Successful Evidence-Based International Emergency Manual Implementation Strategy

Kyle Sanchez; and Jeffrey Huang, MD

Emergency ChecklistIt has been suggested that increasing access to resources and decreasing reliance on rote memory are two potential methods to combat medical errors;1 both of which can be achieved through the use of cognitive aids, such as emergency manuals (EMs).

Operating room (OR) EMs are paper or digital books with a series of current, medically established guidelines that detail how health care professionals should respond to specific perioperative critical events.2,3 The use of EMs by health care providers, especially anesthesia professionals, to guide their performance during nonroutine critical events has been shown to reduce errors and maximize productivity.4 It has been demonstrated that health care providers can respond to crises more efficiently,4 confidently,5,6 and collaboratively5,6 with the aid of OR EMs. Additionally, utilizing EMs reduced the likelihood of failure to adhere to lifesaving processes of care by four times.7

International awareness of the benefits of EM utilization continues to increase over time,8 but implementation itself remains a challenge. Some specific challenges for EM implementation include difficulty building consensus on content and format of EMs, resistance by health care providers who prefer to rely solely on their own skills and experience, infeasibility of ideal studies that measure the effect of EMs on clinical outcomes, and lingering concerns about the pitfalls of EM use, such as fixation on an incorrect diagnosis.9


The Anesthesia Patient Safety Foundation (APSF) sponsored a workshop in 2015 entitled Implementing and Using Emergency Manuals and Checklists to Improve Patient Safety, where audience discussion elicited recommendations such as the development of a strong social media presence of EMs, inclusion of EMs in the presurgical timeout, creation of a public APSF education packet on EM usage, and use of research to design an EM simple enough to be used without training.9

Simulation Training:

A lack of sufficient training programs on EMs is reported as the single greatest barrier to EM usage,5 and thus choosing an effective method to train providers on the proper use of EMs is critical. Simulation-based education allows for continuous, directed practice that supports the development and advancement of knowledge and clinical skills without risking harm to patients.10-12 Since simulation-based medical education has been shown to be superior to traditional education for teaching other technical skills,10,13,14 the effectiveness of simulation training on EM usage was studied. Participation in simulation training events has indeed been associated with increased routine use of EMs during critical events.4,5,10,15 Additionally, the location of the simulation training (OR versus simulation center) likely has no impact on a provider’s propensity to use EMs in future critical events.10 Thus, the implementation of EMs may be facilitated by participation in simulation competitions or other hands-on educational experiences.

Simulation Competition:

Simulation Wars was created in 2017 by the Zhongshan City Society of Anesthesiology in China as a competition to promote simulation training.16 Participating hospitals were instructed to create a video that demonstrates the application of EMs to an anesthesia-related critical event, with a specific focus on the use of crisis resource management skills.9 During the competition’s final round, each hospital performed an in-person crisis management demonstration.16 A 2018 study performed by Huang et al. one year after the inaugural competition found that EM usage during real critical events increased significantly following a simulation training competition.15

Train the Trainer:

With more hospitals adapting simulation training, it is important to ensure that the EM training instructors are proficient and able to organize their own workshops, especially given that many anesthesia professionals report not participating in simulation trainings because no one organized them.5 A two-hour EM simulation instructor training was given at the Chinese Association of Anesthesiologists annual meeting and was shown to be successful in allowing participants to organize their own EM simulation training workshops in their home institutions.17

Free Books:

Reading Emergency ManualAnother potential barrier of EM implementation is the required resources and cost of distributing EMs in every OR of a hospital or health care system. Since there is currently a lack of research on OR EM utilization in China, translated versions of EM were distributed free of charge to anesthesiology departments throughout several hospitals in China in 2018. Clinicians who received EMs demonstrated higher levels of EM simulation training participation, EM usage during critical events, self-review of EMs, and group study of EMs than anesthesia professionals who did not receive free books.5 While free EM placement alone is likely unable to provoke actual implementation,18 free books can enhance the implementation of EMs and actual EM use during critical events,5 especially when combined with simulation training and other methods to increase implementation.

Book Location:

Currently, there is still no standardized protocol for EM usage, despite the widespread usage of EMs, abundant evidence to support the benefit of EMs when used during critical events, and ongoing national and international efforts to enhance implementation. An obstacle to using EM may be that events in the operating room happen too quickly.5 This obstacle may be overcome by developing a concrete set of instructions regarding the time-sensitive access, handling, and utilization of EMs in routine daily practice. A standardized protocol would be especially beneficial for health care providers with minimal exposure to EMs who become acutely involved in a critical event. The preferred location for EM placement during critical events is the anesthesia station of the OR,6 which is congruent with Stanford University EM group’s recommendation.2 This location should minimize the time spent retrieving the EM and, thus, facilitate the development of a standardized protocol that allows all providers to quickly and efficiently use an EM in a critical situation.

The Reader’s Role:

The preferred reader of EMs during critical events is the most experienced health care professional,6 which suggests that the leading team member should assume the reader role. The distinction between the reader and leader is critical because the reader of EMs temporarily assumes a leader-like role with no actual responsibility for the clinical outcome. By assigning the reader role to the most experienced anesthesia professional, any effect of EM usage on clinical outcome—whether positive or negative—will be ascribed to the reader. More research is needed to determine whether the preferred location and reader of EMs have a significant influence on clinical outcomes. Moreover, other parameters related to EM usage should be identified, explored, and standardized to gain a more comprehensive picture. We propose that perhaps the next step toward increasing EM implementation is the development of a standardized protocol for EM usage.

Paper versus Electronic EMs:

Determining the most effective format for EMs is critical in creating a standardized protocol for use. There are several potential advantages and disadvantages to the use of hard copy versus digital EMs. Advantages to hard-copy books include familiarity among all providers, independence from electronic platforms or Wi-Fi, and simple modification by replacing or adding pages. However, some disadvantages of paper copies include the requirement to take up OR space and their tendency to get misplaced.19 On the contrary, electronic EMs may facilitate user-EM interaction, allow a more patient-specific response via input of patient data, and enable decision-making based on elapsed time.19 Disadvantages of electronic EMs include difficulty with navigation or manipulation of the application, limited display size, and the obvious risk of technological failures. Despite the proposed advantages and disadvantages of these formats, the mode of delivery of EMs—whether paper versus electronic—likely does not affect clinician performance or clinical outcome.19 Moreover, clinician compliance with the use of EMs and other cognitive aids is also likely unaffected by format.19

In conclusion, the use of simulation training was among the first methods shown to facilitate the implementation and usage of EMs.4,5,10,15,16 Providing formal EM simulation instructor training may nurture the growth and effectiveness of EM simulation programs.17 Free distribution of EMs may further enhance implementation.5 A universal, standardized protocol for EM usage, which specifies parameters such as location of placement and reader role,6 is critical to support the development and implementation of EMs worldwide.


Kyle Sanchez is a fourth-year medical student at the University of Central Florida College of Medicine in Orlando, FL.

Dr. Jeffrey Huang is program director of the HCA Healthcare/USF Morsani College of Medicine GME Anesthesiology Residency at Oak Hill Hospital in Brooksville, FL, professor at the USF Morsani College of Medicine and professor at the University of Central Florida College of Medicine. He serves on the APSF Committee on Education and Training.

The authors have no conflicts of interest.


  1. Leape LL. Error in medicine. JAMA. 1994;272:1851–1857.
  2. Goldhaber-Fiebert SN, Howard SK. Implementing emergency manuals: can cognitive aids help translate best practices for patient care during acute events. Anesth Analg. 2013;117:1149–1161.
  3. Goldhaber-Fiebert SN, Lei V, Nandagopal K, Bereknyei S. Emergency manual implementation: can brief simulation-based or staff trainings increase familiarity and planned clinical use?. Jt Comm J Qual Patient Saf. 2015;41:212–220.
  4. Goldhaber-Fiebert SN, Pollock J, Howard SK,et al. Emergency manual uses during actual critical events and changes in safety culture from the perspective of anesthesia residents: a pilot study. Anesth Analg. 2016;123:641–649.
  5. Huang J, Hoang P, Simmons W, Zhang J. Free emergency manual books improve actual clinical use during crisis in China. Cureus. 2019;11:e4821.
  6. Huang J, Sanchez K, Wu J, Suprun A. Best location and reader role in usage of emergency manuals during critical events: experienced emergency manual users’ opinions. Cureus. 2019;11: e4505.
  7. Fowler AJ, Agha RA. In response: simulation-based trial of surgical-crisis checklists. Ann Med Surg. 2013;2:31.
  8. Simmons W, Huang J. Operating room emergency manuals improve patient safety: a systemic review. Cureus. 2019;1:e4888. 10.7759/cureus.4888
  9. Morell RC, Cooper JB. APSF sponsors workshop on implementing emergency manuals. APSF Newsletter. 2016;30:68–71. Accessed October 7, 2019.
  10. Huang J, Wu J, Dai C, et al. Use of emergency manuals during actual critical events in China: a multi-institutional study. Simul Healthc. 2018;4:253–260.
  11. Kneebone R. Simulation in surgical training: educational issues and practical implications. Med Educ. 2003;37:267–277.
  12. Ericsson KA. Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Acad Med. 2004;79:S70–581.
  13. McGaghie WC, Issenberg SB, Cohen ER, et al. Does simulation-based medical education with deliberate practice yield better results than traditional clinical education? A meta analytic comparative review of the evidence. Acad Med. 2011;86:706–711.
  14. Daniels K, Arafeh J, Clark A, et al. Prospective randomized trial of simulation versus didactic teaching for obstetrical emergencies. Simul Healthc. 2010;5:40–45.
  15. Huang J, Parus A, Wu J, Zhang C. Simulation competition enhances emergency manual uses during actual critical events. Cureus. 2018;10:e3188. 10.7759/cureus.3188
  16. Zhang C, Zeng W, Rao Z, et al. Assessment of operating room emergency manual simulation training. [Article in Chinese]. Perioperative Safety and Quality Assurance. 2017;5:260-262.
  17. Huang J. Successful implementation of a two-hour emergency manual (EM) simulation instructor training course for anesthesia professionals in China. APSF Newsletter. Oct 2018;33:60–61. Accessed May 5, 2020.
  18. Neily J, DeRosier JM, Mills PD, et al. Awareness and use of a cognitive aid for anesthesiology. Jt Comm J Qual Patient Saf. 2007;33:502-511.
  19. Watkins SC, Anders S, Clebone A et al. Mode of information delivery does not effect anesthesia trainee performance during simulated perioperative pediatric critical events: a trial of paper versus electronic cognitive aids. Simul Healthc. 2016;11:385–393.