PROVIDING INFORMATION BY STANDARDS, GUIDELINES, COGNITIVE AIDSStandards and guidelines provide relevant information for the best treatment options to reduce outdated and inefficient practice. While standards are criteria established by authority that result in best outcomes, guidelines are “practical helpers” that explain how to perform a task. Guidelines and cognitive aids offer the possibili-ty to bundle the enormous amount of knowledge and provide it to clinicians.

Not the silver bullet Nevertheless, there are no guidelines for every situation, and the information overload might even result in conflicting guidelines to

the same topic. Full compliance is often hindered due to the com-plexity of the rules, multiple versions, or the unawareness of the existence of all rules because of their obscure location or inade-quate dissemination 16. For example, in the UK there are about 75 guidelines and policies for a patient admitted for emergency surgery on a femoral neck fracture. Also, inconsistencies exist regarding anaesthesia monitoring recommendations in different parts of the world, especially for cardiopulmonary parameters 13. To simplify and standardise guidelines at (inter)national and local level and also to involve healthcare staff in the development phase will increase the compliance to guidelines and therefore the quality in patient care.

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Why are standards necessary but tricky?Standards offer some challenges as they often stick to a linear and stable work environment which require the “standard patient” un-der “standard conditions”. So, although standards are crucial and useful, sometimes a mindful adaptation of working patterns may be required in this complex dynamic environment. This adaptati-on should be based on “proper education and training as well as acquiring the mindset of safe performance and teamwork” 3. In this

WORK AS IMAGINED AND WORK AS DONEWork-as-imagined differs from what actually goes on (work-as-do-ne) and the difference increases the further people are away from the ‘front line’. Work-as-imagined cannot represent the complexity of clinical work with varying circumstances, diversity of patients or missing resources 14. New approaches are necessary that allow for the complexity of clinical work like the concept of Safety-II as described above. Nevertheless, standards are crucial in order to agree on com-mon ways on how to perform the tasks and to prevent the need

context, the term “resilience” is often used which describes the ability to respond effectively by shifts in performance in response to varying demands to keep the number of intended outcomes as high as possible. But it should be kept in mind: while the ability of resilience is valuable and important, the ability of humans to adapt should not serve as an excuse for the system not to make changes itself.

to reinvent the wheel every single day. But standards have their limitations as they will never be able to cover all conditions in a complex world. So, front-end clinicians must be enabled to deviate from a standard when that standard does not meet the demands (resilience).

In the following example, you can see the flow through an emer-gency department: in the first picture “work as imagined”, in the second “work as done”. This example illustrates the contrast of the ideal standardised work flow to the “real life scenario”:

“Given the inherent unreliability of the (healthcare) system it now seems remarkable that there are so few adverse

events, which is probably testament to the resilience and powers of recovery of clinical staff.” 17

WORK-AS-IMAGINED The ideal standardised workflow often doesn’t include varying circumstances or the complexity of real-life situations, but describes the processes in a straight and simple way.

The idealized notion of an emergency room visit

WORK-AS-DONECompared to the imagined scenario, work-as-done often differs a lot from the ideal standardised situation as real-life-scenarios have to deal with daily challenges like diversity of situations or missing resources.

Work-related problem-solving network in an emergency department, “work as done” 18

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Learn more about the eGENA Appwww.bda.de/projekte-themen/egena/egena-the-german-digital-cognitive-aid-for-crisis-management-in-anaesthesiology.html

In sum, standards, guidelines and cognitive aids are valuable tools in keeping track of the high demands in healthcare management, and current movements are aimed at integrating the complex dy-

namic processes. But they are no “silver bullet” when it comes to handling complexity – an exponential increase in knowledge makes it more and more difficult to extract the relevant facts for the practical work done at the ‘front line’. Nevertheless, new approaches like digital cognitive aids supported by other new concepts like Safety-II show efforts are being made for a modern management of the current challenges.

Cognitive aids – what are the new trends? Standford Emergency Manual

eGENA

HELPFUL TOOLS. PREVENT AND MANAGE CRITICAL INCIDENTS IN ANAESTHESIA

In stressful situations, cognitive aids may offer a quick reference guide. They concentrate on relevant knowledge and bring it in a handy size to the clinician’s workplace. For example, a well-estab-lished emergency manual is provided by the Stanford Anaesthesia Cognitive Aid Group and can be downloaded in several languages:

Learn more about the Standford Emergency Manualhttps://emergencymanual.stanford.edu

Checklists, manuals and action cards are mainly provided in a paper-based and static format. The Professional Association of German Anaesthesiologists (BDA) and the German Society of Anaesthesiology and Intensive Care Medicine (DGAI) recently developed a digital cognitive aid for intra- and postoperative emer-gencies using a user-centred design process. The progressive-web-application eGENA stores information offline on stationary and mobile devices, gets updates if online, and can be added with lo-cally relevant information like phone numbers or storage locations. It can be downloaded for free and is currently available in German, but requests for foreign language collaborations are welcome.

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REPORTING SYSTEMS – WHAT CAN WE LEARN FROM THE REPORTING OF CRITICAL INCIDENTS? Critical incident reporting systems (CIRS) have been imple-mented in healthcare in many nations in the last decades 20 and provide a mechanism to raise concerns of human actions, technical problems as well as human-machine-interactions voluntarily and an-onymously. Some reporting systems focus on a special area, some are public while others are private. There are national reporting systems, but some hospitals are also implementing their own local reporting systems. This offers the possibility to directly react to the reported events by local system changes; on the other hand, it involves the risk that valuable reports get lost for the community if the local CIRS management does not forward those reports to national systems. In a survey about patient safety in 2019, many of the interviewed European anaesthesiologists “felt that incidents reports went no further than departmental ‘chiefs’, and did not feel any further sharing took place” 1. Timely feedback is therefore crucial to keep the staff motivated to report incidents and to take the opportunity to learn from these events.

Incident Reporting Systems are an important tool for organisations to identify risks, but there are also limitations that should be kept in mind 21: They are not suited to measure safety (error rates of over- and underreporting) or compare organisations, and they can-not measure safety changes over time (reporting bias). Keeping these aspects in mind, we can focus on what reporting systems are able to provide: They can be used to educate and inform based on individual cases; they can detect local safety hazards and if done on a supra-regional level they can even detect clusters of hazards. All CIRS systems are based on a culture of transparency – “What happens in Vegas does NOT stay in Vegas.”

To optimise safety culture and the use of reporting systems, some aspects would be helpful:- simple, confidential systems with quick access- a patient safety officer who investigates events that have merit- the reporter should get timely feedback to make incident re-

porting more meaningful and increase future reporting- the reporting should be shared with staff- blaming or accusations must be avoided- institutions should be willing to change- prioritise events that need to be reported to focus more on

meaningful investigations.With these strategies in mind, reporting systems may maximise their value 21,22.

As an example, the German CIRS for anaesthesiology and intensi-ve care can be found here: https://www.cirs-ains.de/

Beneath these abstract supporting tools like guidelines and reporting systems, there are also tools available to support the anaesthesia team with a practical approach, for example simulation training to improve technical as well as teamwork skills.

SIMULATION TRAININGHOW CAN SIMULATION TRAINING HELP TO IMPROVE PATIENTS’ SAFETY?Simulation is another helpful tool to improve patient safety. In a proactive way, it can train difficult procedures to internalise work patterns so that the clinician is able to act adequately in stressful situations with a high cognitive workload. Besides, simulation can help diagnose unsafe or inefficient aspects of the work environ-ment without the risk of harming patients. In Germany, the term “protected environment” is therefore frequently used within the framework of postgraduate education in anaesthesiology23.

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Starting with technical simulation…In the 1960s, technical simulation started with the first resus-citation mannequin “Resusci Anne”, followed by true high-fidelity simulators integrating the operating room monitors in the late 1980s 24. In the last decades, education by simulation training for technical skills has developed and has shown its effectiven-ess compared to traditional clinical education 4. Also, simulation techniques using augmented reality have demonstrated benefits over conventional learning techniques and have been used for the simulation of central vein catheterisation, lumbar puncture, and ultrasound examination for trauma. Furthermore, simulation allows physicians to practice rare but potentially fatal conditions like mali-gnant hyperthermia 24.

… complementing with non-technical skills (CRM)In-depth investigations revealed that teamwork failures are often related to errors rather than deficiencies in knowledge or technical skills 25. So, in addition to the technical simulation, the develop-ment of non-technical skills came more and more into focus. In the 1990s, the first Crew Resource Management (CRM) courses were implemented that focused on crucial teamwork skills inspired

by the aviation industry 26. Cognitive skills like decision-making or planning are combined with social skills such as communication and team work. This means that in real stressful situations, the team is familiarised not just with local protocols and equipment, but also with the skills, background and experience of the colle-agues and how to work as a team and communicate in the best way.

A growing body of evidence demonstrated the effectiveness of CRM programs in reducing adverse patient outcomes and enhan-cing team performance 27. A structured debriefing allows partici-pants to review their performance and provides a critical compo-nent of training 25. Involving a multidisciplinary team with members from surgery, anaesthesia, and nursing is also a relevant factor for best training results.

As simulation trainings become more and more cost-effective and flexible using portable and/or virtual reality solutions, innovative learning by simulation has the power to be broadly implemented and thereby improving the quality of clinical care.

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In our article on critical incidents in anaesthesia, we reviewed relevant literature and discussed with renowned experts to provide an overview. For references and details, please visit our website: www.draeger.com/patient-safety

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Images: Simulation Center of the Hannover Medical School, Hannover, Germany.

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REFERENCES

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