Checklists Improve Team Performance During Simulated Extracorporeal Membrane Oxygenation Emergencies: A Randomized Trial

Abstract

Objectives: Extracorporeal membrane oxygenation–related complications are potentially catastrophic if not addressed quickly. Because complications are rare, high-fidelity simulation is recommended as part of the training regimen for extracorporeal membrane oxygenation specialists. We hypothesized that the use of standardized checklists would improve team performance during simulated extracorporeal membrane oxygenation emergencies. Design: Randomized simulation-based trial. Setting: A quaternary-care academic hospital with a regional extracorporeal membrane oxygenation referral program. Subjects: Extracorporeal membrane oxygenation specialists and other healthcare providers. Interventions: We designed six read-do checklists for use during extracorporeal membrane oxygenation emergencies using a modified Delphi process. Teams of two to three providers were randomized to receive the checklists or not. All teams then completed four simulated extracorporeal membrane oxygenation emergencies. Measurements and Main Results: Simulation sessions were video-recorded, and the number of critical tasks performed and time-to-completion were compared between groups. A survey instrument was administered before and after simulations to assess participants’ attitudes toward the simulations and checklists. We recruited 36 subjects from a single institution, randomly assigned to 15 groups. The groups with checklists completed more critical tasks than participants in the control groups (90% vs 75%; p < 0.001). The groups with checklists performed a higher proportion of both nontechnical tasks (71% vs 44%; p < 0.001) and extracorporeal membrane oxygenation–specific technical tasks (94% vs 86%; p < 0.001). Both groups reported an increase in reported self-efficacy after the simulations (p = 0.003). After adjusting for multiple comparisons, none of the time-to-completion measures achieved statistical significance. Conclusions: The use of checklists resulted in better team performance during simulated extracorporeal membrane oxygenation emergencies. As extracorporeal membrane oxygenation use continues to expand, checklists may be an attractive low-cost intervention for centers looking to reduce errors and improve response to crisis situations.

A Scoping Review and Appraisal of Extracorporeal Membrane Oxygenation Education Literature

“…Half of the studies (50%) included multiple disciplines ( 16 – 33 ), most frequently including physicians and nurses. More than one-third (36%) of studies included trainee physician ( 16 , 19 , 21 , 24 , 25 , 29 , 33 – 39 ), and four studies included healthcare students ( 26 , 40 – 42 ).…”

“…Half of the studies (50%) included multiple disciplines ( 16 – 33 ), most frequently including physicians and nurses. More than one-third (36%) of studies included trainee physician ( 16 , 19 , 21 , 24 , 25 , 29 , 33 – 39 ), and four studies included healthcare students ( 26 , 40 – 42 ). Of uniprofessional studies listing target audiences, 11% targeted ECMO specialists ( 43 – 46 ), 8% targeted nurses ( 47 – 49 ), 3% targeted paramedics ( 50 ), and 14% targeted physicians ( 34 , 36 – 39 ).…”

“…Among the remainder, one study used a screen-based simulator ( 21 ), three studies used simulator models ( 37 , 40 , 46 ), one study used an animal model ( 51 ), and one study did not specify how simulation was used ( 49 ). Eighteen studies described realistic, multidisciplinary simulation scenarios, focused on ECMO emergencies ( 16 – 20 , 22 – 33 , 42 ). Of these, nine also incorporated “water drills” ( 16 – 20 , 24 , 26 , 27 , 42 ).…”

“…No studies focused solely on the affective domain. Thirteen studies targeted cognitive and psychomotor domains ( 17 – 19 , 33 – 36 , 43 , 46 – 48 , 50 , 51 ), and 2 studies addressed technical skills and behaviors ( 22 , 23 ). Twelve studies (33%) targeted all three domains ( 24 – 32 , 38 , 39 , 44 ).…”

Checklists and cognitive aids: underutilized and under-researched tools to promote patient safety and optimize clinician performance

“…More recently, investigators employed a randomized trial that demonstrated improved team performance, as measured by completion of both technical and nontechnical tasks, in simulated extracorporeal membrane oxygenation emergencies [15 ▪ ]. Interestingly, in the control arm of this study (no checklist), three-person teams performed better than two-person teams; teams exposed to the intervention (checklist use) outperformed the control arm regardless of team size, and two- and three-person teams using the checklist performed equally well.…”