Adherence to Guidelines for the Management of Local Anesthetic Systemic Toxicity Is Improved by an Electronic Decision Support Tool and Designated “Reader”

Abstract

Background and Objectives A hardcopy or paper cognitive aid has been shown to improve performance during the management of simulated local anesthetic systemic toxicity (LAST) when given to the team leader. However, there remains room for improvement in order to ensure a system that can achieve perfect adherence to the published guidelines for LAST management. Recent research has shown that implementing a checklist via a designated reader may be of benefit. Accordingly, we sought to investigate the effect of an electronic decision support tool (DST) and designated ‘Reader’ role on team performance during an in-situ simulation of LAST. Methods Participants were randomized to Reader+DST (N = 16, rDST) and Control (N = 15, memory alone). The rDST group received the assistance of a dedicated Reader on the response team who was equipped with an electronic DST. The primary outcome measure was adherence to guidelines. Results For overall and critical percent correct scores, the rDST group scored higher than Control (99.3% vs 72.2%, P < 0.0001; 99.5% vs 70%, P < 0.0001, respectively). In the LAST scenario, 0 of 15 (0%) in the control group performed 100% of critical management steps, while 15 of 16 (93.8%) in the rDST group did so (P < 0.0001). Conclusions In a prospective, randomized single-blinded study, a designated Reader with an electronic DST improved adherence to guidelines in the management of an in-situ simulation of LAST. Such tools are promising in the future of medicine, but further research is needed to ensure the best methods for implementing them in the clinical arena.

The Third American Society of Regional Anesthesia and Pain Medicine Practice Advisory on Local Anesthetic Systemic Toxicity

“…Fourth, simulated LAST scenarios have demonstrated the usefulness of the ASRA Checklist 57 as a cognitive aid during LAST treatment 58 and the value of a reader to prompt adherence to recommendations. 59 An updated version of the ASRA Checklist is part of this practice advisory series. 13 The ASRA LAST smart phone app (iOS and Android) has been updated coincident with this practice advisory.…”

Who should read cognitive aid prompts?

“…Furthermore, Burden's group found that clinicians demonstrated difficulty reading a cognitive aid whilst simultaneously gathering clinical information and communicating to the team [3]. They, along with others, have described employing a designated 'reader', who enabled the leader to manage an emergency appropriately through improved team working where all team members were aware of the evolving situation, management plan, and ultimately singing from the same hymn sheet [4]. We felt this was critical and so have developed the 'reader of the cards' or 'ROC' rolea team member responsible for getting the prompt cards and bringing them to the team leader during the evolving emergency and working through the prompt cards with them.…”

The American Society of Regional Anesthesia and Pain Medicine Checklist for Managing Local Anesthetic Systemic Toxicity

“…1) is based on updated knowledge derived from the Third ASRA Practice Advisory on Local Anesthetic Systemic Toxicity 4 and additional insights gained through experience with the 2012 version when used during various simulation exercises. 5,6 Table 1 summarizes content and visual presentation changes.…”

“…3,5,6 Treatment of LAST differs from other resuscitation scenarios involving cardiac arrest. Standard (1 mg) doses of epinephrine, vasoconstrictors such as vasopressin, drugs that impair cardiac contractility such as β-blockers or calcium-channel blockers, and local anesthetic antiarrhythmics are all detrimental to the local anesthetic-toxic heart.…”

“…4 Yet simulation exercises show that practitioners revert consistently to standard advanced cardiac life support protocols when LAST involves cardiac arrest, especially when the patient is recalcitrant to initial treatment. 3,5 Based on this observation, the checklist now begins with the admonition that the practitioner is dealing with a different resuscitation scenario than that of a more typical cardiac arrest and thereafter provides specific recommendations for epinephrine dosing 7 and drugs to avoid. Thompson 6 reported confusion related to lipid emulsion dosing.…”