Cognitive Aids May Improve Surgeons' Care of Deteriorating Patients

By Will Boggs MD

December 05, 2019

NEW YORK (Reuters Health) - Cognitive aids increased adherence to best practice in the treatment of deteriorating surgical patients in simulation studies, researchers report.

"From our experience with cognitive aids, we have seen that they are not only useful during critical events, but also that there is a big role for them in educational settings in preparing doctors for these kind of events," said Dr. Lena Koers of the University of Amsterdam.

"Furthermore, they can also be used in debriefing settings to learn from these events by seeing if steps are missed or if management could have been improved," she told Reuters Health by email.

Cognitive aids have been shown to improve communication, teamwork and leadership and to promote a surgical safety culture, which, in turn, has reduced perioperative morbidity and mortality. There are no commonly used cognitive aids for the management of deteriorating surgical patients.

Dr. Koers's team created cognitive aids for the management of deteriorating surgical patients (CAMDS) and tested their effects on adherence to best practices in a simulation laboratory.

Surgical teams were randomized to the CAMDS-intervention group or to a control group and were assigned to three of 10 preprogrammed standardized scenarios involving surgical-patient deterioration. Performance was measured on 15 critical management steps for each scenario.

Use of the CAMDS cut the number of omitted critical management steps by 70%, from 33% to 10%, and was the only significant factor in this reduction in a multivariate analysis.

There were significant decreases in the failure to adhere to best-practice management for each individual scenario with the use of the CAMDS, the researchers report in JAMA Surgery, online November 27.

Despite being available in the scenario, the cognitive aids were not used in 8% of the sessions. When these sessions were excluded from the analysis, there was an 82% drop in missed steps (from 33% to 6%).

The teams scored the overall usability of the CAMDS at a median 8.7 on a 10-point scale, with 10 being most usable, and all participants rated the scenarios as being realistic in terms of resembling daily clinical work.

"We feel that there is a role for cognitive aids in the management of surgical patients in the ward," Dr. Koers said. "They should, however, be implemented well, and (high-fidelity) simulation will help in incorporating the use of cognitive aids in the routine of managing critical events."

"They are most useful if time is spent in adjusting the cognitive aids to the local situation (for instance, incorporate phone/pager numbers, location of specific drugs or materials, and local protocols)," she said. "This process helps to evaluate the escalation of care pathways and can help to tighten the bonds between the surgical department and the ICU."

Dr. Koers added, "We are very happy to share our cognitive aids with other hospitals, also as an editable version so people can optimize them for their local situation."

"A review of the literature demonstrates that research on cognitive aids has been done almost entirely on simulated patients," write Dr. Muneera R. Kapadia of the University of Iowa Hospitals and Clinics, in Iowa City, and Dr. Srinivas J. Ivatury of Geisel School of Medicine at Dartmouth, in Hanover, New Hampshire, in a linked editorial. "The biggest question remains: would cognitive aids for rescue be useful in actual clinical practice? Of course, this would be difficult to test, because these events are not planned."

"In their next generation, our hope is to see cognitive aids transition from the simulated training environment to a digitized clinical one," they conclude.


JAMA Surg 2019.