My interest is in implementation science, improving systems practice, quality improvement, and patient safety, often utilizing various tools from medical simulation that can translate to clinical changes. Currently, our group's main focus is understanding effective implementation and use of emergency manuals (context relevant sets of cognitive aids or checklists), for crisis management of critical events. We enjoy collaborating with multiple colleagues throughout healthcare and other safety-critical industries,
For background and free resources for implementing these tools see http://emergencymanual.stanford.edu/ from Stanford Anesthesia Cognitive Aid Group and www.emergencymanuals.org/ from the broader Emergency Manuals Implementation Collaborative
Clinical Professor, Anesthesiology, Perioperative and Pain Medicine
Board Certification: Anesthesia, American Board of Anesthesiology (2009)
Residency:Massachusetts General Hospital (2007) MA
Internship:Brigham and Women's Hospital Harvard Medical School (2004) MA
Medical Education:Harvard Medical School (2003) MA
Fellowship, Center for Medical Simulation, Harvard, Simulation (2007)
Current Research and Scholarly Interests
Implementation of emergency manuals (context relevant sets of cognitive aids or crisis checklists) and other evidence-based patient safety advances can help excellent clinicians to deliver optimal care, if designed and implemented effectively.
My, and our group's, interests include:
1. Implementation of emergency manuals for crisis management of critical events, in both simulation-based and clinical settings
For free resources, see: http://emergencymanual.stanford.edu, a website I developed to share the work of our Stanford Anesthesia Cognitive Aid Group and our interdisciplinary clinical implementation team. And www.emergencymanuals.org, Emergency Manuals Implementation Collaborative, which a group of us founded to freely share tools and implementation resources nationally and globally.
2. Applying mixed-methods of implementation science to research #1.
3. Utilizing high fidelity simulation along with debriefing to teach principles of Crisis Resource Management (CRM). Faculty for multiple courses and Co-Director of Stanford's Evolve simulation program.
4. Combining verbal 'What If's' with low-tech screen-based simulation to harness the power of simulation and debriefing in much wider, more frequent, and even clinical settings.
5. Difficult airway management, and ENT anesthesia, integrating procedural and full-scenario simulation to practice and debrief approaches to challenging cases.
Bringing Perioperative Emergency Manuals to Your Institution: A "How To" from Concept to Implementation in 10 Steps
JOINT COMMISSION JOURNAL ON QUALITY AND PATIENT SAFETY
2019; 45 (3): 170–79
Emergency manuals (EMs) are context-relevant sets of crisis checklists or cognitive aids designed to enable professional teams to deliver optimal care during critical events. Evidence from simulation and other high-risk industries have proven that use of these types of checklists can significantly improve event management and decrease omissions of key steps. However, simply printing and placing tools in operating rooms (ORs) is unlikely to be effective. How interventions are implemented influences whether clinicians actually change practice and whether patient care is affected. This article provides an in-depth description of a rigorous implementation plan with three goals: (1) place EMs in every anesthetizing location, (2) create interprofessional engagement, and (3) demonstrate that a majority of anesthesia clinicians would use the new tool in some way within the first year.The implementation of EMs included 10 steps across four distinct phases. EM use was measured using an electronic quality assurance tool, with data collected after each case about whether and how the EM was used.During the six months following implementation, 67.0% of clinicians had used the manual, with 24.1% using it for clinical care and 9.2% using it during a critical event.This article presents a framework and detailed description of the steps a large academic institution followed in successfully implementing EMs. In conjunction with other available resources, those interested in introducing OR EMs at large, complex institutions may benefit from the experience shared in anticipating challenges and overcoming barriers to adoption.
View details for DOI 10.1016/j.jcjq.2018.08.012
View details for Web of Science ID 000461797400005
View details for PubMedID 30341014
Cognitive Aids in Obstetric Units: Design, Implementation, and Use.
Anesthesia and analgesia
Obstetrics has unique considerations for high stakes and dynamic clinical care of ≥2 patients. Obstetric crisis situations require efficient and coordinated responses from the entire multidisciplinary team. Actions that teams perform, or omit, can strongly impact peripartum and perinatal outcomes. Cognitive aids are tools that aim to improve patient safety, efficiency in health care management, and patient outcomes. However, they are intended to be combined with clinician judgment and training, not as absolute or exhaustive standards of care for patient management. There is simulation-based evidence showing efficacy of cognitive aids for enhancing appropriate team management during crises, especially with a reader role, with growing literature supporting use in obstetric and nonobstetric clinical settings when combined with local customization and implementation efforts. The purpose of this article is to summarize current understanding and available resources for cognitive aid design, implementation, and use in obstetrics and to highlight existing gaps that can stimulate further enhancement in this field.
View details for DOI 10.1213/ANE.0000000000004354
View details for PubMedID 31425259
Use of an Emergency Manual During an Intraoperative Cardiac Arrest by an Interprofessional Team: A Positive-Exemplar Case Study of a New Patient Safety Tool
JOINT COMMISSION JOURNAL ON QUALITY AND PATIENT SAFETY
2018; 44 (8): 477–84
An emergency manual (EM) is a set of evidence-based crisis checklists, or cognitive aids, that can improve team performance. EMs are used in other safety-critical industries, and health care simulation studies have shown their efficacy, but use in clinical settings is nascent. A case study was conducted on the use of an EM during one intraoperative crisis, which entailed the assessment of the impact of the EM's use on teamwork and patient care and the identification of lessons for effectively using EMs during future clinical crises.In a case study of a single crisis, an EM was used during a cardiac arrest at a tertiary care hospital that had systematically implemented perioperative EMs. Semistructured interviews were conducted with all six clinicians present, interview transcripts were iteratively coded, and thematic analysis was performed.All clinician participants stated that EM use enabled effective team functioning via reducing stress of individual clinicians, fostering a calm work environment, and improving teamwork and communication. These impacts in turn improved the delivery of patient care during a clinical crisis and influenced participants' intended EM use during future appropriate crises.In this positive-exemplar case study, an EM was used to improve delivery of evidence-based patient care through effective clinical team functioning. EM use must complement rather than replace good clinician education, judgment, and teamwork. More broadly, understanding why and how things go well via analyzing positive-exemplar case studies, as a converse of root cause analyses for negative events, can be used to identify effective applications of safety innovations.
View details for PubMedID 30071967
Emergency Manuals: How Quality Improvement and Implementation Science Can Enable Better Perioperative Management During Crises.
2018; 36 (1): 45–62
How can teams manage critical events more effectively? There are commonly gaps in performance during perioperative crises, and emergency manuals are recently available tools that can improve team performance under stress, via multiple mechanisms. This article examines how the principles of implementation science and quality improvement were applied by multiple teams in the development, testing, and systematic implementations of emergency manuals in perioperative care. The core principles of implementation have relevance for future patient safety innovations perioperatively and beyond, and the concepts of emergency manuals and interprofessional teamwork are applicable for diverse fields throughout health care.
View details for PubMedID 29425598
Factors associated with the use of cognitive aids in operating room crises: a cross-sectional study of US hospitals and ambulatory surgical centers.
Implementation science : IS
2018; 13 (1): 50
Operating room (OR) crises are high-acuity events requiring rapid, coordinated management. Medical judgment and decision-making can be compromised in stressful situations, and clinicians may not experience a crisis for many years. A cognitive aid (e.g., checklist) for the most common types of crises in the OR may improve management during unexpected and rare events. While implementation strategies for innovations such as cognitive aids for routine use are becoming better understood, cognitive aids that are rarely used are not yet well understood. We examined organizational context and implementation process factors influencing the use of cognitive aids for OR crises.We conducted a cross-sectional study using a Web-based survey of individuals who had downloaded OR cognitive aids from the websites of Ariadne Labs or Stanford University between January 2013 and January 2016. In this paper, we report on the experience of 368 respondents from US hospitals and ambulatory surgical centers. We analyzed the relationship of more successful implementation (measured as reported regular cognitive aid use during applicable clinical events) with organizational context and with participation in a multi-step implementation process. We used multivariable logistic regression to identify significant predictors of reported, regular OR cognitive aid use during OR crises.In the multivariable logistic regression, small facility size was associated with a fourfold increase in the odds of a facility reporting more successful implementation (p = 0.0092). Completing more implementation steps was also significantly associated with more successful implementation; each implementation step completed was associated with just over 50% higher odds of more successful implementation (p ≤ 0.0001). More successful implementation was associated with leadership support (p < 0.0001) and dedicated time to train staff (p = 0.0189). Less successful implementation was associated with resistance among clinical providers to using cognitive aids (p < 0.0001), absence of an implementation champion (p = 0.0126), and unsatisfactory content or design of the cognitive aid (p = 0.0112).Successful implementation of cognitive aids in ORs was associated with a supportive organizational context and following a multi-step implementation process. Building strong organizational support and following a well-planned multi-step implementation process will likely increase the use of OR cognitive aids during intraoperative crises, which may improve patient outcomes.
View details for PubMedID 29580243
View details for PubMedCentralID PMC5870083
Operating Room Crisis Checklists and Emergency Manuals.
2017; 127 (2): 384–92
View details for PubMedID 28604405
Building Comprehensive Strategies for Obstetric Safety: Simulation Drills and Communication.
Anesthesia and analgesia
2016; 123 (5): 1181-1190
As pioneers in the field of patient safety, anesthesiologists are uniquely suited to help develop and implement safety strategies to minimize preventable harm on the labor and delivery unit. Most existing obstetric safety strategies are not comprehensive, lack input from anesthesiologists, are designed with a relatively narrow focus, or lack implementation details to allow customization for different units. This article attempts to address these gaps and build more comprehensive strategies by discussing the available evidence and multidisciplinary authors' local experience with obstetric simulation drills and optimization of team communication.
View details for PubMedID 27749353
Emergency Manual Uses During Actual Critical Events and Changes in Safety Culture From the Perspective of Anesthesia Residents: A Pilot Study.
Anesthesia and analgesia
2016; 123 (3): 641-649
Emergency manuals (EMs), context-relevant sets of cognitive aids or crisis checklists, have been used in high-hazard industries for decades, although this is a nascent field in health care. In the fall of 2012, Stanford clinically implemented EMs, including hanging physical copies in all Stanford operating rooms (ORs) and training OR clinicians on the use of, and rationale for, EMs. Although simulation studies have shown the effectiveness of EMs and similar tools when used by OR teams during crises, there are little data on clinical implementations and uses. In a subset of clinical users (ie, anesthesia residents), the objectives of this pilot study were to (1) assess perspectives on local OR safety culture regarding cognitive aid use before and after a systematic clinical implementation of EMs, although in the context of long-standing resident simulation trainings; and (2) to describe early clinical uses of EMs during critical events.Surveys collecting both quantitative and qualitative data were used to assess clinical adoption of EMs in the OR. A pre-implementation survey was e-mailed to Stanford anesthesia residents in mid-2011, followed by a post-implementation survey to a new cohort of residents in early 2014. The post-implementation survey included pre-implementation survey questions for exploratory comparison and additional questions for mixed-methods descriptive analyses regarding EM implementation, training, and clinical use during critical events since implementation.Response rates were similar for the pre- and post-implementation surveys, 52% and 57%, respectively. Comparing post- versus pre-implementation surveys in this pilot study, more residents: agreed or strongly agreed "the culture in the ORs where I work supports consulting a cognitive aid when appropriate" (73.8%, n = 31 vs 52.9%, n = 18, P = .0017) and chose more types of anesthesia professionals that "should use cognitive aids in some way," including fully trained anesthesiologists (z = -2.151, P = .0315). Fifteen months after clinical implementation of EMs, 19 respondents (45%) had used an EM during an actual critical event and 15 (78.9% of these) agreed or strongly agreed "the EM helped the team deliver better care to the patient" during that event, with the rest neutral. We present qualitative data for 16 of the 19 EM clinical use reports from free-text responses within the following domains: (1) triggering EM use, (2) reader role, (3) diagnosis and treatment, (4) patient care impact, and (5) barriers to EM use.Since Stanford's clinical implementation of EMs in 2012, many residents' self-report successful use of EMs during clinical critical events. Although these reports all come from a pilot study at a single institution, they serve as an early proof of concept for feasibility of clinical EM implementation and use. Larger, mixed-methods studies will be needed to better understand emerging facilitators and barriers and to determine generalizability.
View details for DOI 10.1213/ANE.0000000000001445
View details for PubMedID 27541721
Checklists and multidisciplinary team performance during simulated obstetric hemorrhage.
International journal of obstetric anesthesia
2016; 25: 9-16
Checklists can optimize team performance during medical crises. However, there has been limited examination of checklist use during obstetric crises. In this simulation study we exposed multidisciplinary teams to checklist training to evaluate checklist use and team performance during a severe postpartum hemorrhage.Fourteen multidisciplinary teams participated in a postpartum hemorrhage simulation occurring after vaginal delivery. Before participating, each team received checklist training. The primary study outcome was whether each team used the checklist during the simulation. Secondary outcomes were the times taken to activate our institution-specific massive transfusion protocol and commence red blood cell transfusion, and whether a designated checklist reader was used.The majority of teams (12/14 (86%)) used the checklist. Red blood cell transfusion was administered by all teams. The median [IQR] times taken to activate the massive transfusion protocol and transfuse red blood cells were 5min 14s [3:23-6:43] and 14min 40s [12:56-17:28], respectively. A designated checklist reader was used by 7/12 (58%) teams that used the checklist. Among teams that used a checklist with versus without a designated reader, we observed no differences in the times to activate the massive transfusion protocol or to commence red blood cell transfusion (P>0.05).Although checklist training was effective in promoting checklist use, multidisciplinary teams varied in their scope of checklist use during a postpartum hemorrhage simulation. Future studies are required to determine whether structured checklist training can result in more standardized checklist use during a postpartum hemorrhage.
View details for DOI 10.1016/j.ijoa.2015.08.011
View details for PubMedID 26421705
Emergency manual implementation: can brief simulation-based or staff trainings increase familiarity and planned clinical use?
Joint Commission journal on quality and patient safety / Joint Commission Resources
2015; 41 (5): 212-217
Emergency manuals (EMs)-context-relevant sets of cognitive aids such as crisis checklists-are useful tools to enhance perioperative patient care. Studies in high-hazard industries demonstrate that humans, regardless of expertise, do not optimally retrieve or deploy key knowledge under stress. EM use has been shown in both health care simulation studies and other industries to help expert teams effectively manage critical events. However, clinical adoption and use are still nascent in health care. Recognizing that training with, access to, and cultural acceptance of EMs can be vital elements for successful implementation, this study assessed the impact of a brief in situ operating room (OR) staff training program on familiarity with EMs and intention to use them during critical events.Nine 50-minute training sessions were held with OR staff as part of a broader perioperative EM implementation. Participants primarily included OR nurses and surgical technologists. The simulation-based in situ trainings included why and how to use EMs, familiarization with format, simulated scenarios of critical events, and debriefings. A retrospective pre-post survey was conducted to determine participants' levels of EM familiarity and intentions to use EMs clinically.The 126 trained OR staff self-reported increases in awareness of the EM (p < .01), familiarity with EM (p < .01), willingness to use for educational review (p < .01), and intention to use during critical events (p < .01). Participants rated the sessions highly and expressed interest in more opportunities to practice using EMs.Implementing institutions should not only provide EMs in accessible places in ORs but also incorporate training mechanisms to increase clinicians' familiarity, cultural acceptance, and planned clinical use.
View details for PubMedID 25977248
- In response. Anesthesia and analgesia 2014; 118 (6): 1389-1390
Implementing emergency manuals: can cognitive AIDS help translate best practices for patient care during acute events?
Anesthesia and analgesia
2013; 117 (5): 1149-1161
In this article, we address whether emergency manuals are an effective means of helping anesthesiologists and perioperative teams apply known best practices for critical events. We review the relevant history of such cognitive aids in health care, as well as examples from other high stakes industries, and describe why emergency manuals have a role in improving patient care during certain events. We propose 4 vital elements: create, familiarize, use, and integrate, necessary for the widespread, successful development, and implementation of medical emergency manuals, using the specific example of the perioperative setting. The details of each element are presented, drawing from the medical literature as well as from our combined experience of more than 30 years of observing teams of anesthesiologists managing simulated and real critical events. We emphasize the importance of training clinicians in the use of emergency manuals for education on content, format, and location. Finally, we discuss cultural readiness for change, present a system example of successful integration, and highlight the importance of further research on the implementation of emergency manuals.
View details for DOI 10.1213/ANE.0b013e318298867a
View details for PubMedID 24108251
Simulation Exercises as a Patient Safety Strategy A Systematic Review
ANNALS OF INTERNAL MEDICINE
2013; 158 (5): 426-?
Simulation is a versatile technique used in a variety of health care settings for a variety of purposes, but the extent to which simulation may improve patient safety remains unknown. This systematic review examined evidence on the effects of simulation techniques on patient safety outcomes. PubMed and the Cochrane Library were searched from their beginning to 31 October 2012 to identify relevant studies. A single reviewer screened 913 abstracts and selected and abstracted data from 38 studies that reported outcomes during care of real patients after patient-, team-, or system-level simulation interventions. Studies varied widely in the quality of methodological design and description of simulation activities, but in general, simulation interventions improved the technical performance of individual clinicians and teams during critical events and complex procedures. Limited evidence suggested improvements in patient outcomes attributable to simulation exercises at the health system level. Future studies would benefit from standardized reporting of simulation components and identification of robust patient safety targets.
View details for Web of Science ID 000316058600010
View details for PubMedID 23460100
- Trigger Video of Simulated Intraoperative Cardiac Arrest. MedEdPORTAL 2010
Knowledge-based errors in anesthesia: a paired, controlled trial of learning and retention
CANADIAN JOURNAL OF ANAESTHESIA-JOURNAL CANADIEN D ANESTHESIE
2009; 56 (1): 35-45
Optimizing patient safety by improving the training of physicians is a major challenge of medical education. In this pilot study, we hypothesized that a brief lecture, targeted to rare but potentially dangerous situations, could improve anesthesia practitioners' knowledge levels with significant retention of learning at six months.In this paired controlled trial, anesthesia residents and attending physicians at Massachusetts General Hospital took the same 14-question multiple choice examination three times: at baseline, immediately after a brief lecture, and six months later. The lecture covered material on seven "intervention" questions; the remaining seven were "control" questions. The authors measured immediate knowledge acquisition, defined as the change in percentage of correct answers on intervention questions between baseline and post-lecture, and measured learning retention as the difference between baseline and six months. Both measurements were corrected for change in performance on control questions.Fifty of the 89 subjects completed all three examinations. The post-lecture increase in percentage of questions answered correctly, adjusted for control, was 22.2% [95% confidence interval (CI) 16.0-28.4%; P < 0.01], while the adjusted increase at six months was 7.9% (95% CI 1.1-14.7%; P = 0.024).A brief lecture improved knowledge, and the subjects retained a significant amount of this learning at six months. Exposing residents or other practitioners to this type of inexpensive teaching intervention may help them to avoid preventable uncommon errors that are rooted in unfamiliarity with the situation or the equipment. The methods used for this study may also be applied to compare the effect of various other teaching modalities while, at the same time, preserving participant anonymity and making adjustments for ongoing learning.
View details for DOI 10.1007/s12630-008-9002-9
View details for Web of Science ID 000263012800006
View details for PubMedID 19247776
Male involvement in cardiovascular preventive healthcare in two rural Costa Rican communities
2005; 40 (6): 690-695
Gender differences in health system usage can lead to differences in the incidence of morbidity and mortality. We conducted a pilot screening targeted towards men to evaluate gender differences in cardiovascular disease risk factor detection and time since last clinic visit.Three evening sessions in two communities screened 148 people, mean age 47.7 years. Height, weight, body mass index, blood pressure, blood glucose, and total cholesterol were measured. A questionnaire on past medical history was administered. Participants with elevated measurements were referred to appropriate care.Men accounted for 60.1% of those screened; 65.5% of the group was overweight, and 22.3% was obese with 42.6% hypertension, 39.2% hypercholesterolemia, and 2.7% high blood glucose. Among men aged 35 to 65, 65.2% were overweight, 20.3% obese, 46.4% hypertensive, 42.0% hypercholesterolemic, and 1.5% with high blood glucose. Within the last 2 years, 53.3% of men and 9.1% of women aged 35 to 65 had not visited a doctor (P = 0.004).A significant portion of those screened had elevated cardiovascular disease risk factors. Given that men visited doctors significantly less frequently, efforts to involve men in prevention of cardiovascular disease within these communities are warranted.
View details for DOI 10.1016/j.ypmed.2004.09.009
View details for Web of Science ID 000229006700011
View details for PubMedID 15850866
Randomized controlled community-based nutrition and exercise intervention improves glycemia and cardiovascular risk factors in type 2 diabetic patients in rural Costa Rica
2003; 26 (1): 24-29
The prevalence of type 2 diabetes, especially in developing countries, has grown over the past decades. We performed a controlled clinical study to determine whether a community-based, group-centered public health intervention addressing nutrition and exercise can ameliorate glycemic control and associated cardiovascular risk factors in type 2 diabetic patients in rural Costa Rica.A total of 75 adults with type 2 diabetes, mean age 59 years, were randomly assigned to the intervention group or the control group. All participants received basic diabetes education. The subjects in the intervention group participated in 11 weekly nutrition classes (90 min each session). Subjects for whom exercise was deemed safe also participated in triweekly walking groups (60 min each session). Glycosylated hemoglobin, fasting plasma glucose, total cholesterol, triglycerides, HDL and LDL cholesterol, height, weight, BMI, and blood pressure were measured at baseline and the end of the study (after 12 weeks).The intervention group lost 1.0 +/- 2.2 kg compared with a weight gain in the control group of 0.4 +/- 2.3 kg (P = 0.028). Fasting plasma glucose decreased 19 +/- 55 mg/dl in the intervention group and increased 16 +/- 78 mg/dl in the control group (P = 0.048). Glycosylated hemoglobin decreased 1.8 +/- 2.3% in the intervention group and 0.4 +/- 2.3% in the control group (P = 0.028).Glycemic control of type 2 diabetic patients can be improved through community-based, group-centered public health interventions addressing nutrition and exercise. This pilot study provides an economically feasible model for programs that aim to improve the health status of people with type 2 diabetes.
View details for Web of Science ID 000185504900004
View details for PubMedID 12502654