agree or no: anesthesia needs more formal checklists

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Agree, yes.
How many times have you come in to help a resident or CRNA with extubation to find no suction, or it's there but not working because it was never checked. Or your reversal drugs are not there because you used them all up on the last patient and it was not restocked. Some things, like a bougie, are rarely used and more rarely checked so if it was used the day before and not replaced, you're left high and dry.
A properly used check list avoids that kind of stuff 100% of the time.
Some of the other check lists are dumb, but a written "per flight" check list would be useful. Most of us probably run one in our head when we're sitting for our own cases, but supervising opens the door to missing important things.
 
Checklists are fine, I use a mental one for equipment checks and preinduction. But I'm not sure I need or would benefit from a printed checklist.

If anything needs to be fixed, it's the guys who show up 6 minutes before their case is scheduled to start and just trust the AM tech's machine checkout. Giving those people a laminated list of things to check won't help.

I don't particularly like the aviation analogies. I'm not a pilot. Well, I am, but I haven't flown a plane in almost 20 years. I think the central line checklist the RN foists off on me every time I stick a neck is utterly ******ed. I'd hate to see that particular strain of idiocy spread. I'm reluctant to buy off on any kind of checklist mandate. I suspect that if they became "standardized" that I wouldn't like whatever list some committee came up with and stapled to the anesthesia machine.
 
anyone have a great checklist or resource that would be useful for a medical student completing an anesthesia rotation?
 
I don't know the answer as to whether we need "more" checklists, but the data is clear that pre-surgical checklists/timeouts have saved lives and prevented unnecessary morbidity. It might feel ritualistic, but even if you're not paying attention, someone else may be and harm can be avoided.
 
A checklist / timeout to verify correct patient, correct surgery, correct side, abx given, etc is one thing.

The checklist that requires an observer to tic off the "wire not left in patient" box when I'm placing a central line is idiocy.

I fear the helpful but uninformed people who are likely to mandate checklists will compose more of the latter and less of the former. They tend to be nonclinicians more familiar with clipboards than medicine, and they think their lean sigma six black belt and systems engineering background and brainstorming over bagels meeting proves that all you have to do to prevent all complications is write the perfect policy.



I contend that the most beneficial checklist for anesthesiologists would have one line and one box on it: [] do a machine check

Of course, those people probably need another one-item checklist: [] complete the checklist telling you to do a machine check

Eventually it'll be checklists all the way down.
 
pgg said:
A checklist / timeout to verify correct patient, correct surgery, correct side, abx given, etc is one thing.

The checklist that requires an observer to tic off the "wire not left in patient" box when I'm placing a central line is idiocy.

I fear the helpful but uninformed people who are likely to mandate checklists will compose more of the latter and less of the former. They tend to be nonclinicians more familiar with clipboards than medicine, and they think their lean sigma six black belt and systems engineering background and brainstorming over bagels meeting proves that all you have to do to prevent all complications is write the perfect policy.

I contend that the most beneficial checklist for anesthesiologists would have one line and one box on it: [] do a machine check

Of course, those people probably need another one-item checklist: [] complete the checklist telling you to do a machine check

Eventually it'll be checklists all the way down.
Click to expand...

Heh. Agree, although I'd still like to see one like:

[] machine checked
[] suction checked
[] airway equipment present and properly working
[] drugs present and, where applicable, drawn up

Personally, I think the aviation analogy is great, at least as far as dealing with equipment. And just like pilots have to run their checklists, even if they're running late, I think that establishing the idea of "haste should not trump safety" in OR culture would be healthy.
 
norwood said:
[] machine checked
[] suction checked
[] airway equipment present and properly working
[] drugs present and, where applicable, drawn up
Click to expand...

On our paper anesthesia records, the first three of those are actually listed. Of course, those boxes get checked when we do our charting, after induction ... which negates the purpose of a checklist in the first place.

And that's the funny thing about checklists when they become mandated ... at some point, they tend to cease being "checklists" and they become "charting" ... because you know the OR RN will have a checklist item "[] anesthesiologist used anesthesia checklist"

Anyway, that checklist wouldn't stop there. Eventually it'd be
[] endotracheal tube taped in place
[] eyes taped
[] if patient is crazy, eyes taped with hypoallergenic paper tape
[] OG tube placed (if indicated)
[] low-volume ventilation strategy of 6 cc/kg used (if indicated)
[] arterial line placed (if indicated)
[] form 63B-Q checklist (arterial line placement checklist) completed
[] inspired O2 % at appropriate level
[] if airway procedure, inspired O2 % reduced below 30%
[] desflurane vaporizer turned to appropriate concentration
[] desflurane vaporizer at least half full
[] desflurane vaporizer plugged in
[] desflurane vaporizer preventive maintenance sticker in correct place


Maybe I'm being irrational.
 
Big NO to further checklists. They are proliferating in my hospital like the rest of the cancer which is healthcare bureaucracy. We, as a society, should start attaching the true cost to all these cretin bureaucratic procedures; time does not come free. An extra minute of bureucracy per hour probably increases the cost of healthcare by 1.5%. How many such minutes do we actually waste daily?

I haven't seen this amount of crap since my childhood in a communist country.

P.S. Those who need a checklist for suction etc. may be in the wrong field. I am all for mnemotechnics like MSMAID, or an optional printed list as a reminder, especially for residents/CRNAs, but not official checklists.
 
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FFP said:
Big NO to further checklists. They are proliferating in my hospital like the rest of the cancer which is healthcare bureaucracy. We, as a society, should start attaching the true cost to all these cretin bureaucratic procedures; time does not come free. An extra minute of bureucracy per hour probably increases the cost of healthcare by 1.5%. How many such minutes do we actually waste daily?

I haven't seen this amount of crap since my childhood in a communist country.

P.S. Those who need a checklist for suction etc. maybe are in the wrong field. I am all for mnemotechnics like MSMAID, or an optional printed list as a reminder, especially for residents/CRNAs, but not official checklists.
Click to expand...
I use MMAIDS but I like MSMAID better 🙂
 
BobBarker said:
I use MSMAIDS every case.
Click to expand...

+1.

No, we don't need more checklists. People need to engage their brain, keep it simple, and use common sense.

IMHO the most beneficial checklist for anesthesiologists would have two lines:
[] constant vigilance
[] repeat line #1
 
Agree with using MSMAIDS mentally with every case. Recently, I started running back through it immediately before the start and again toward the end of the case, as I have had more than a few instances where I had suction when I set up my room a few minutes before bringing the patient back, but some OR nurse unplugged it without telling me. That happened most recently on an emergent CABG that aspirated on induction.

A printed checklist would not make anything we do any safer.
 
psychbender said:
Agree with using MSMAIDS mentally with every case. Recently, I started running back through it immediately before the start and again toward the end of the case, as I have had more than a few instances where I had suction when I set up my room a few minutes before bringing the patient back, but some OR nurse unplugged it without telling me. That happened most recently on an emergent CABG that aspirated on induction.

A printed checklist would not make anything we do any safer.
Click to expand...

I had an anesthesia tech remove the etco2 canister while I was pushing the pt to the OR. No PPV. Good preox and I was able to replace the canister before having to break out the ambubag.
 
The problem there is not the absence of a checklist, but the stupidity of the tech. This is almost like being boycotted. One cannot make checklists for everything, and even then one can have malfunctioning sensors. But sheer human stupidity should be punished with a pink slip; IQ doesn't get better with age.
 
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BobBarker said:
I had an anesthesia tech remove the etco2 canister while I was pushing the pt to the OR. No PPV. Good preox and I was able to replace the canister before having to break out the ambubag.
Click to expand...

I always check the machine for positive pressure before inducing. Too many saboteurs in the OR: residents, fellows, crnas, nurses, techs.

What does MSMAIDS stand for?
 
I always had the second S stand for "Stuff," as in anything else not already covered. Example: You plan on doing a spinal for the case, do you have a kit in the room? Is the blood that you requested for this re-do sternotomy in the room?
 
Thats just what we need.

A mandatory 113-point checklist that any person with reading comprehension skills and a knowledge of OR equipment can follow.

Next week, a mindless robot could take your job.
 
Checklists are a hot topic, but have proven effects.
The big, philosophical question that rankles most of the people I talk to about this is how they feel it's "dumbing things down."

It's not, we're just looking at it the wrong way.

The whole point of a checklist, in aviation, or in anaesthesia, is to minimize variation in critical situations, and serve as a guide during rapidly evolving critical events.

We deal with a lot of unstable situations. It's part of our job, and for a lot of us, part of the attraction to the job. Regardless of how good we feel we are at managing drama and trauma, we're fairly poor at handling surprises.

Think of the times you've had a patient rapidly go south. . . most of the time you have at least an idea of why, or have been watching the decline, trying to fight it.
When things surprisingly go wrong and we don't have a perspective on where it's coming from, we tend to flail around in a first response panic, and in these situations we often miss things. Critical things.

Experience helps minimize the number of "surprises" we come against, but at what cost does this come? Patient harm? Patient's lives?

Checklists work to help organize not just yourself, but also your team (which is what happens when you push that "arrest" buzzer on the wall, it goes from you to a big mess of people). When practiced they also help streamline communication amongst team members in critical events.

Those critical of checklists should be. You can't just throw together a bunch of ideas, laminate them and tape them onto a wall, hoping it will work or make a difference.

They need to be developed, evaluated, vetted, and then practiced.

I'm a big believer in checklists, but I'm also one of their biggest critics.
I work with medical simulators and trauma team training, and for a checklist to work, it needs to be slick, functional, and it needs to be practiced. . . even just a little bit.

If you're really, genuinely, interested in this topic, a significant part of the november 2013 issue of A&A was about checklists in anesthesia.

http://journals.lww.com/anesthesia-analgesia/toc/2013/11000

Here's one for peds:
http://bja.oxfordjournals.org/content/111/6/1027.full.pdf+html

Again,
The key thing is not pasting some piece of crap together and taping it to the wall.
 
S&M MAIDS is far better.
 
Hell No!

Our patients are not machines and should not be treated as such.

Checklists are so successful in the airlines industry because you are dealing with issues that develop in a man-made machine and the human interface with it.

In anesthesia they are at best a joke and at worst a disaster waiting to happen.

What happens when the system deviates from your checklist? Are you now lost because you habitually rely on a checklist to keep you safe? Was the checklist harmful because you were focused on it and not your patient (seen that one happen with some of the BS surgical checklists).

S&M MAIDS... Yum!

- pod
 
I think we can all agree that the use of a checklist for things which we already do is pointless and a nuisance. I take as an example when the OR nurse comes up to me halfway through the case, and asks if I did my machine check, and if I thought the patient was going to be a difficult airway. This is box-checking for the sake of box-checking at its worst. It does nothing to alter patient care, is annoying, and serves no purpose other than to please some non-clinical bean counter in a cubicle.

I would divide the useful checklists into two categories. In keeping with the aviation analogy (bear with me): some checklists are more like pre-flight checklists- i.e. a list of things to be done in order to safely provide anesthesia. MSMAIDS is such an checklist, although some prefer to call it a mnemonic. You don't proceed to administer anesthesia unless the Machine, Suction, Monitors, Airway, IV, Meds, Stool/stuff/special are already in place and ready to go. Like it or not, this is a checklist. We just generally don't use a paper with these listed on it with check boxes.

The other category of checklists are those used in a crisis. A more palatable description that might not conjure up images of OR nurses asking ill-timed questions, is that of "cognitive aid". In keeping with the aviation analogy, you surely would hope that the pilot knows how to react to a hydraulic failure, or engine fire, or bird strike, or whatever disaster happens, WITHOUT a checklist, but the checklist is there to ensure that he does so without omitting a crucial step. The point is not that the pilot is dependent on the checklist to perform his tasks, but that the cognitive aid assists in the execution thereof.

For example, at our hospital the malignant hyperthermia and regional anesthesia carts all have checklists for things to do and things to think about during MH or LAST. These are relatively rare occurranes, and as such the immediate management may not be at the tips of your mental fingertips. The checklist exists to assist, but not replace a well trained physician.

Yes, we should know how to react in a crisis without being dependent on a checklist, but I think the real strength lies in its ability to be a cognitive aid, to suggest alternative diagnoses, and to help mitigate some of the cognitive biases that can occur during stressful, rapidly evolving situations. The availability of a checklist should not supplant, but rather complement the training of a clinician.

The manner in which checklists are implemented and used of course plays a huge role in how they are accepted and ultimately if they prove useful. As in my previous example, having the OR RN do a "safety check" which requires her to ask me inane questions without impact on patient care is frankly idiotic. Just posting a few on the OR wall is also a poor method for implementation.
 
geogil, that was a great answer. In the end, ACLS, the ACC/AHA preop guidelines and all our algorithms are checklists.

However, the bureaucrats tend to overdo these things on such a scale that any intelligent physician's response to more checklists will be an idiosyncratic and emphatic "No!". The airplane cockpit contains just 3 people, but the OR and periop are full of nurses that need to check fields on their electronic "clipboards".

Checklists/algorithms are great for people who are not actually good at their jobs (remember nurses looking up the BLS/ACLS during a code?). They are also good as reminders - for example, as part of the EHR anesthesia script (it reminds me occasionally that I forgot to connect the warmer - that's about it), or in the case of rare complications and treatments (we have the intralipid administration doses on the wall in our OR's, the MH cart comes with a bunch of instructions etc.). However, I don't see many applications for them in 99% of anesthesia. This is an acute and intensive care specialty; if one needs printed checklists for more than a few rare things, one should not be in it.

Constant and obsessive vigilance is truly the best checklist.
 
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A key question is who gets to wield the checklist in a crisis. The last thing you want is someone who doesn't really understand what's going on demanding you do something on a checklist, simply because the list says you have to. Getting physician buy-in is key to success as well, otherwise it will be another bureaucratic hassle that eventually is superseded by yet another bureaucratic hassle. As you can see even on this board, there is strong resistance to the idea, perhaps justifiably, perhaps not, with the underlying notion being essentially "you're a physician, you should know how to do this".

I just finished my first quarter of cardiac and to me, this seems to be an area ripe for the use of the pre-flight type of checklist. If nothing else, a simple list of things that should be all ready to go, for example, to come off pump. This does not have to be in the hands of anyone other than the anesthesiologist, but serves to remind you of everything you need to have ready (or hopefully is already in place), i.e. Zoll on the correct setting, pacer handy, calcium, epi, vaso, ventilator, volatile, paralytic, etc…. I recall several years ago one of the senior posters here (Jet maybe even?) stated that they had made themselves a checklist for coming off pump, and this was prior to checklists be en vogue
 
There is a huge difference between having checklists and being obliged to go through them.

On the other hand, the more things we standardize in anesthesia/medicine, the more replaceable we become. Haven't we learned anything? Just look at what happened to the pilots. 😉
 
urge said:
I always check the machine for positive pressure before inducing. Too many saboteurs in the OR: residents, fellows, crnas, nurses, techs.

What does MSMAIDS stand for?
Click to expand...
I use DAMMIT.... drugs, airway,monitors, machines IV, tubes,
 
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