New OR Checklist Tool Kit Combats ‘Print and Pluck’ Practices

First introduced to the medical community in 2012, the Ariadne Labs Operating Room Crisis Checklists have been shown to provide a significant boost to the completeness of clinician response to operating room (OR) critical events. Yet success depends on comprehensive implementation.

Now, however, a collaboration between Ariadne and Stanford School of Medicine has resulted in the OR Emergency Checklist Implementation Toolkit (ImplementingEmergencyChecklists.org), an easy, comprehensive, step-by-step online tool that can help surgical teams realize the full potential of the checklists. As organizers told Anesthesiology News, they hope the implementation tool kit will help prevent what they call the “print and plunk” phenomenon that often afflicts many medical checklists.

“The English-language versions of the checklists have been downloaded more than 60,000 times,” said Alexander A. Hannenberg, MD, a member of the research faculty of Boston-based Ariadne Labs, and the chief quality officer of the American Society of Anesthesiologists. “But once downloaded, what does it take to actually make the checklists part of clinical practice? Both in real life and in simulation, it’s dramatic to see clinicians stand a foot away from a guide and forget about its existence at the moment they actually need it.”

Next, researchers surveyed nearly 2,000 clinicians who downloaded either Ariadne Labs OR Crisis Checklists or Stanford’s “Emergency Manual: Cognitive Aids for Perioperative Critical Events.”

“To no surprise, the more implementation-related activities you undertake, the more likely you are to be successful,” Dr. Hannenberg said. “By comparison, the ones that just printed and plunked were generally unsuccessful in producing reliable utilization.”

As a result of this study, the researchers built a list of implementation strategies that could be adapted for a variety of settings:

• Identify a clinical champion.
• Get buy-in from clinical and administrative leadership and front-line clinical staff.
• Create a multidisciplinary team.
• Select, customize and test the checklists.
• Train staff.
• Start using the checklists.
• Monitor use.
• Spread the use of the checklists beyond the OR.

Knowing that a simple list of strategies would have limited effect, the collaborators turned digital. The result is a hands-on, dynamic website that not only explains the tool kit but also walks surgical teams through its various steps and describes examples of successful implementation. Indeed, the tool kit includes videos, tutorials, customizable templates for checklist adaptations and even links to simulation apps.

“And we go into fairly excruciating levels of detail, for example, providing the Staples catalog numbers of the binder, sheet protectors and dividers that users have found to work well in printing and binding the checklist for distribution,” Dr. Hannenberg said. Overkill? Not to the organizers, who see it as a pathway for clinicians who don’t have the time to reinvent the wheel.

Fear of Checklists

As Dr. Hannenberg explained, one of the best strategies to ensure continuing success with the checklist is practice. Research has demonstrated that when clinicians practice with the tools, they are more likely to actually use the tools when an emergency arises. “Use begets use. So every time you pick it up makes you that much more likely to use it when you really need it.”

Despite the tool kit, some surgical teams are still hesitant to implement checklists for fear they may actually obstruct care. “I think potential users need to see the checklists in use to understand their value and dispel misconceptions about their use,” Dr. Hannenberg added. “When we’ve done that through video and team training, people realize that the checklists do not interfere with or delay care and interventions.”

The researchers are continuing to refine it. “There was quite a bit of input gathered over a year and a half to identify the things we should be doing to be able to do this successfully,” Dr. Hannenberg concluded. “And we’re continuing to improve it. We haven’t altered the basic text, but there are additional resources that we’ve connected to the website as we’ve become aware of them, and are prepared to do that on an ongoing basis.”

For Michael A. Olympio, MD, a retired professor of anesthesiology at Wake Forest University, in Winston-Salem, N.C.—who created his own emergency checklist binder based on various sources—the advent of the implementation tool kit would have saved considerable time and energy. Nevertheless, he has witnessed the benefit of such checklists, having used one in a recent local anesthetic toxicity incident during a community hospital locum tenens assignment.

“The best thing about having the manual was that during the emergency we were able to check some of the details that were a little fuzzy, like dosing and contraindicated drugs,” he said. “When they saw me pull the binder out in a crisis and tell them exactly what to do, they were shocked; they had never seen anything like it,” he commented. “But then they wanted to implement it.”

—Michael Vlessides