Cognitive aids Using cognitive aids is a common practice in emergent situations. Cognitive aids are tools developed to assist in decision-making during a crisis, and their purpose is to provide pertinent information necessary to formulate a plan of action related to the context of the situation. Cognitive aids ensure consistent delivery of evidence-based care based on research and practice, and teams that use them have more appropriate, efficient decision-making (Goldhaber-Fiebert et al., 2016). Cognitive aids used in emergencies have been established for life-saving protocols, including BLS, ALCS, and PALS (pediatric advanced life support), malignant hyperthermia protocols, surgical safety checklists for the ORs, and OB hemorrhage and emergent C-section pathways (Alidina et al, 2018). Cognitive aids must be evidence-based and approved by the institution as best clinical practice or standard of care. Some cognitive aids are well-known and accepted; for example, all the American Heart Association (AHA) protocols for life support and advanced life support. They are updated based on evidence- based research every five years, with the last update occurring in 2015 (Hazinski et al., 2015; Merchant et al., 2020). Most institutions accept these algorithms for responding to cardiac arrests. The individual institution can develop other cognitive aids. An example is a map of where responders are expected to stand when responding to a cardiac arrest. The “Where Do I Stand” figure was developed by a large academic medical center and shows the key roles of responders and their functional position centered on the patient. The figures provide a visual representation of responders and can assist other team members to notice if any members are absent, allowing someone to assume the role. The anesthesiologist and respiratory therapist deal with the airway and always stand at the head of the bed. The pharmacist and medication nurse stand at the code cart to prepare the medications. If the event is documented within the electronic medical record, the nurse or scribe who records the event will be at the computer. WHERE DO I STAND
Notice on this figure (Corey, 2016) that there is also a role called the “code whisperer.” This institution has a person assigned to support the leader. The institution is an academic facility, and often less senior and inexperienced staff may act as the leader in an emergency. The code whisperer may be a more senior or experienced staff member with a cognitive aid such as the AHA ACLS card, providing cues and protocols to the leader of the event. Evidence-based practice! ACLS, BLS, and PALS are cognitive aids developed and updated every 5 years by the American Heart Association to assist a responder in life-threatening events such as cardiac arrest, choking, and pediatric emergencies (Merchant et al., 2020). Healthcare Professional Consideration: Health Care providers, in their role in a response, collect data through assessment of the patient. It is imperative that pertinent data is shared with the leaders of the response so that timely decisions can be made incorporating all the data points.
Self-Assessment Quiz Question #9 “Where Do I Stand” is an example of a: a. Cognitive aid.
b. Response algorithm. c. Mnemonic device. d. National response tool. Fixation errors
Situational awareness, necessary for managing a crisis, requires the team to be cognizant of what is going on in the immediate environment. Fixation errors occur when a team member stalls on only one aspect or detail and may miss other pertinent data, and there is a failure to change the course of action without consideration of any new information (Fioratou et al., 2010). Fixation can be related to tasks or diagnosis (SWAPNet, 2018). There are three main types of fixation errors: This and only this; Everything but this; and Everything is OK (Ortega, 2018). This and only this is the inability to see any other possible solutions to a situation except the one the person is doing. An example is when a leader may believe that the patient’s symptom of desaturation is related to an airway issue (misplaced endotracheal tube) when the issue may be circulatory collapse. The interventions for these causes are very different. Time spent focused on the airway and reinserting a perfectly functioning airway while not focusing on the low perfusion and shock state could negatively affect the patient’s outcome. Communication to the leader on new information is critical in preventing this type of fixation error (Ortega, 2018). This type of error can be avoided by the leader stating what they see as the cause or diagnosis during the state of the response updates and then allowing other respownders to provide input. The Everything but this fixation error is when the responder pursues irrelevant data and does not choose the best course of action for the issue (Miller et al., 2014). An example is when, after inserting an endotracheal tube, the anesthesiologist meets resistance when ventilating the patient and explores the possibility of tube misplacement, rather than that of a foreign body, pneumothorax, or chest wall rigidity. The time spent reinserting the tube caused the patient to be hypoxic longer than necessary and delayed searching for the actual cause of the desaturation. This error is often seen when a provider has less experience in the presented situation. Communication among team members and asking the team for input allows the entire group to play a part in the decision-making on a course of action for this type of error. The final type of fixation error is Everything is OK . This is when an abnormal finding is attributed to an artifact or the failure to recognize signs of deterioration (Fanning et al., 2013). For example, the vital sign finding of low oxygen saturation is attributed to a detached probe when the patient may be in
Where do I stand diagram for code blue responders at Jones Medical Center. CPR represents three staff who alternate every 2 minutes. Code Whisperer supports code leader. Defibrillator is located on code cart, but is placed so code leader can view monitor screen at all times. If family present, they are supported by social worker, Clergy or nurse manager.
Book Code: ANCCUS2423
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