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Anesth Analg 2006;102:530-532
© 2006 International Anesthesia Research Society
doi: 10.1213/01.ane.0000189583.93127.a5

ECONOMICS, EDUCATION, AND HEALTH SYSTEMS RESEARCH

An Assessment of a Point-of-Care Information System for the Anesthesia Provider in Simulated Malignant Hyperthermia Crisis

Haim Berkenstadt, MD, Yakov Yusim, MD, Amitai Ziv, MD, Tiberiu Ezri, MD, and Azriel Perel, MD

The Department of Anesthesiology and Intensive Care and M.S.R - The Israel Center for Medical Simulation, Sheba Medical Center, Tel Hashomer, and the Department of Anesthesiology, Edith Wolfson Medical Center, Holon, Sackler School of Medicine, Tel Aviv University, Israel

Address correspondence and reprint requests to Haim Berkenstadt, MD, Director of Neuroanesthesia, Department of Anesthesiology and Intensive Care, Deputy Director, The Israeli Center for Medical Simulation, Sheba Medical Center, Tel Hashomer, 52621 Israel. Address e-mail to berken{at}netvision.net.il.


   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 Appendix: Malignant Hyperthermia...
 References
 
In this prospective, controlled study we compared the ability of anesthesia residents to diagnose and treat a simulated malignant hyperthermia (MH) scenario with and without the ability to use the On-Line Electronic Help (OLEH) information system or any other written guidelines. The OLEH is a point-of-care information system for the anesthesia provider in the operating room. The score for MH treatment after diagnosis based on clinical actions was significantly higher (P = 0.018) in the OLEH-user group (21.5 ± 4.9) compared with a control group (15.5 ± 7.6). This study demonstrates the possible value of a point-of-care information system in patient care; however, the significance of the results may be limited by the participants’ anticipation of an acute event during training requiring the use of the OLEH.


   Introduction
Top
 Abstract
 Introduction
Methods
 Results
 Discussion
 Appendix: Malignant Hyperthermia...
 References
 
Malignant hyperthermia (MH) is an uncommon yet potentially lethal genetic disorder that is manifested by hyperthermia, tachycardia, and increased CO2 production in susceptible individuals (1,2). Prompt diagnosis and improved treatment of MH, including the early use of dantrolene; have decreased the reported MH mortality from 70% to <5% (3).

The importance of adhering to established treatment algorithms in this disorder has led to the creation of memory aids, such as the MH protocol distributed by the Malignant Hyperthermia Association of the United States (4). The value of such memory aids in the treatment of simulated MH was recently demonstrated (5).

We have prospectively assessed the value of an innovative point-of-care information system to help resident anesthesiologists in the diagnosis and treatment of MH.


   Methods
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 Abstract
 Introduction
 Methods
Results
 Discussion
 Appendix: Malignant Hyperthermia...
 References
 
After written informed consent allowing videotaping of performance, 29 anesthesia residents, who were at least 6 mo into their residency training, participated in the study. Participants had been provided a didactic session regarding the diagnosis, differential diagnosis, and treatment of MH 4 to 5 mo before the study.

On-Line Electronic Help (OLEH) is a point-of-care information system for the anesthesia provider that was developed by the European Society of Anaesthesiologists (ESA). The OLEH contains sections on drugs, preoperative considerations, surgical subspecialties, intraoperative complications, and emergency algorithms and was designed so that any information item can be accessed in no more than 4 steps. More detailed information on the OLEH system can be found in the ESA website (6). The OLEH is available on the Philips IntelliVue monitor and more than 5000 copies of its personal-use CD version were recently distributed to all ESA members.

The MH scenario was developed using a human patient simulator (METI; Sarasota, FL) located in a fully equipped simulated operating room (OR). During the scenario participants were asked to perform a rapid sequence induction of anesthesia for an otherwise healthy trauma patient. A clinical picture suggestive of MH developed within the next 10–15 min with progressive increases in carbon dioxide levels, heart rate, arterial blood pressure, and temperature. Participants were given 20 min to diagnose and treat the clinical scenario.

The simulation training sessions were videotaped using digital video recordings. Three cameras connected to a digital recording system were used in addition to a four-quadrant screen that included separate views of the participants, the mannequin, and one screen demonstrating monitor. Two senior anesthesiologists reviewed the videotapes separately and independently for performance assessment. The assessors documented the timing and number of entries to the OLEH during the scenario, the subjects searched, and the time spent using the system. Once diagnosis of MH was made, treatment was assessed using a modification of a scoring system, based on critical clinical action items and their timing that was recently described by Harrison et al. (Appendix) (5).

Before the study, each participant had a 30-min individual introductory session to the OLEH system. Participants were than randomly allocated to two groups: a control group without any memory aid or written guidelines, and the study group in which the OLEH was available (use recommended but not mandatory). Participants were instructed to verbalize all observations, possible problems, and treatments administered. The mean score in each group was calculated and scores between groups were compared using the Student’s t-test.


   Results
Top
 Abstract
 Introduction
 Methods
 Results
Discussion
 Appendix: Malignant Hyperthermia...
 References
 
The two groups of participants were similar in gender and experience. Correct diagnosis of MH was made by 14 of 15 participants of the OLEH group and 12 of 14 participants of the control group. In the OLEH Group 14 of 15 participants gave appropriate dose of dantrolene after correct dilution in comparison with 9 of 14 participants in the control group (P < 0.05). Anesthetic gas administration was stopped and a rapid flow of oxygen was administered by 14 of 15 participants in the OLEH group in comparison to 11 of 15 participants in the control group (P < 0.05). The score for MH treatment after diagnosis was 21.5 ± 4.9 (maximum score, 23) in the OLEH group and 15.5 ± 7.6 in the control group (P = 0.018).

Thirteen participants in the OLEH group used the system during the scenario, the number of entries ranging between 1 and 4 per participant (median, 2 entries). The key words that were searched included "hyperthermia" (2 entries), "hypercarbia" (6 entries), "malignant hyperthermia" (9 entries), "sodium bicarbonate" (1 entree) and "hyperkalemia" (7 entries). The time per entry ranged from 20 to 210 s (63 ± 45 s). The decision to give dantrolene in the OLEH group was made after 6 of the 14 participants had used the system. The decision regarding the exact dose and dilution was made after 9 of the 14 participants had used the system.


   Discussion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
Appendix: Malignant Hyperthermia...
 References
 
The use of an electronic point-of-care information system improved the quality of treatment given by anesthesia residents during a simulated MH scenario. Although 14 of 15 participants in the OLEH group gave the appropriate dose of dantrolene after correct dilution, only 9 of 14 participants in the control group addressed these actions correctly, influencing the total performance scoring. Similarly, Harrison et al. (5), whose scoring system for evaluating performance was used in our study, have shown that the use of a memory aid improved performance in similar conditions. In contrast to our study and Harrison et al.’s study, Gardi et al. (7) found that treatment of a similar MH simulated scenario was satisfactory without memory aids.

In recent years, there has been an increasing availability of electronic information access at the point-of-care with the development of automated record keeping systems, computers and personal digital assistants within the OR. The value of electronic information access at the point-of-care for supporting clinical decision-making in medicine has been described previously (8,9), although excessive search time (up to 12 minutes) has been a major obstacle (10,11). The relatively fast retrieval time that was found in the present study (63 ± 45 seconds) may be related to the configuration of the OLEH system, in which information can be accessed with a minimum number of steps, the search being aided by a logic design of content and by multiple internal hyperlinks.

Using advanced simulation allowed us the opportunity to assess the OLEH in an environment similar to the real clinical milieu where the anesthesia provider needs to accumulate knowledge about the patient’s medical status. The routine OR monitoring system does not enable the incorporation of all this knowledge (12), thus challenging the multiple levels of cognitive activity required for an adequate response to critical incidents during anesthesia (13).

However, because participants were instructed to act as if they were performing in a real OR and the assessment of performance was based only on actions performed by the participants during the scenario and the time frame of actions, the study protocol did not allow for conclusions on variables such as the exact timing of appropriate diagnosis.

The positive results of our study may be limited because of the participants’ anticipation of an acute event during the session and the knowledge that they were expected to use the OLEH. During an acute event in the OR, anesthesiologists may forget about, or may not be aware of, the availability (14) of the point-of-care information system unless proactive training is part of anesthesia curriculum.


   Appendix: Malignant Hyperthermia Treatment Score
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Appendix: Malignant Hyperthermia...
References
 
Points for each intervention were given only if it was fully and correctly performed

1. Anesthetic gas off – 1 point

2. High flow oxygen – 3 points

3. Cooling (cooled IV fluids and external cooling) – 3 points

4. Surgeon notified – 3 points

5. Treatment of hyperkalemia (infusion of glucose solution and insulin in correct doses) – 1 point

6. Administer NaHCO3 (dose corrected according to the base deficit if arterial blood gases results are available) – 1 point

7. Laboratory tests sent – 1 point

8. Mixed dantrolene 60 mL/H2O – 3 points

9. Appropriate dose of dantrolene – 1 point

10. First dose ≤10 min – 3 points

11. First Dose ≤15 min – 2 points

12. First dose ≤20 min – 1 point

13. Second dose ≤15 min – 3 points

14. Second dose ≤20 min – 2 points

15. Second dose ≤30 min – 1 point

16. Third dose ≤30 min – 2 points (not applicable to the present study)

Total 23 points (in comparison to 25 in the original score)


   Footnotes
 
The Sheba Medical Center has received an educational grant from the European Society of Anaesthesiologists (ESA) for the production of the OLEH.

The ESA has received an educational grant from Philips Medical Systems for the development of the OLEH.

Accepted for publication September 2, 2005.


   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Appendix: Malignant Hyperthermia...
 References
 

  1. Krause T, Gerbershagen MU, Fiege M, et al. Dantrolene: a review of its pharmacology, therapeutic use and new developments. Anaesthesia 2004;59:364–73.[ISI][Medline]
  2. Nelson TE. Malignant hyperthermia: a pharmacogenetic disease of Ca++ regulating proteins. Curr Mol Med 2002;2:347–69.[Medline]
  3. Ali SZ, Taguchi A, Rosenberg H. Malignant hyperthermia. Best Pract Res Clin Anaesthesiol 2003;17:519–33.[Medline]
  4. Malignant Hyperthermia Association of the United States www.mhaus.org/.
  5. Harrison TK, Manser T, Howard SK, Gaba DM. The use of cognitive aids in simulated anesthetic crises. Anesthesiology 2004;A–1250.
  6. http://www.euroanesthesia.org/education/OLEH.php.
  7. Gardi T, Christensen UC, Jacobsen J, et al. How do anaesthesiologists treat malignant hyperthermia in a full-scale anaesthesia simulator? Acta Anaesthesiol Scand 2001;45:1032–5.[ISI][Medline]
  8. McGowan JJ, Richwine M. Electronic information access in support of clinical decision making: a comparative study of the impact on rural health care outcomes. Proc AMIA Symp 2000:565–9.
  9. Johnston ME, Langton KB, Haynes RB, Mathieu A. Effects of computer-based clinical decision support systems on clinician performance and patient outcome. Ann Intern Med 1994;120:135–42.[Abstract/Free Full Text]
  10. Ely JW, Osheroff JA, Ebell MH, et al. Obstacles to answering doctors’ questions about patient care with evidence: qualitative study. BMJ 2002;324:710.[Abstract/Free Full Text]
  11. D’Alessandro DM, D’Alessandro MP, Galvin JR, et al. Barriers to rural physician use of a digital health sciences library. Bull Med Libr Assoc 1998;86:583–93.[ISI][Medline]
  12. Smith AF, Goodwin D, Mort M, Pope C. Making monitoring "work": human-machine interaction and patient safety in anaesthesia. Anaesthesia 2003;58:1070–8.[ISI][Medline]
  13. DeAnda A, Gaba DM. Role of experience in the response to simulated critical incidents. Anesth Analg 1991;72:308–15.[Abstract/Free Full Text]
  14. Mills PD, DeRosier JM, Neily J, et al. A cognitive aid for cardiac arrest: you can’t use it if you don’t know about it. Jt Comm J Qual Saf 2004;30:488–96.[Medline]




This Article
Right arrow Abstract Freely available
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Lippincott, Williams & Wilkins Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999 HighWire Press