, is shown in tables 1 and 2. When
the manual which resulted from this set of 25 articles was
compiled, more detailed instructions were made available
about aspects of this core algorithm (see figs 1 and 2). The
use of the traditional cardiac arrest mnemonic ABCD was
considered but it was thought that it would miss some
dangerous problems related to the surgery, the use of the
anaesthetic machine, and ancillary equipment which would
require immediate resolution; this is discussed in the last
section of this paper.
The initial component, COVERwhich addresses problems
arising from circulatory compromise, the gas supply, the
anaesthetic machine, the breathing circuit, the ventilator and
the endotracheal tubehas been validated against the 1301relevant incidents under general anaesthesia amongst the
first 2000 reported to AIMS.4 It was found that just under
Table 1 Crisis management algorithm memorise and practise: an explanation of eachcue in the mnemonic COVER ABCD
C1 Circulation Establish adequacy of peripheral circulation (rate, rhythm and character of pulse). Ifpulseless, institute cardiopulmonary resuscitation (CPR). The core algorithm must stillbe completed as soon as possible.
C2 Colour Note saturation. Examine for evidence of central cyanosis. Pulse oximetry is superiorto clinical detection and is recommended. Test probe on own finger, if necessary,whilst proceeding with O1 and O2.
O1 Oxygen Check rotameter settings, ensure inspired mixture is not hypoxic.O2 Oxygen analyser Adjust inspired oxygen concentration to 100% and note that only the oxygen
flowmeter is operating. Check that the oxygen analyser shows a rising oxygenconcentration distal to the common gas outlet.
V1 Ventilation Ventilate the lungs by hand to assess breathing circuit integrity, airway patency, chestcompliance and air entry by feel and careful observation and auscultation. Alsoinspect capnography trace.
V2 Vaporiser Note settings and levels of agents. Check all vaporiser filler ports, seatings andconnections for liquid or gas leaks during pressurisation of the system. Consider thepossibility of the wrong agent being in the vaporiser.
E1 Endotracheal tube Systematically check the endotracheal tube (if in use). Ensure that it is patent with noleaks or kinks or obstructions (see suggested protocol in Anaesth Intensive Care1993;21:615). Check capnograph for tracheal placement and oximeter for possibleendobronchial position. If necessary, adjust, deflate cuff, pass a catheter, or removeand replace.
E2 Elimination Eliminate the anaesthetic machine and ventilate with self-inflating (e.g. Air Viva) bagwith 100% oxygen (fro m alternative source if necessary). Retain gas monitor samplingport (but be aware of possible problems).
R1 Review monitors Review all monitors in use (preferably oxygen analyser, capnograph, oximeter, bloodpressure, electrocardiograph (ECG), temperature and neuromuscular junctionmonitor). For proper use, the algorithm requires all monitors to have been correctlysited, checked and calibrated.
R2 Review equipment Review all other equipment in contact with or relevant to the patient (e.g. diathermy,humidifiers, heating blankets, endoscopes, probes, prostheses, retractors and other
appliances).A Airway Check patency of the unintubated airway. Consider laryngospasm or presence of
foreign body, blood, gastric contents, nasopharyngeal or bronchial secretions.B Breathing Assess pattern, adequacy and distribution of ventilation. Consider, examine and
auscultate for bronchospasm, pulmonary oedema, lobar collapse and pneumo- orhaemothorax.
C Circulation Repeat evaluation of peripheral perfusion, pulse, blood pressure, ECG and fillingpressures (where possible) and any possible obstruction to venous return, raisedintrathoracic pressure (e.g. inadvertent PEEP) or direct interference to (e.g. stimulationby central line) or tamponade of the heart. Note any trends on records.
D Drugs Review intended (and consider possible unintended) drug or substance administration.Consider whether the problem may be due to unexpected effect, a failure ofadministration or wrong dose, route or manner of administration of an intended orwrong drug. Review all possible routes of drug administration.
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60% of these problems had arisen from these sources and
that COVER, correctly applied, would have provided a
functional diagnosis and an appropriate response in virtuallyall the cases in 4060 seconds.4 Subsequent users and many
case presentations at audits have confirmed that COVER can
be rapidly performed and is reliable.
If the remainder of the algorithm had been used (ABCDA
SWIFT CHECK), it was considered that, correctly applied, a
functional diagnosis would have been obtained in 99% of
these incidents. However, unlike the COVER component, the
ABCDA SWIFT CHECK component is largely a diagnostic
checklist. The anaesthetist would still have to handle the 40%
of problems remaining after COVERthat is, those arising
from the patient or from patient/doctor/procedure/drug
interactions. To do this the anaesthetist may work from first
principles, employ pattern recognition and learned sequences
or, failing this, apply one of a set of prescribed sub-
algorithms. Experience from audits of anaesthetic practiceand ongoing review of AIMS forms has confirmed that it
would be desirable for there to be a basic set of structured
sub-algorithms to handle the problems arising from these
sources when the problem is not immediately resolved, as on
many occasions the management described constitutes a
considerable departure from what would generally be
regarded as currently accepted practice. The development of
the 24 sub-algorithms deemed necessary is described in the
other articles in this series as shown in table 3.932
How this was done is presented below. However, first, the
issue of how to use the COVER component of the core
algorithm is discussed in more detail.
HOW TO USE COVERAn important issue to arise from discussions about the core
algorithm was the question as to when and how it should beinvoked. The majority of potential incidents are recognised
early in their evolution and are headed off by appropriate
responses on the part of the anaesthetist. Of those events that
actually moved an anaesthetist to fill in an incident report,
seven out of eight were correctly recognised and promptly
handled; for these, pattern recognition was clearly successful
and the use of COVER was unnecessary, and would
potentially have been more time consuming and disruptive
than the initial response.
How should the anaesthetist recognise when the situation
justifies invoking the full set of actions required by COVER?4
It is obvious, for example, that it is not worth getting rid of
the anaesthetic machine when the saturation falls from 98%
to 94% over 10 minutes. However, it is equally obvious that
COVER should be invoked in full if a patient is suddenlyfound pulseless and cyanosed with slow wide QRS complexes
on the electrocardiogram.
SCAREA solution to this problem lies in grading the application of
each component of COVER into four levels represented by the
mnemonic SCARE, depending on the degree of perceived
urgency (Scan-Check-Alert/Ready-Emergency). These are
shown in figs 36.
The various levels of each component of COVER should be
used in combinations deemed appropriate for the situation.
This provides great flexibility and appropriateness of response
Table 2 A SWIFT CHECK (the checklist arising from the mnemonic need not bememorised but should be immediately available in the operating theatre)
Condition Comments
A Air embolus Hypotension, hypocarbiaA Ana phylaxis Hypo tensio n, broncho spas m, u rti cariaA Air in pleura Pneumothorax, any unexpected circulatory or respiratory deteriorationA Awareness Consider dilut ion of anaesthet ic gases, resistant pat ient S Surgeon/situation Vagal stimulation, caval compression, bleeding, direct myocardial
stimulationS Sepsis H ypot en sion, desat urat ion, acidosis, hy perdynamic c ircu la tion
W W ound T rauma, b leeding, t amponade, pneumoth orax, problems due t oretractorsW Water intoxicat ion E lectrolyte disturbance, f luid overloadI Infarct M yocardia l c on duct ion or rhy thm problem, hy potension, poor c ardiac
outputI Insufflat ion Vagal tone, reduced venous return, pulmonary venous or paradoxical
arterial gas embolismF Fat syndrome Desaturation and/or hypotension, especially after induction and in the
lithotomy position including distended abdomen for any causeF Ful l bladder May cause marked haemodynamic changes and/or sympathet ic
stimulationT T rauma C on sider spina l injury, undiagn osed sub- or d iaphragmatic injury,
ruptured viscusT Tourniquet down Local anaesthet ic toxicity or unseen bleedingC Catheter/IV cannula/chest drain
problemsLeaks, failure to deliver, wrong drug or label, obstructed, wrongconnected, wrong rate
C Cement Haemodynamic change with methylmethacrylateH Hyperthermia (hypothermia) Tachycardia and hypercarbia/ECG changes, (poor perfusion, ECG
changes)H Hypoglycaemia Consider inappropriate or inadvertent insulin preoperatively, fasting and
beta blockers, hepatic compromise and beta blockersE Embolus Fat, thrombus, amniotic f luid; hypotension, hypocarbia, ECG changesE Endocrine Hyperthyroid or hypothyroid/adrenal medul lar or cortex/pituitary/
diabetes/5-HTC Check Right patient, right operation, right surgeonC C heck C ase n ot es, preoperat ive s ta tus, preoperat ive drugs, preoperat ive
diseasesK K+ Potassium and any other electrolyte abnormality (hyper or hypo),
ECG changes, CNS signsK K eep Ke ep the pati ent asleep unti l a new anae sthetic machine can be
obtained (e.g. diazepam, ketamine)
If the problem has not been solved, direct the available resources to its solution. Get skilled and experienced help. Workfrom first principles.
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while still reducing the cognitive load for the anaesthetist. It
can be argued that COVER is no longer an algorithm when
different actions can be taken, depending on circumstances,
and that it should more properly be called a cognitive aid,
encouraging the use of various pre-compiled responses.
However, for the sake of simplicity, we will continue to use
the term algorithm for this set of articles.The use of the SCAN level every 5 minutes during each
case (fig 3) and of the CHECK level at regular intervals (fig 4)
also overcomes the problem of regular formal training being
required for the effective use of the core crisis management
algorithm. Commercial jet airline pilots are required to
undertake simulator sessions and be accredited every
3 months. However, to introduce this for every practising
anaesthetist, whilst desirable, is not feasible at the moment,
especially in developing countries.
In general, the slower and less serious the deviations from
normal and the more monitoring and other information
available, the less likely it will be that the EMERGENCY
mode of COVER will need to be used. However, in
circumstances in which the situation is obscure or not readily
apparent due to opaque or non-specific signs, or is progress-
ing rapidly, there should be no hesitation in invoking the
algorithm to the full. In contexts in which no monitors are
available, it is likely that the full application of the
EMERGENCY mode of COVER would be much morefrequently invoked.39
For those who have practised using COVER in this way,
appropriate responses may rapidly be achieved while the
anaesthetist is confident that the majority of possible
contingencies have been accounted for. This knowledge is
valuable for trainees who have not yet fully developed their
pattern recognition and clinical response routines, for any
anaesthetist who encounters a novel situation, when all is
not going well, or when there is likely to be an adverse
outcome. In this last context, the anaesthetist can proceed
with handling the problem to the best of his or her ability,
taking some comfort in the knowledge that any independent
T h e m n e m o n i c s e r v e s a s a r e m i n d e r t o a l w a y s c y c l e s y s t e m a t i c a l l y
t h r o u g h a b a s i c s e r i e s o f t h o u g h t s a n d a c t i o n s , t h e i n t e n s i t y o f w h i c h
w i l l d e p e n d o n t h e c i r c u m s t a n c e s . T h i s s e r i e s o f t h o u g h t s a n d
a c t i o n s i s :
C
O
V
E
R
A
B
C
D
A
S W I F T C H E C K o f p a t i e n t , s u r g e o n , p r o c e s s , a n d r e s p o n s e s .
T h e f o u r l e v e l s o f i n t e n s i t y f o r e a c h o f t h e s e c o m p o n e n t s a r e
r e p r e s e n t e d b y a n o t h e r m n e m o n i c - S C A R E ( S C A N , C H E C K ,
A L E R T / R E A D Y , E M E R G E N C Y ) a n d c o m p r i s e p a g e s 4 t o 1 1 * o f t h i s
m a n u a l .
T h e S C A N s e q u e n c e s h o u l d b e f o l l o w e d e v e r y 5 m i n u t e s o f a n y
a n a e s t h e t i c , o r m o r e o f t e n i f n e c e s s a r y . T h i s o v e r c o m e s t h e n e e d f o r
s p e c i a l t r a i n i n g s e s s i o n s , a s t h e s e q u e n c e r a p i d l y b e c o m e s s e c o n d
n a t u r e a n d c a n u s u a l l y b e c o m p l e t e d i n 4 0 - 6 0 s e c o n d s . T h e C H E C K
s e q u e n c e s h o u l d b e u s e d w h e n e v e r a l l i s n o t g o i n g a c c o r d i n g t o
p l a n , a n d s h o u l d a l s o b e p r a c t i s e d r e g u l a r l y .
D o n o t h e s i t a t e t o m o v e o n t o t h e A L E R T / R E A D Y a n d E M E R G E N C Y
s e q u e n c e s i f y o u a r e w o r r i e d , i f e v e n t s a r e m o v i n g q u i c k l y , o r i f i t
s e e m s t h a t a n a d v e r s e o u t c o m e i s p o s s i b l e . T h e s e s h o u l d a l s o b e
p r a c t i s e d f r o m t i m e t o t i m e .
* P a g e r e f e r e n c e s r e f e r t o t h e C r i s i s M a n a g e m e n t M a n u a l .
3 8
W H E N A N D H O W T O U S E T H I S M A N U A L
T h e m a n u a l i s b a s e d o n t h e m n e m o n i c C O V E R A B C D A S W I F T
C H E C K a n d i s d e s i g n e d f o r u s e w h e n a n y p a t i e n t i s u n d e r g o i n g
g e n e r a l o r r e g i o n a l a n a e s t h e s i a . T h e s e q u e n c e b e c o m e s A B C O V E R
C D A S W I F T C H E C K w h e n t h e p a t i e n t i s b r e a t h i n g s p o n t a n e o u s l y ,
a n d s o m e c o m p o n e n t s b e c o m e r e d u n d a n t i n c e r t a i n c i r c u m s t a n c e s ;
e x a m p l e s a r e g i v e n a t t h e e n d o f t h i s s e c t i o n .
D e p e n d i n g o n t h e c i r c u m s t a n c e s , c o m p o n e n t s o f e a c h l e v e l o f
S C A R E m a y b e a s s e m b l e d a s a p p r o p r i a t e , a s l o n g a s t h e s e q u e n c e
o f C O V E R i s a l w a y s a d h e r e d t o . F o r e x a m p l e , w i t h s u d d e n , s e v e r e
h y p e r t e n s i o n , i f t h e f i r s t f o u r c o m p o n e n t s o f C O V E R ( C i r c u l a t i o n ,
C o l o u r , O x y g e n , O x y g e n A n a l y s e r ) a r e s t a b l e a n d n o r m a l a t t h e
S C A N l e v e l , n o f u r t h e r a c t i o n i s r e q u i r e d f o r t h e s e . H o w e v e r , i t
w o u l d b e d e s i r a b l e t o u s e t h e C H E C K l e v e l f o r t h e V e n t i l a t i o n ,
V a p o r i s e r , R e v i e w m o n i t o r s , a n d R e v i e w e q u i p m e n t c o m p o n e n t s o f
C O V E R , f o r t h e C ( C i r c u l a t i o n ) a n d D ( D r u g s ) c o m p o n e n t s o f A B C D ,
f o r t h e A ( f o r A w a r e n e s s ) a n d f o r S W I F T C H E C K ( e s p e c i a l l y w i t h
r e s p e c t t o w h a t t h e s u r g e o n i s d o i n g ) . H y p e r t e n s i o n a n d a w a r e n e s s
a r e t w o c i r c u m s t a n c e s i n w h i c h t h e c o n c e n t r a t i o n o f v o l a t i l e a g e n t
m a y b e i n c r e a s e d - f o r m o s t c r i s e s i t i s l e f t a l o n e a t t h e S C A N a n d
C H E C K l e v e l s a n d t u r n e d o f f a t t h e R E A D Y / A L E R T a n d E M E R G E N C Y
l e v e l s .
O n t h e o t h e r h a n d , i f , f o r e x a m p l e , i t i s s u d d e n l y n o t i c e d t h a t t h e
p a t i e n t i s p u l s e l e s s a n d b l u e , t h e f u l l E M E R G E N C Y s e q u e n c e o f
C O V E R s h o u l d b e c a r r i e d o u t i m m e d i a t e l y w i t h p r o g r e s s i o n t o a n y
a p p r o p r i a t e s u b - a l g o r i t h m s .
I t i s i m p o r t a n t t h a t t h e b a s i c C O V E R A B C D s e q u e n c e i s f o l l o w e d
b e f o r e b e c o m i n g f o c u s e d o n a n y p a r t i c u l a r s u b - a l g o r i t h m ; a m a j o r
p r o b l e m i s l o c k i n g o n t o a d i a g n o s i s w h i c h m a y n o t b e c o r r e c t .
W h e n a s s i s t a n c e i s c a l l e d f o r , o n e p e r s o n s h o u l d r e p e a t e d l y c y c l e
t h r o u g h t h e C O V E R A B C D s e q u e n c e a n d c o n s i d e r o t h e r p o s s i b i l i t i e s ,
w h i l s t t h e s t e p s i n a n y r e l e v a n t s u b - a l g o r i t h m s a r e f o l l o w e d . S o m e
s u b - a l g o r i t h m s r e p e a t c o m p o n e n t s o f C O V E R ( e . g . g i v e 1 0 0 %
o x y g e n ) , u s u a l l y w h e n t h e e n t i r e s e q u e n c e d o e s n o t n e c e s s a r i l y
h a v e t o b e f o l l o w e d i n f u l l a t t h e o u t s e t , w h e r e a s o t h e r s s t a r t b y
i n s t r u c t i n g a n a e s t h e s i o l o g i s t s t o e n s u r e t h a t t h e f u l l C O V E R s e q u e n c e
h a s b e e n c o m p l e t e d b e f o r e s t a r t i n g t h e s u b - a l g o r i t h m ( e . g . t h a t f o r
p e r s i s t e n t d e s a t u r a t i o n , o r a i r e m b o l i s m ) .
A l t h o u g h t h e s t a n d a r d C O V E R A B C D A S W I F T C H E C K s e q u e n c e
s h o u l d a l w a y s b e f o l l o w e d , s o m e c o m p o n e n t s b e c o m e l e s s
i m p o r t a n t o r r e d u n d a n t u n d e r p a r t i c u l a r c i r c u m s t a n c e s : f o r
i n t u b a t e d , v e n t i l a t e d p a t i e n t s t h e A a n d B a f t e r C O V E R b e c o m e
r e d u n d a n t ; f o r p a t i e n t s b r e a t h i n g s p o n t a n e o u s l y v i a a m a s k , A a n d
B p r e c e d e C O V E R , a s i n d i c a t e d a t t h e s t a r t o f t h i s s e c t i o n , a n d V f o r
V e n t i l a t i o n b e c o m e s r e d u n d a n t ; f o r a p a t i e n t b e i n g v e n t i l a t e d v i a a
l a r y n g e a l m a s k , B b e c o m e s r e d u n d a n t ; a n d f o r a p a t i e n t b r e a t h i n g
s p o n t a n e o u s l y a n d r e c e i v i n g o x y g e n f r o m a s o u r c e i n d e p e n d e n t o f
a n a n a e s t h e t i c m a c h i n e ( e . g . f r o m a w a l l m o u n t e d f l o w m e t e r d u r i n g
r e g i o n a l o r i n t r a v e n o u s a n a e s t h e s i a ) , t h e V a n d E o f C O V E R
b e c o m e r e d u n d a n t .
C i r c u l a t i o n , C a p n o g r a p h , a n d C o l o u r ( s a t u r a t i o n )
O x y g e n s u p p l y a n d O x y g e n a n a l y s e r
V e n t i l a t i o n ( i n t u b a t e d p a t i e n t ) a n d V a p o r i s e r s
E n d o t r a c h e a l t u b e a n d E l i m i n a t e m a c h i n e
R e v i e w m o n i t o r s a n d R e v i e w e q u i p m e n t
A i r w a y ( w i t h f a c e o r l a r y n g e a l m a s k )
B r e a t h i n g ( w i t h s p o n t a n e o u s v e n t i l a t i o n )
C i r c u l a t i o n ( i n m o r e d e t a i l t h a n a b o v e )
D r u g s ( c o n s i d e r a l l g i v e n o r n o t g i v e n )
B e A w a r e o f A i r a n d A l l e r g y - p a g e 4 *
Figure 1 Introduction to the Crisis Management Manual.
4 of 12 Runciman, Kluger, Morris, et al
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retrospective review must find that the appropriate responses
had been made for over 99% of the spectrum of problems
reported to AIMS.
The SCARE algorithms have been incorporated into the
Crisis Management Manual developed from this set of 25
articles.38 There has been considerable feedback that the use
of this SCARE-based graded response has proved to be quite
satisfactory for those who have decided to use the manual as
it is. However, the concept of using such a highly structured
graded response does not have universal acceptance. Someprefer to remember the COVER algorithm only for emergency
use when pattern recognition appears to have failed. Also,
while the SCAN routine of the COVER mnemonic is perfectly
satisfactory, some clinicians prefer their own SCAN routine
based on local circumstances and their own equipment setup.
It is recognised that complexity can cause errors13 and that
reducing choice, reducing the number of steps required, and
ensuring that the duration of execution is as short as possible
all assist in reducing the complexity of a system. However,
this should not be at the cost of ensuring safety. There is a
trade-off between relying on pattern recognition and using
the highly structured approach represented in the Crisis
Management Manual by the SCARE sequence. The challenge
is to cover all contingencies while retaining as simple a set of
responses as possible. It is likely that COVER will be refined
with more use; there are advantages to defaulting to a
standard sequence of actions when people have to work in
teams in a crisis.36
ABCDA SWIFT CHECKThe rationale for the use of sub-algorithms for the ABCDA
SWIFT CHECK portion of the mnemonic is the same as that
which underpins the use of the core algorithm for the first
part (COVER). Complex problems may be manifested by non-
specific cues in circumstances in which a minor transgression
or a delay in taking corrective measures might have serious
consequences. For example, of 179 incidents first detected by
oximetry and thus having manifested as desaturation, just
under three quarters (represented by nine clinical situa-
tions including dangerous problems requiring rapid resolu-
tion such as hypoxic gas mixture and undetected oesophageal
intubation) were handled by COVER.4 3 9 4 0 However, over one
quarter fell into the ABCDA SWIFT CHECK portion of the
algorithm. These were represented by 12 clinical situations,
some of which had relatively rare or obscure causes but
required rapid diagnosis and a prompt responsefor
example, anaphylaxis, air embolism, tension pneumothorax,
pulmonary oedema. In some of these cases the correctdiagnosis was missed for a prolonged time. With such an
array of possibilities it is too time consuming to work from
first principles. In such circumstances, if the problem is not
resolved immediately by actions based on pattern recogni-
tion, the use of a carefully validated prescribed algorithm is
safer and more reliable than trying to work out what the
problem is, and what to do about it, from first principles.
Early on, a number of anaesthetists commented that they
found the use of A SWIFT CHECK as a mnemonic, as shown
in table 2, to be contrived and unhelpful. It was therefore
replaced as follows. Firstly, the sentence Be Aware of Air
and Allergy was suggested as a reminder for what the As in
S O M E F I N A L T I P S
R E M E M B E R : A l w a y s g o t h r o u g h C O V E R A B C D f o r v e n t i l a t e d
p a t i e n t s a n d A B C O V E R C D f o r s p o n t a n e o u s l y b r e a t h i n g p a t i e n t s
f o l l o w e d i n e a c h i n s t a n c e b y A S W I F T C H E C K . I t w i l l b e o b v i o u s i n
a n y p a r t i c u l a r c i r c u m s t a n c e w h i c h c o m p o n e n t s b e c o m e r e d u n d a n t .
R E M E M B E R : R e q u e s t a s s i s t a n c e e a r l y o n , a l l o c a t e t a s k s a n d
c a l m l y c o o r d i n a t e a c t i v i t i e s , r e p e a t e d l y c y c l i n g t h r o u g h C O V E R a s
w e l l a s a n y s u b - a l g o r i t h m / s t h o u g h t t o b e a p p r o p r i a t e .
R E G I O N A L A N A E S T H E S I A
T h e r e a r e t w o d i f f e r e n c e s w i t h r e g i o n a l a n a e s t h e s i a .
1 A t t h e A f o r A w a r e n e s s s t a g e o f A S W I F T C H E C K : i f t h e p a t i e n t
i s s e d a t e d o r c o n s c i o u s , t a l k t o t h e p a t i e n t , a n d , i f c o n c e r n e d ,
a s k h o w t h e y a r e f e e l i n g .
2 A t t h e C H E C K l e v e l o f A S W I F T C H E C K : c h e c k t h e q u a l i t y a n d
e x t e n t o f a n y b l o c k , a n d c o r r e l a t e t h e e s t i m a t e d e x t e n t o f
s y m p a t h e t i c b l o c k a d e w i t h a n y c a r d i o v a s c u l a r s e q u e l a e .
A B B R E V I A T I O N S :
M o n i t o r s
E T C O
2
F I O
2
S p O
2
B P
E C G
C i r c u l a t i o n
V F
V T
A i r w a y
E T T
L M A
B r e a t h i n g
I P P V
P E E P
C P A P
A R D S
L A Y O U T O F T H E M A N U A L : T h e i m m e d i a t e s e q u e n c e s o f
t h o u g h t s a n d a c t i o n s a r e s h o w n o n t h e r i g h t h a n d p a g e s .
R e f e r e n c e s t o o n g o i n g c a r e a n d f u r t h e r d e t a i l s a r e o n t h e r e v e r s e
s i d e s o f t h e s e p a g e s . T h i s w i l l a l l o w s i n g l e p a g e s t o b e r e p l a c e d a s
s u b - a l g o r i t h m s a r e u p d a t e d .
E n d t i d a l c a r b o n d i o x i d e c o n c e n t r a t i o n
O x y g e n f r a c t i o n o f t h e i n s p i r e d g a s
P u l s e o x i m e t e r s a t u r a t i o n r e a d o u t
B l o o d p r e s s u r e
E l e c t r o c a r d i o g r a m
V e n t r i c u l a r f i b r i l l a t i o n
V e n t r i c u l a r t a c h y c a r d i a
E n d o t r a c h e a l t u b e
L a r y n g e a l m a s k a i r w a y
I n t e r m i t t e n t p o s i t i v e p r e s s u r e v e n t i l a t i o n
P o s i t i v e a n d e x p i r a t o r y p r e s s u r e
C o n t i n u o u s p o s i t i v e a i r w a y p r e s s u r e
A d u l t r e s p i r a t o r y d i s t r e s s s y n d r o m e .
Figure 2 Final instructions and abbreviations for the CrisisManagement Manual.
Table 3 Papers in Crisis Management series
A Obstruction of th e natural airway9
A Laryngospasm10
A Regurgitation, vomiting and aspi ration11
A Difficult intubation12
B Desaturation13
B Bronchospasm14
B Pulmonary oedema15
C Bradycardia16
C Tachycardia17
C Hypotension18
C Hypertension19
C Myocardial ischaemia20
C Cardiac arrest21
D Problems associated with drug administration during anaesthesia22
A Awareness23
A Embolism24
A Pneumothorax25
A Anaphylaxis and allergy26
* Vascular access problems27
* Trauma: development of a sub-algorithm28
* Sepsis29
* Water intoxication30
* Crisis management during regional anaesthesia31
* Recovering from a crisis32
The 24 sub-algorithms are described in this set of articles. These arerepresented by ABCD (A - Airway; B - Breathing; C - Circulation; D -Drugs), A(the four As be Aware of Air (embolism or in the pleura) and
Allergy), SWIFT CHECK(*miscellaneous problems such as vascular access
problems, trauma, sepsis, water intoxication, problems arising duringregional anaesthesia, and recovering from a crisis). Additional problemssuch as endocrine, electrolyte and metabolic problems (includingmalignant hyperthermia) are also dealt with in the manual.
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ASWIFT CHECK stand for (Michael Burt, personal commu-
nication). Each A in this sentence acts as a reminder for two
things: Awareness in the patient and as an exhortation to the
anaesthetist to be Aware; Air for Air (and other) embolism
and for Air in the pleural space (pneumothorax); and Allergy
to act as a reminder for Allergic reactions and Anaphylaxis
(see table 3).
Secondly, it was suggested that the SWIFT CHECK should
now be taken simply as a reminder for a swift check during
the normal 5 minute scan of the surgeons, assistants,
nurses and orderlies activities and of the operative site, a
quick consideration of the pattern of physiological change
revealed by the monitors, and a mental review of the
patients history and preoperative status.4 The conditions
listed under SWIFT CHECK in table 2 have been dealt with in
some of the companion papers (see asterisks in table 3) and
in some additional algorithms in the Crisis Management
Manual.38
T h e c o l u m n o n t h e l e f t l i s t s , i n t h e o r d e r o f t h e m n e m o n i c ,
w h a t s h o u l d b e s c a n n e d . T h i s w i l l c o m p r i s e a f a c i n g p a g e
o f t h e m a n u a l . N o t e s c o r r e s p o n d i n g t o t h e n u m b e r s i n
p a r e n t h e s e s w i l l b e o n t h e r e v e r s e s i d e .
S C A N a s n e e d e d , o r e v e r y 5 m i n u t e s
C i r c u l a t i o n : N o t e t h e r a t e , r h y t h m a n d v o l u m e o f t h e p u l s e a n d n o t e
t h e e n d t i d a l c a r b o n d i o x i d e c o n c e n t r a t i o n ( E T C O
2
) ( 1 ) * .
C o l o u r : N o t e t h e c o l o u r o f t h e p a t i e n t s m u c o u s m e m b r a n e s a n d
b l o o d a n d n o t e t h e s a t u r a t i o n r e a d i n g o f t h e o x i m e t e r ( S p O
2
) .
O x y g e n : N o t e t h e r o t a m e t e r s e t t i n g s a n d t h a t t h e b o b b i n s a r e
s p i n n i n g a n d c a l c u l a t e t h e i n s p i r e d o x y g e n f r a c t i o n ( F I O
2
) ( 2 ) .
O x y g e n A n a l y s e r : N o t e t h a t t h e r e a d o u t m a t c h e s t h a t e x p e c t e d i n
t h e i n s p i r a t o r y l i m b o f t h e b r e a t h i n g c i r c u i t . C a l i b r a t e i f n e c e s s a r y .
V e n t i l a t i o n : N o t e t h e p a t i e n t s c h e s t m o v e m e n t s . C o r r e l a t e t h e s e
w i t h t h e c a p n o g r a p h , b r e a t h i n g c i r c u i t p r e s s u r e s a n d t i d a l v o l u m e s .
V a p o r i s e r s : N o t e t h e v a p o r i s e r s e t t i n g s o n a l l v a p o r i s e r s a n d t h e
v o l a t i l e a g e n t l i q u i d l e v e l o n t h e v a p o r i s e r i n u s e .
E n d o t r a c h e a l t u b e o r l a r y n g e a l m a s k a i r w a y : N o t e i t s p o s i t i o n
( d i s t a n c e m a r k e r a t t h e l i p s ) , i t s o r i e n t a t i o n a n d i t s s e c u r i t y ( 3 ) .
E l i m i n a t e : N o t e t h a t , i n a c r i s i s , y o u m a y n e e d t o r e m o v e m a c h i n e ,
c i r c u i t , f i l t e r , E T T a n d i t s c o n n e c t i o n s , e . g . t h e c a t h e t e r m o u n t .
R e v i e w m o n i t o r s : N o t e m o n i t o r s i n u s e a n d r e v i e w a l l r e a d i n g s ,
w a v e f o r m s a n d a l a r m s e t t i n g s . U p d a t e t h e a n a e s t h e t i c r e c o r d ( 4 ) .
R e v i e w e q u i p m e n t : N o t e a l l e q u i p m e n t i n u s e , e s p e c i a l l y i t e m s i n
c o n t a c t w i t h t h e p a t i e n t . R e v i e w i t s s a f e t y a n d f u n c t i o n ( 5 ) .
A i r w a y : N o t e t h e p o s i t i o n o f t h e h e a d a n d n e c k , a n d t h e p o s i t i o n ,
p a t e n c y a n d s e c u r i t y o f a n y a r t i f i c i a l a i r w a y s o r m a s k s ( 6 ) .
B r e a t h i n g : N o t e c h e s t a n d a b d o m i n a l m o v e m e n t s a n d c o r r e l a t e
t h e s e w i t h t h e r e s p i r a t o r y r a t e a n d p a t t e r n o f s p o n t a n e o u s
v e n t i l a t i o n .
C i r c u l a t i o n : N o t e t r e n d s i n a l l c a r d i o v a s c u l a r p a r a m e t e r s a n d
c o r r e l a t e t h e s e w i t h e s t i m a t e d b l o o d o r o t h e r f l u i d l o s e s ( 7 ) .
D r u g s : N o t e d r u g s t h a t h a v e b e e n g i v e n a n d c o r r e l a t e d o s e s w i t h
e f f e c t s . N o t e c o r r e c t f u n c t i o n o f a l l I V l i n e s a n d i n f u s i o n s ( 8 ) .
A : B e A w a r e o f A i r a n d A l l e r g y . B e A w a r e y o u r s e l f , t h i n k o f
p o s s i b l e A w a r e n e s s i n t h e p a t i e n t , a n d o f A i r ( o r o t h e r ) e m b o l i s m ,
A i r i n t h e p l e u r a ( p n e u m o t h o r a x ) , A l l e r g y o r A n a p h y l a x i s ( 9 ) .
S W I F T C H E C K : N o t e w h a t t h e s u r g e o n a n d o t h e r p e r s o n n e l a r e
d o i n g , c h e c k t h e p a t i e n t s p o s i t i o n o n t h e t a b l e a n d t h a t t h e
p h y s i o l o g i c a l r e s p o n s e s m a t c h t h e c i r c u m s t a n c e s .
* N u m b e r s i n b r a c k e t s r e f e r t o n o t e s o f t h e C r i s i s M a n a g e m e n t
M a n u a l
3 8
a s s h o w n i n t h e s e c o n d c o l u m n o f t h i s f i g u r e .
C o r r e s p o n d i n g n o t e s t o b e s h o w n o n t h e r e v e r s e s i d e
S C A N
( 1 )
( 2 )
( 3 )
( 4 )
( 5 )
( 6 )
( 7 )
( 8 )
( 9 )
C i r c u l a t i o n : N o t e t h e v o l u m e o f t h e p u l s e . T h e E T C O
2
i s u s e d
h e r e a s a n i n d e x o f v e n o u s r e t u r n a n d c a r d i a c o u t p u t .
O x y g e n : I f t h e s o u r c e i s n o t v i a a n a n a e s t h e t i c m a c h i n e ( e . g .
d i r e c t s u p p l y f r o m w a l l o u t l e t , c y l i n d e r o r o x y g e n c o n c e n t r a t o r ) ,
c h e c k t h e f l o w m e t e r a n d t h e i n t e g r i t y o f s u p p l y f r o m s o u r c e t o
p a t i e n t .
E n d o t r a c h e a l t u b e : A t i n s e r t i o n n o t e a n d c h a r t t h e d i s t a n c e
m a r k e r a t t h e t e e t h o r g u m s w h e n t h e t i p i s 3 c m ( i n a n a d u l t )
p a s t t h e v o c a l c o r d s . C h e c k t h i s d i s t a n c e a g a i n s t t h e c h a r t e d
v a l u e , e s p e c i a l l y a f t e r t h e p a t i e n t h a s b e e n m o v e d , t h e s u r g e o n
i s w o r k i n g n e a r t h e t u b e , o r h a m m e r i n g o r m a n i p u l a t i o n h a s
t a k e n p l a c e . I f a n L M A i s i n u s e , d i s t a n c e c h e c k s d o n o t a p p l y .
R e v i e w M o n i t o r s : N o t e t h a t a l l s e n s o r s a r e c o r r e c t l y p l a c e d ,
z e r o e d a n d l e v e l l e d w h e r e a p p r o p r i a t e , a n d n o t e t h a t t h e y h a v e
b e e n c a l i b r a t e d , i f t h i s i s p o s s i b l e a n d p r a c t i c a l . N o t e t h a t a l a r m
a n d a l e r t s e t t i n g s a r e a p p r o p r i a t e a n d a r e t u r n e d o n .
R e v i e w E q u i p m e n t : R e v i e w a l l e q u i p m e n t i n u s e b y y o u r s e l f
a n d t h e s u r g i c a l t e a m i n c l u d i n g d i a t h e r m y , e n d o s c o p e s ,
p r o b e s , r e t r a c t o r s , h e a t i n g b l a n k e t s , h u m i d i f i e r s e t c . E n s u r e t h a t
n o p h y s i c a l , t h e r m a l o r c h e m i c a l d a m a g e c a n b e d o n e t o t h e
p a t i e n t , a n d t h a t t h e e q u i p m e n t i s f u n c t i o n i n g a s e x p e c t e d .
A i r w a y : N o t e a n y i n a p p r o p r i a t e u s e o r p a t t e r n o f t h e a c c e s s o r y
m u s c l e s o f r e s p i r a t i o n , a n y e x c e s s i v e r e t r a c t i o n o f t h e t r a c h e a o r
t h y r o i d , a n d a n y u n c o o r d i n a t e d o r p a r a d o x i c a l m o v e m e n t s o f
t h e c h e s t o r a b d o m e n i n r e l a t i o n t o r e s p i r a t o r y e f f o r t s .
C i r c u l a t i o n : I n e s t i m a t i n g b l o o d o r o t h e r f l u i d l o s s , s u c t i o n
b o t t l e c o n t e n t s , s w a b s , d r a p e s a n d f l o o r s h o u l d b e c h e c k e d .
R e m e m b e r t h a t b l o o d c a n p o o l u n d e r t h e p a t i e n t o n t h e t a b l e ,
a n d t h a t c o n s i d e r a b l e b l e e d i n g c a n t a k e p l a c e i n t o t i s s u e s p a c e s
a n d b o d y c a v i t i e s . N o t e t h a t v e n o u s r e t u r n c a n b e s u b s t a n t i a l l y
i n f l u e n c e d b y r e t r a c t i o n , p r e s s u r e b y t h e s u r g e o n , b y t h e g r a v i d
u t e r u s l y i n g o n t h e i n f e r i o r v e n a c a v a , o r b y m a n i p u l a t i o n o f t h e
h e a r t , l u n g s o r g r e a t v e s s e l s . A l s o , r e m e m b e r t h a t t r a c t i o n ,
e s p e c i a l l y o n t h e e y e m u s c l e s a n d p e r i t o n e u m , c a n c a u s e v a g a l
s t i m u l a t i o n .
D r u g s : N o t e t h a t a l l s y r i n g e s o r i n f u s i o n s h a v e b e e n l a b e l l e d i n
a s t a n d a r d i s e d m a n n e r w i t h t h e g e n e r i c n a m e o f t h e d r u g ( o r
f l u i d ) a n d t h e d o s e ( i n m g / m l ) , a n d t h a t t h e a m p o u l e s f r o m
w h i c h t h e i n g r e d i e n t s h a v e b e e n t a k e n a r e a v a i l a b l e f o r
c h e c k i n g . N o t e t h a t a l l I V l i n e s a r e s e c u r e , a n d , i f p o s s i b l e ,
v i s i b l e f r o m s o u r c e t o p a t i e n t e n t r y s i t e .
A : A l w a y s c o n s i d e r t h e s e p o s s i b i l i t i e s ; e a c h m a d e u p a b o u t
1 % o f A I M S r e p o r t s .
Figure 3 Items which, in the order of the mnemonic, should be SCANNED.
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DEVELOPMENT OF THE SUB-ALGORITHMSFollowing analysis of the first 2000 reports as described in the
1993 symposium issue,34 the need for a number of specific
sub-algorithms was identified to assist the anaesthetist in
treating the remaining 40% of the incidents that were not
corrected by the COVER core algorithm. Volunteer anaes-
thetists were given sets of incident reports from the first 4000
AIMS reports that dealt with the specific clinical problems
shown in table 3. These sets were generated by using the key
word section on the AIMS form. For incidents that involved
large numbers of reports (such as airway obstruction and
desaturation), at least two anaesthetists were involved in the
initial data analysis while for those where there were fewer
reports (such as water intoxication) one investigator initially
reviewed the data. As the majority of reported cases were
clearly dealt with well, the reporting anaesthetists described
actions played an important role in creating the crisis
management sub-algorithms. Each sub-algorithm was
T h e c o l u m n o n t h e l e f t l i s t s , i n t h e o r d e r o f t h e m n e m o n i c ,
w h a t s h o u l d b e c h e c k e d . T h i s w i l l c o m p r i s e a f a c i n g p a g e
o f t h e m a n u a l . N o t e s c o r r e s p o n d i n g t o t h e n u m b e r s i n
p a r e n t h e s e s w i l l b e o n t h e r e v e r s e s i d e .
C H E C K : w h e n e v e r y o u a r e w o r r i e d
C i r c u l a t i o n : P a l p a t e a p u l s e . C o r r e l a t e r a t e , r h y t h m a n d v o l u m e w i t h
t h e o x i m e t e r a n d E C G . C h e c k c a p i l l a r y r e f i l l a n d E T C O
2
t r a c e ( 1 ) .
C o l o u r : I f s u s p i c i o u s t r y t h e p u l s e o x i m e t e r o n y o u r s e l f . T a k e a r t e r i a l
b l o o d f o r a l a b c h e c k o n s a t u r a t i o n o r b l o o d g a s e s .
O x y g e n : B r i e f l y i n c r e a s e t h e o x y g e n f l o w r a t e a n d c a l c u l a t e t h e n e w
e x p e c t e d F I O
2
i n t h e b r e a t h i n g c i r c u i t .
O x y g e n A n a l y s e r : C h e c k t h a t t h e c h a n g e s i n t h e F I O
2
a r e i n l i n e w i t h
t h e c a l c u l a t e d c h a n g e s i n F I O
2
i n t h e b r e a t h i n g c i r c u i t .
V e n t i l a t i o n : V e n t i l a t e b y h a n d . C h e c k c i r c u i t , s c a v e n g i n g , v a l v e s a n d
v i s i b l e m o v i n g v e n t i l a t o r p a r t s .
V a p o r i s e r s : C h e c k t h e v a p o r i s e r ( s ) a r e c o r r e c t l y s e a t e d a n d s e t ,
l o c k e d i n a n d c o n n e c t e d a n d t h a t t h e r e a r e n o g a s o r l i q u i d l e a k s .
E n d o t r a c h e a l t u b e o r l a r y n g e a l m a s k a i r w a y : C h e c k p o s i t i o n ,
o r i e n t a t i o n a n d p a t e n c y . I f E T t u b e i s i n u s e e x c l u d e e n d o b r o n c h i a l
i n t u b a t i o n ( 2 ) .
E l i m i n a t e : C h e c k t h a t a n i n d e p e n d e n t m e a n s o f v e n t i l a t i n g t h e
p a t i e n t ( e . g . s e l f - i n f l a t i n g b a g ) a n d a n a l t e r n a t e s u p p l y o f o x y g e n
a r e a v a i l a b l e .
R e v i e w m o n i t o r s : C h e c k a l l m o n i t o r s i n u s e a n d c o m p a r e c u r r e n t
m o n i t o r v a l u e s w i t h t h o s e o n t h e a n a e s t h e t i c r e c o r d ( 3 ) .
R e v i e w e q u i p m e n t : C h e c k t h a t a l l e q u i p m e n t i n c o n t a c t w i t h o r
r e l e v a n t t o t h e p a t i e n t i s s a f e a n d f u n c t i o n i n g c o r r e c t l y .
A i r w a y : O b s e r v e , p a l p a t e a n d a u s c u l t a t e t h e n e c k . I f s u s p i c i o u s o f
a i r w a y o b s t r u c t i o n , p l a n d i r e c t p h a r y n g o s c o p y .
B r e a t h i n g : P a l p a t e a n d a u s c u l t a t e t h e c h e s t w h i l s t r e p e a t i n g S C A N .
R e v i e w t h e E T C O
2
i f a c a p n o g r a p h i s i n u s e .
C i r c u l a t i o n : C r o s s c h e c k a n y a b n o r m a l B P r e a d i n g s w h e r e p o s s i b l e .
C h e c k t h e z e r o a n d s c a l e s o f t r a n s d u c e r s .
D r u g s : C h e c k a l l a m p o u l e s , s y r i n g e s , l a b e l s , i n f u s i o n a p p a r a t u s ,
c o n n e c t i o n s & c a n n u l a e f r o m f l u i d s o u r c e t o v e i n ( 4 ) .
A : S p e c i f i c a l l y c o n s i d e r t h e p o s s i b i l i t y o f A w a r e n e s s ( 5 ) , A i r ( o r
o t h e r ) e m b o l i s m ( 6 ) , A i r i n p l e u r a ( p n e u m o t h o r a x ) ( 7 ) , A l l e r g y o r
A n a p h y l a x i s ( 8 ) . S e e t h e r e l e v a n t s u b - a l g o r i t h m s f o r s i g n s a n d h i g h
r i s k s i t u a t i o n s .
S W I F T C H E C K : C o r r e l a t e t h e m o n i t o r e d p a r a m e t e r s w i t h t h e
c l i n i c a l s i t u a t i o n a n d r i s k f a c t o r s . S p e c i f i c a l l y q u e s t i o n t h e s u r g e o n
a b o u t w h a t i s b e i n g d o n e , a n d c h e c k t h e p r e - o p e r a t i v e a s s e s s m e n t ,
m e d i c a l r e c o r d a n d w a r d d r u g c h a r t .
C o r r e s p o n d i n g n o t e s t o b e s h o w n o n t h e r e v e r s e s i d e
C H E C K
( 1 )
( 2 )
( 3 )
( 4 )
( 5 )
( 6 )
( 7 )
( 8 )
C i r c u l a t i o n : I f p o s s i b l e , m a n u a l l y c h e c k a p u l s e o t h e r t h a n t h e
o n e b e i n g s e n s e d b y t h e o x i m e t e r . B e w a r e - s o m e o x i m e t e r s
a u t o m a t i c a l l y i n c r e a s e t h e s i z e o f t h e p l e t h y s m o g r a p h t r a c e , i f i t s
v o l u m e i s s m a l l .
E n d o t r a c h e a l t u b e : E n d o b r o n c h i a l i n t u b a t i o n m u s t a l w a y s b e
e x c l u d e d . P a l p a t i o n o f t h e p i l o t b a l l o o n w h i l e s q u e e z i n g t h e c u f f
i n t h e t r a c h e a a b o v e t h e s t e r n a l n o t c h w i l l c o n f i r m i t s p o s i t i o n ,
a n d s l i g h t w i t h d r a w a l m a y a l s o r e s o l v e d e s a t u r a t i o n .
P a t e n c y : V e n t i l a t e t h e t u b e d i r e c t l y ( r e m o v e c i r c u i t , f i l t e r ,
c o n n e c t i o n s ) w i t h a s e p a r a t e s y s t e m ( s e e E l i m i n a t e ) . T h e t i p o f
t h e t u b e m a y h a v e m o v e d , t h e l u m e n b e c o m e o b s t r u c t e d o r t h e
c u f f h e r n i a t e d i n t o t h e l u m e n o r o v e r t h e e n d o f t h e t u b e . I f t h e r e
i s a n y s u s p i c i o n o f r e g u r g i t a t i o n , a s p i r a t i o n o r o b s t r u c t i o n o f a
t u b e , p e r f o r m d i r e c t l a r y n g o s c o p y , s u c k o u t t h e p h a r y n x , a d j u s t
t h e t u b e s p o s i t i o n , c o n s i d e r a d j u s t i n g t h e c u f f a n d p a s s a
s u c t i o n c a t h e t e r t h r o u g h t h e t u b e . D o n ' t f o r g e t s w a b s o r p a c k s .
R e v i e w m o n i t o r s : A l w a y s a t t e m p t t o c o n f i r m c o r r e c t s i t i n g ,
c a l i b r a t i o n , a l a r m s e t t i n g s a n d f u n c t i o n :
O x i m e t e r : C h e c k t h e p r o b e o n y o u r s e l f , t r y a n o t h e r s i t e , t r y
a n o t h e r p r o b e , t r y a n o t h e r o x i m e t e r .
C a p n o g r a p h : B r e a t h e i n t o t h e s e n s o r y o u r s e l f a n d c h e c k t h a t
t h e E T
C O
2
r e a d s 5 % o r 4 0 m m H g . R e m e m b e r , a s u d d e n f a l l i n
E T C O
2
m a y b e d u e t o e n t r a i n m e n t o f r o o m a i r b e t w e e n t h e g a s
s a m p l i n g s i t e a n d t h e c a p n o g r a p h .
B l o o d p r e s s u r e : C o n f i r m a u t o m a t e d n o n i n v a s i v e b l o o d
p r e s s u r e m e a s u r e m e n t s m a n u a l l y b e f o r e a c t i n g . C h e c k z e r o a n d
c a l i b r a t i o n o f d i r e c t m e a s u r e m e n t s .
E C G : C h e c k t h e r i g h t l e a d s a r e i n u s e , t h a t w a v e f o r m s a r e
c a l i b r a t e d a n d t h a t t h e m o n i t o r i s i n d i a g n o s t i c m o d e b e f o r e
a s s e s s i n g S T s e g m e n t s .
D r u g s : C o n s i d e r w h e t h e r t h e p r o b l e m m i g h t b e t h e r e s u l t o f
f a i l u r e o f d r u g d e l i v e r y o r t h e w r o n g d r u g , w r o n g d o s e , w r o n g
r o u t e , o r w r o n g t i m e o f a d m i n i s t r a t i o n b e i n g u s e d .
A w a r e n e s s : C o n s i d e r p r e v i o u s d r u g / a l c o h o l u s e . L o o k f o r s i g n s
o f s y m p a t h e t i c a c t i v i t y . C h e c k t h e a n a e s t h e t i c i s a c t u a l l y b e i n g
d e l i v e r e d . I f i n d o u b t , d e e p e n a n a e s t h e s i a .
A i r ( a n d o t h e r ) e m b o l i s m : A l w a y s c o n s i d e r w i t h a f a l l i n
E T C O
2
d e s a t u r a t i o n , h y p o t e n s i o n a n d / o r a s u d d e n c h a n g e i n
E C G r a t e o r c o n f i g u r a t i o n , e s p e c i a l l y i n a r i s k y s i t u a t i o n .
A i r i n p l e u r a ( p n e u m o t h o r a x ) : I f c a r d i o - r e s p i r a t o r y
c o m p r o m i s e r e m a i n s u n d i a g n o s e d a f t e r C O V E R A B C D , e x p o s e
t h e c h e s t a n d a b d o m e n , a n d c a r e f u l l y c o m p a r e l e f t a n d r i g h t
s i d e s , u s i n g i n s p e c t i o n , p a l p a t i o n a n d a u s c u l t a t i o n .
A l l e r g y o r a n a p h y l a x i s : L o o k f o r h y p o t e n s i o n , a f a l l i n E T C O
2
b r o n c h o s p a s m , d e s a t u r a t i o n a n d s k i n s i g n s .
Figure 4 Items which, in the order of the mnemonic, should be CHECKED.
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developed by those who had reviewed the reports and by at
least one other specialist with a clinical interest in that area.
Once a sub-algorithm had been created, the relevant analysts
again reviewed each of the reports in the relevant set. The
potential value of using a structured approachthat is, the
application of COVER ABCDA SWIFT CHECK to the
diagnosis and initial management of each problemfollowed
by the application of the sub-algorithm for that specific
problem was assessed in the light of each of the relevant
AIMS reports from the first 4000. This was done by
comparing the potential effectiveness of the structured
approach for each incident with that of the actual manage-
ment, as recorded in each report. A judgement was made by
the reviewers as to whether the sub-algorithm, properly
applied, would have led to a better or quicker resolution of
the problem, and specific consideration was also given to
whether use of the sub-algorithm could have caused a
problem. Other relevant aspects of the incidents were
T h e c o l u m n o n t h e l e f t l i s t s , i n t h e o r d e r o f t h e m n e m o n i c ,
w h a t s h o u l d b e d o n e i n t h e A L E R T / R E A D Y p h a s e . T h i s w i l l
c o m p r i s e a f a c i n g p a g e o f t h e m a n u a l . N o t e s c o r r e s p o n d i n g
t o t h e n u m b e r s i n p a r e n t h e s e s w i l l b e o n t h e r e v e r s e s i d e .
A L E R T / R E A D Y C a l l f o r h e l p / t r o l l e y s ( 1 , 2 )
C i r c u l a t i o n : I f t h e r e i s a n i m p e n d i n g a r r e s t a l l o c a t e t h e
c i r c u l a t i o n t a s k ( 1 ) a n d a s k f o r t h e a r r e s t t r o l l e y t o b e f e t c h e d .
C o l o u r : I f t h e o x i m e t e r i s s u s p e c t , r e s i t e o r r e p l a c e i t a n d / o r d o a n
a r t e r i a l b l o o d g a s . C o n s i d e r i n s e r t i n g a n a r t e r i a l l i n e .
O x y g e n : I f a d e q u a t e s a t u r a t i o n c a n n o t b e c o n f i r m e d , a d m i n i s t e r
1 0 0 % o x y g e n . P l a n h o w t o p r o v i d e a n a l g e s i a a n d a n a e s t h e s i a .
O x y g e n A n a l y s e r : C o n f i r m t h a t t h e g a s i n t h e i n s p i r e d l i m b o f t h e
b r e a t h i n g c i r c u i t i s 1 0 0 % o x y g e n .
V e n t i l a t i o n : A l l o c a t e t h e a i r w a y a n d b r e a t h i n g t a s k ( 1 ) .
V e n t i l a t e w i t h a s e l f - i n f l a t i n g b a g . S e e b r e a t h i n g b e l o w .
V a p o r i s e r s : T u r n t h e v a p o r i s e r o f f i f t h e r e i s c a r d i o r e s p i r a t o r y
c o m p r o m i s e . P l a n h o w t o p r o v i d e a n a l g e s i a a n d a n a e s t h e s i a .
E n d o t r a c h e a l t u b e o r l a r y n g e a l m a s k a i r w a y : A l l o c a t e t h e
e q u i p m e n t t a s k ( 1 ) . I f s u s p i c i o u s , p r e p a r e t o r e m o v e a n d
c h a n g e t h e t u b e o r L M A .
E l i m i n a t e : P r e p a r e a n d c h e c k t h e c o r r e c t f u n c t i o n o f a n a l t e r n a t e
b r e a t h i n g s y s t e m a n d s e p a r a t e o x y g e n s o u r c e .
R e v i e w m o n i t o r s : R e c h e c k , c o r r e l a t e a n d r e c o r d a l l r e a d o u t s a n d
t r e n d s . C a l l f o r a d d i t i o n a l m o n i t o r s a s n e c e s s a r y .
R e v i e w e q u i p m e n t : R e m o v e o r r e p l a c e s u s p e c t e q u i p m e n t . B r i n g i n
a d d i t i o n a l e m e r g e n c y e q u i p m e n t a s a p p r o p r i a t e .
A i r w a y : A d j u s t h e a d a n d n e c k , a t t e m p t g e n t l e c h i n l i f t . P r e p a r e f o r
p h a r y n g o s c o p y ; i f s u s p i c i o u s , g o t o a i r w a y o b s t r u c t i o n .
B r e a t h i n g : E x p o s e t h e c h e s t a n d a b d o m e n . R e p e a t S C A N a n d
C H E C K w h i l s t c o m p a r i n g L a n d R s i d e s . C o n s i d e r c a u s e s .
C i r c u l a t i o n : C h e c k I V a c c e s s . S e c u r e a d d i t i o n a l a c c e s s ( v e n o u s a n d
a r t e r i a l ) a s n e c e s s a r y . P r e p a r e t o t r a n s f u s e .
D r u g s : A l l o c a t e t h e d r u g s t a s k ( 1 ) . C h e c k a l l d r u g s a n d
i n f u s i o n s a n d t h e e n t i r e I V a p p a r a t u s . D r a w u p , c h e c k a n d l a b e l
d r u g s t h a t m a y b e n e e d e d .
A : D e c i d e w h e t h e r A w a r e n e s s , A i r ( o r o t h e r ) e m b o l i s m , A i r i n p l e u r a
( p n e u m o t h o r a x ) , A l l e r g y a n d A n a p h y l a x i s a r e p o s s i b l e c a u s e s o f t h e
p r o b l e m , a n d a c t a c c o r d i n g l y ( s e e a l g o r i t h m s ) .
S W I F T C H E C K : M a k e a n o t h e r a s s e s s m e n t o f t h e g e n e r a l s i t u a t i o n ,
o f t h e p a t i e n t , o f t h e a c t i v i t i e s o f t h e s u r g e o n a n d o t h e r p e r s o n n e l ,
a n d o f t h e p o s s i b l e e f f e c t s o f t h e o p e r a t i o n a n d / o r a n y d r u g s o r
i n f u s i o n s .
C o r r e s p o n d i n g n o t e s t o b e s h o w n o n t h e r e v e r s e s i d e .
A L E R T / R E A D Y
( 1 ) C a l l f o r H e l p - A l l o c a t e T a s k s
T A S K S : A i r w a y ( A ) , B r e a t h i n g ( B ) , C i r c u l a t i o n ( C ) , D r u g s ( D ) ,
E q u i p m e n t ( E ) .
P E R S O N 1 : I n i t i a l l y t h e a n a e s t h e s i o l o g i s t - t o l o o k a f t e r A , B , o v e r a l l
c o o r d i n a t i o n a n d c y c l i n g t h r o u g h C O V E R a n d t h e a p p r o p r i a t e
a l g o r i t h m / s . W h e n s k i l l e d a s s i s t a n c e i s a v a i l a b l e t h e
a n a e s t h e s i o l o g i s t m a y d e l e g a t e A , B , a n d c o n c e n t r a t e o n
c o o r d i n a t i n g a c t i v i t i e s a n d c h e c k i n g a l g o r i t h m s .
P E R S O N 2 : T h e a n a e s t h e t i c a s s i s t a n t . T h i s p e r s o n s h o u l d b e
p r i m a r i l y r e s p o n s i b l e f o r D , E , a l t h o u g h m a y b e d e p l o y e d b y t h e
a n a e s t h e s i o l o g i s t t o o t h e r t a s k s .
P E R S O N 3 : T h i s p e r s o n s h o u l d l o o k a f t e r C . I f t h e r e i s a c a r d i a c
a r r e s t , t h i s p e r s o n s h o u l d b e r e s p o n s i b l e f o r E C M .
P E R S O N 4 : T o b e d e p l o y e d b y t h e a n a e s t h e s i o l o g i s t . I f t h e r e i s a
c a r d i a c a r r e s t , t h i s s h o u l d b e t h e s e c o n d p e r s o n l o o k i n g a f t e r C ,
e n s u r i n g g o o d i n t r a v e n o u s a c c e s s , i n j e c t i o n o f i n t r a v e n o u s d r u g s ,
a n d e n s u r i n g t h e y a r e f l u s h e d t h r o u g h .
P E R S O N 5 : T h i s p e r s o n a n d a n y o t h e r a v a i l a b l e p e r s o n s h o u l d b e
d e p l o y e d b y t h e a n a e s t h e s i o l o g i s t . I t i s m o s t i m p o r t a n t t h a t e a c h
p e r s o n b e g i v e n a s p e c i f i c t a s k , e . g . C a n y o u i n d e p e n d e n t l y a s s e s s
t h e s i t u a t i o n , g o t h r o u g h C O V E R a n d s u b - a l g o r i t h m s X a n d Y , a n d
c h e c k t h a t a l l i s g o i n g t o p l a n ? O R P l e a s e h e l p t h e a n a e s t h e t i c
a s s i s t a n t g e t t i n g d r u g Z r e a d y , O R P l e a s e h e l p P e r s o n 3 ( o r 4 ) g e t
t h e d e f i b r i l l a t o r r e a d y .
( 2 ) E m e r g e n c y E q u i p m e n t a n d D r u g T r o l l e y s
S t a n d a r d s e t s o f e q u i p m e n t a n d d r u g s s h o u l d b e a v a i l a b l e o n
t r o l l e y s w h i c h c a n b e b r o u g h t i n , o r i n d r a w e r s o n t h e a n a e s t h e t i c
m a c h i n e . T h e f o l l o w i n g s h o u l d b e a v a i l a b l e :
A i r w a y E q u i p m e n t I ( S t a n d a r d )
A i r w a y E q u i p m e n t I I ( D i f f i c u l t i n t u b a t i o n )
B r e a t h i n g E q u i p m e n t I ( S t a n d a r d )
B r e a t h i n g E q u i p m e n t I I ( P l e u r a l d r a i n a g e / b r o n c h o s c o p y )
C i r c u l a t o r y E q u i p m e n t I ( S t a n d a r d )
C i r c u l a t o r y E q u i p m e n t I I ( C a r d i a c a r r e s t )
D r u g s - E m e r g e n c y I ( S t a n d a r d )
D r u g s - E m e r g e n c y I I ( F o r u n u s u a l p r o b l e m s )
E q u i p m e n t E x t r a s I ( S p a r e s e t o f m o n i t o r s )
E q u i p m e n t E x t r a s I I ( F o r u n u s u a l p r o b l e m s )
Figure 5 Items which, in the order of the mnemonic, should be done in the ALERT/READY phase.
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manual there are easy-to-use tabs down the right hand sides
of the pages to allow the anaesthetist immediate access to
sub-algorithms for problems with non-specific cues such as
desaturation, but which also allow direct access to sub-
algorithms for specific problems such as anaphylaxis or air
embolism, when these are immediately recognised. There are
also tabs at the tops of the first few pages for rapid access to
the SCARE sequences.
An electronic copy of the algorithms in the manual was
made available on the internet.38 Unlike paper manuals, these
web based manuals are more flexible a nd allow rapid updatesto all users. With the more frequent use of personal
computers and hand held devices, it was felt that this would
be a beneficial medium in which to house the manual. To this
end, an electronic software form of the manual has been
developed using hypertext documentation that can be used
on a personal computer or a hand held personal desk
assistant (e.g. Palm PilotTM). The program uses frames with
resizable boxes and scroll bars on the sides. Underlined text
expands into full text boxes and, within the crisis algorithm
itself, collapsible headings and hyperlinks and pop-up boxes
are used to fully describe each of the sub-algorithms. The
personal computer program is of most use as a teaching tool,
while the ease of use and instant availability of a hand held
device allows the manual to be instantly accessible during
times of a crisis. This version is currently being used by some
trainee anaesthetists in New Zealand (Charles Bradfield,personal communication).
COMMENTS ON THE CRISIS MANAGEMENTMANUALSince the publication of the core algorithm, five meetings on
crisis management have been held: one at Noosa in
Queensland in June 1993; one at Toukley in New South
Wales in March 1994; and two 2 day meetings in association
with Annual Scientific Meetings of the Australian Society of
Anaesthetists, one in Fiji in November 1994 and one in
Melbourne in October 1995. Finally, the electronic version
was demonstrated at the 2001 Annual Scientific Meeting of
the Australian Society of Anaesthetists in Canberra. The 2001
Canberra meeting was especially important as it was the first
meeting for several years following dissemination of the draft
manual. At all of these meetings the sub-algorithms
presented in this issue were presented, discussed, and
refined. It was recognised that the methods used for
validating the algorithms were intrinsically limited and
subject to hindsight bias. Prospective validation using
simulation would be ideal but will require a large scale,
carefully designed study.
It was agreed by all that the algorithms should only be
used when the usual responses based on pattern recognition
do not appear to have been successful. Also, right from the
start it was agreed that the use of the traditional cardiac
arrest mnemonic ABCD was too limited for more complex
problems which arise because of the interposition of artificial
gas supplies, anaesthetic machines (with additional hazards
such as vaporisers), artificial airways, and various breathingcircuits with failure prone components such as one-way
valves and arrangements for carbon dioxide absorption. For
example, hypoxic gas mixtures (especially 100% nitrous
oxide), potentially fatal vapour concentrations, and circuit
over-pressures must be excluded almost immediately or
severe patient harm or death may ensue rapidly. A number of
additional important points were raised at the various
meetings.
Firstly, it is important to recognise that the AIMS reports
simply constitute a body of information arising from
occasions when anaesthetists were sufficiently interested or
concerned by an event to report it and the surrounding
circumstances as an incident. It is known that common or
mundane events are under-reportedfor example, circuit
disconnections and leaks are under-reported but are never-
theless the most frequently reported incidentswhereas very
dramatic and unusual events are more likely to be reported
for example, anaphylactic reactions or air embolism.41 42
The relative frequencies with which various types of
incident are reported thus provide some hybrid reflection of
the relative frequency with which they occur and the degree
of interest or alarm they engender. Although reporting such
comparative frequencies may produce considerable unease inclassical epidemiologists, it does have practical relevance to a
body of anaesthetists who are provided with a prioritised
catalogue of events sequenced according to their perceived
relative importance by fellow practitioners.39 Half of New
Zealand anaesthetists who responded to a survey (57%
response rate) felt that AIMS had changed their practice.43
The second issue addressed was whether the AIMS data
are relevant to crises that actually have adverse outcomes.
Data from anaesthetic deaths which were substantially
attributed to anaesthetic management and which occurred
within 48 hours of anaesthesia in the UK (790 deaths) and
New South Wales (172 deaths) indicate that the AIMS data
are relevant.39 44 In 80% of the deaths on the same day the
first sign of disaster was a life threatening crisis. Of all these
crises leading to death, three quarters are in the AIMS top
10 and nearly all the remainder are in the next 10.39 There is
also a striking similarity between the presenting signs in the
UK and New South Wales studies (table 4);44 the non-
specificity of these signs confirms that a structured approach
would be desirable as there was a large number of causes of
the underlying problems.
In the UK study 30% of deaths were in patients who were
ASA grade 14 and in the New South Wales study 40% of
deaths were in patients regarded as being fair risks. The
conclusions that AIMS crises are relevant for validating crisis
management algorithms, that many crises which result in
death start with non-specific signs, and that problems may
arise in low or moderate risk patients all support the routine
use of a structured algorithm. Studies from elsewhere have
confirmed that there is a strong association between initial
process events and poor outcomes.45 46
The third problem which arose for discussion was that,
even if structured algorithms are available, poor team work
may compromise their execution. Again, the ideal is that
practising anaesthetists should undergo regular simulation
sessions in which they play various roles in crisis situations
that is, the equivalent of cockpit resource management
sessions in the aviation industry.4749 However, in reality this
will not be possible for all anaesthetists in the near future.
Experience from attending real crises and from observing
Australian anaesthetists in simulated crisis situationsfor
example, during the crisis management simulation session in
Toukley, New South Wales in March 1994confirms that
teamwork is often poor. The use of a crisis management
Table 4 Comparison of mode of presentation of 360NCEPOD* and 138 NSW** crises44
Incident NCEPOD NSW
Hypotension 33% 43%Cardiac arrest 24% 25%Arrhythmia 19% 24%Cyanosis 7% 6%Pulmonary oedema 3% 3%
*Data from the National Confidential Enquiry into Perioperative Deaths(UK).**Data from the New South Wales Special Committee InvestigatingDeaths under Anaesthesia (Australia).
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manual allows a coordinating person (usually an anaesthe-
tist) to allocate tasks for individual members of the operating
room team. In this way, tasks will be prioritised and it will be
ensured that the essential basic tasks are carried out in the
correct sequence and in an expeditious manner. The value of
a crew resource management approach cannot be over-
emphasised and its introduction into clinical practice needs
to be widely supported.2 49 Better communication was cited
by over two-thirds of operating room nurses and doctors as
the most important intervention required to improve safety,49
underlining the importance of moving towards formal teamtraining using simulators.
This may be based on the use of crisis management
algorithms which, in the future, may be available as part of
the software of integrated monitoring devices and clinical
decision support systems. The first step was producing Palm
and PC-based versions of this crisis management manual.
The introduction of such an approach into commercial
monitoring systems has gained interest by some manufac-
turers and is well recognised as being an effective way of
applying information of this sort.50 51
Fourthly, the use of COVER ABCDA SWIFT CHECK and
the sub-algorithms does not guarantee a good outcome
merely that an appropriate sequence of actions will have been
carried out in the vast majority of cases. In some instances
something will have been done (such as a wrong drug given)
or something will have occurred (such as pulmonary
embolism) that has consequences that the anaesthetist
cannot reverse or even control. Also, it is inevitable that the
core algorithm and sub-algorithms will not always be
correctly applied. However, if this is the case, as long as these
are available in an easy-to-access form, others called to assist
in the management of an escalating crisis will have a fresh
chance of resolving the problem.
The sub-algorithms have been designed to be a simple set
of instructions that can be followed in an emergency. It is
inevitable that these algorithms will differ from accepted
practice in some regions and do not represent the only
acceptable course of action. However, it is suggested that they
be followed in crises when pattern recognition has failed, at
least in the first instance, as they have been designed to
represent appropriate courses of action in the vast majority ofcircumstances. If this structured approach proves to be
unhelpful, the anaesthetist can always revert to problem
solving from first principles. The relevant sub-algorithm
should also be examined following resolution of an incident
to ensure that the reason for the crisis has not been missed
and to facilitate appropriate ongoing care and management.
Although the structured approach advocated may not be the
best for every situation, it will be consistent, is unlikely to
harm the patient, will assist in the diagnosis of the problem
in 99% of cases, and will be better than the current clinical
management by the average clinician in at least one in eight
incidents.
Finally, crisis management is not complete until the
consequences for the patient, his or her friends and relatives,
all medical (and other) staff involved, and the implicationsfor the institution, practice or system have been dealt with.52
An approach to this is outlined in the final paper in this set of
articles32 and forms the last section of the Crisis Management
Manual.38 An open disclosure standard has now been
developed by the Australian Council for Safety and Quality in
Health Care which supplements the approach advocated in
this last section of the manual.53
The sub-algorithms presented in this set of 24 articles were
developed as an adjunct for the practising clinician to use in
the resolution of incidents that occur during anaesthesia.
They are didactic but are open to debate, discussion, and
criticism. They form the basis of what we believe to be a
useful step in developing a rational evidence-based approach
to crisis management during anaesthesia. However, much
remains to be done. The COVER component has been found
to be satisfactory in real life resuscitation situations.54
Carefully designed simulator based studies, using nave
trainees right at the start of training, could evaluate the
approach advocated here against possible alternatives, and
could systematically examine the merits and demerits of
various aspects of the sub-algorithms and how they are
presented. The extent to which pre-compiled responses
should be required to be usedas in aviation and by the
policies of some hospitals with respect to the use of cardiac
arrest protocolsis likely to be the subject of lively debate as
medical practice receives increased scrutiny. Due to the
complexities of clinical medicine, however, it would seem
prudent, for the foreseeable future, that the core algorithm
and sub-algorithms described in this set of articles be
regarded as decision aids to support and back up a
clinicians natural responses to a crisis when all is notprogressing as expected.55
AC KN OW LE DG EM EN TSThe authors would like to thank all the anaesthetists in Australia and
New Zealand who contributed to the 4000 incident reports upon
which this and the other 24 papers in the Crisis Management Series
are based. The coordinators of the project also thank Liz Brown for
preparing the draft of the original Crisis Management Manual;
Loretta Smyth for typing; Monika Bullock RN for earlier coding and
classifying of data; Dr Charles Bradfield for the electronic version of
the algorithms; Dr Klee Benveniste for literature research; and Drs
Klee Benveniste, Michal Kluger, John Williamson and Andrew Paix
for editing and checking manuscripts.
Key messages
N This paper forms the introduction to a set of 24 articlesthat outline a structured approach for use when thingsgo wrong during anaesthesia. Prevention is not theintent of this set of articles as the focus is on crisismanagement.
N From three meetings involving 60100 anaesthetists itwas agreed that a core crisis management algo-rithm was needed when either cause or response totreatment during an anaesthesia crisis was notapparent.
N From the study of the first 4000 incidents reported toAIMS, a need for 24 specific sub-algorithms wasidentified based on successful strategies identified inthe reports.
N Using the application of the previously reported corealgorithm, the 24 sub-algorithms were assembled in auser friendly manual for trial against the 4000 incidentreports.
N The trial showed that this structured approach wouldaid in diagnosis in 99% of crises and would providebetter management than that of the average clinician,
without patient harm, in one in eight of the situations.N Poor teamwork may compromise the execution of a
structured algorithm.
N These algorithms will differ from accepted practicein some regions and do not represent the onlyacceptable course of action.
N Such structured approaches lend themselves readily tosimulation training in anaesthesia, resuscitation, andintensive care.
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Authors affiliations. . . . . . . . . . . . . . . . . . . . .
W B Runciman, Professor and Head, Department of Anaesthesia andIntensive Care, University of Adelaide and Royal Adelaide Hospital,
Adelaide, South Australia, AustraliaM T Kluger, Senior Staff Specialist, Department of Anaesthesiology andPerioperative Medicine, North Shore Hospital, Auckland, New ZealandR W Morris, Director, Research and Development, Sydney MedicalSimulation Centre, Royal North Shore Hospital, St Leonards, New South
Wales, AustraliaA D Paix, Consultant Anaesthetist, Princess Royal University Hospital,Orpington, Kent, UK
L M Watterson, Senior Staff Specialist and Director, Sydney MedicalSimulation Centre, Royal North Shore Hospital, St Leonards, New SouthWales, AustraliaR K Webb, Senior Staff Specialist, Department of Anaesthesia andIntensive Care, The Townsville Hospital, Douglas, Queensland, Australia
This study was coordinated by The Australian Patient Safety Foundation,GPO Box 400, Adelaide, South Australia 5001, Australia.
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