Perioperative Emergency Manuals for Low-Incidence High-Risk Events

Background or Problem/Issue: There was a suspected case of malignant hyperthermia in the perioperative environment. It was identified that the cognitive aid currently used to manage malignant hyperthermia was challenging to follow for the implementation of best-practice interventions. Clinical Question or Purpose: In perioperative teams (P), how does the implementation of the Stanford Anesthesia Emergency Manuals and safety training (I), compared with current practices (C), affect adherence to critical management steps in low-incidence high-risk events such as malignant hyperthermia (O)? Project Design: The design was a quality improvement project utilizing simulation-based training on Stanford Anesthesia Emergency Manuals. Analysis of the Results: One group failed to diagnose malignant hyperthermia in the PACU, leading to a statistical outlier resulting in a skewed distribution. The group deferred nonparametric testing as the difference would be the result of a failure to diagnose malignant hyperthermia versus a deficiency related to checklist utilization. Organizational Impact/Implications for Practice: Two structured simulations of malignant hyperthermia in the operating room and post-anesthesia care unit were constructed and added to the Wright-Patterson Medical Center simulation database for future use and training.