Our take-homes from the article in Anaesthesia & Analgesia in June 2019 - eloquently written by Stanford's Department of Anaesthesia.
Suggestion for both a "team leader" AND "reader" of cognitive aids. Simulated studies have shown this model to work more effectively, although the reader needs to be comfortable with this role. There are different reader styles that may be influenced by experience (Step-by-Step vs Adjusted Sequence).
Signal towards greater completion of critical tasks when cognitive aids are used, if prior training with cognitive aids is undertaken.
Cognitive aids have a role BEFORE a crisis with "What If" scenarios (verbal simulation), anticipating a likely event and planning for a known event.
Cognitive aids have a role DURING a crisis by enabling prioritisation, preventing omission and offloading working memory.
Cognitive aids have a role AFTER a crisis by enabling effective debrief.
Whilst cognitive aids may facilitate exploration of causation, their primary use should NOT be as diagnostic tools.
The interplay of experience and cognitive aid use has continued to drive adaptations of cognitive aid design and is worth thinking about. US Airways Flight 1549 captained by Cpt. Sullenberger was at 3200ft when the captain used the "Dual Engine Failure" checklist which was originally designed for use above 20,000ft. His experience, led him to activate the APU first (which would ordinarily feature at the very end of the checklist) and then ask his co-pilot to read the checklist. Since then, the Dual Engine Failure checklist has been modified to include versions for both High and Low Altitude. A similar example in Obstetrics might be the 'Management of Maternal Cardiac Arrest' when experience might dictate certain interventions to be enacted first, in deviation from the cognitive aid sequence.
Cognitive Aid use must be married with broader understanding of CRM and Simulation. Essentially, familiarisation AND prior training with aids are essential to ensure they are both used and effectively navigated during a crisis.
Optimal cognitive aid design must account for: 1) Purpose of the aid (check-confirm vs guide) 2) Mode (read aloud, projected) 3) By Whom (reader vs entire team vs leader) 4) conditions (emergency vs elective) 5) Where (OT, Labor Room, ED etc).
Cognitive aid content may need reconciliation due to differences in guidelines from established organisations
Effective implementation requires cultural acceptance, leadership buy-in, inter professional teams and a local champion.