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Educated Hand Publishing LLC 
“The Science Behind the Art” 
Volume 10 - No.1 2022 

 Anesthesia eJournal - Online
ISSN 2333-2611

Page 1

Use of a High-Fidelity Patient Simulator to Introduce an Evidence-Based Emergency 
Manual into Certified Registered Nurse Anesthetist Practice 
LTC James B. Hacker, DNAP, CRNA, AN, USA1

LTC(P) Paul M. Johnson, DNP, CRNA, CHSE, AN, USA1,2

LTC(ret) Sandra S. Bruner, DNAP, CRNA 1,2

CAPT Justice Parrott, DNAP, CRNA, NC, USN2

Lt Col Katherine J. Alguire, DNAP, CRNA, NC, USAF2

LCDR Tiffany Ann Uranga, DNP, MSN, CRNA, NC, USN2

Sunny Jade Yauger, BS, CHSE1

COL Ann Nayback-Beebe, PhD, FNP, AN, USA3

Affiliation:
1Fort Belvoir Community Hospital, Fort Belvoir, Virginia
2Daniel K. Inouye Graduate School of Nursing Registered Nurse Anesthesia Program, Uniformed Services University of the Health Sciences, Bethesda, Maryland
3Walter Reed National Military Medical Center, Bethesda, Maryland 

Grant/Financial Support: 
None 

KEYWORDS: High-Fidelity Simulation, Anesthesia, Critical Events, CRNAs, Emergency

Abstract
Certified Registered Nurse Anesthetists (CRNAs) administer anesthesia care to thousands of patients each year. Despite 
increased anesthetic safety, low-frequency, high-risk perioperative critical events still occur. Although CRNAs have 
been expected to rely on memory alone to manage the spectrum of these critical events, the use of an emergency manual 
(EM) may improve CRNA performance. Recent experiences with similar critical events at one Army community 
hospital led to the development of the following question: Will the use of high-fidelity simulation training with the 
CRNAs on the use of EMs produce both increased performance in key tasks and positive satisfaction scores related to 
the use of the emergency manual during critical events now and in the future? Twenty CRNAs participated in high-
fidelity simulated scenarios involving low-frequency, high-risk critical events before and after training on the use of an 
EM based on a change strategy developed by Goldhaber-Fiebert and Howard in 2012. Changes in performance after 
training were evaluated using a tool designed by Arriaga et al. Before EM training, CRNAs completed 46.05% of key 
tasks in the simulated scenario. After EM training, CRNAs completed up to 94.02% of key tasks in simulated scenarios. 
The increased completion of key tasks by CRNAs during simulated critical events after EM training and increased 
satisfaction scores.  These results demonstrate how a well-constructed training program facilitates implementation of an 
evidence-based EM into practice.

AEJ



Educated Hand Publishing LLC 
“The Science Behind the Art” 
Volume 10 - No.1 2022 

 Anesthesia eJournal - Online
ISSN 2333-2611

Page 2

INTRODUCTION
Certified Registered Nurse Anesthetists (CRNAs) provide 
anesthesia for thousands of patients annually. Despite their 
qualifications and skills, which have drastically reduced the 
morbidity and mortality of patients under anesthesia, low-
frequency, high-risk perioperative critical events still occur, 
including sudden cardiac arrhythmia, airway fire, anaphylaxis, 
hemorrhage, local anesthetic toxicity, and embolism.1 The 
overall incidence of perioperative critical events has been 
estimated at 145 events per year for a hospital that performs 
10,000 operations.2,3 Thus, critical events may be so rare that 
individual anesthesia providers never experience them in practice, 
preventing opportunities to form pattern recognition, which is 
a key characteristic of expert clinical decision-making.4 CRNAs 
are expected to rely on memory alone to recall key actions and 
seamlessly manage a wide array of critical events, therefore, 
mismanagement or deviation from accepted practice due to 
human error, may account for a substantive portion of anesthesia-
related risk.5 Utilization of an emergency manual (EM) can 
increase the number of key actions completed by anesthesia 
providers during low-frequency, high-risk perioperative critical 
events.6-10 
In 1924, Babcock expressed if a critical event during surgery 
required a response that was not instantly obtained by simple 
measures, a fixed emergency routine should be posted on the 
walls of every operating room, drilled into every staff member, 
and strictly enforced.11 Over 90 years later, there remains a 
cultural reluctance among anesthesia providers towards use of 
emergency checklists during perioperative critical events, with 
one study reporting 60% of anesthesia residents believing they 
should be able to manage a critical event from memory alone.6 
Substantial evidence indicates anesthesia providers routinely do 
not remember all actions involved in managing emergent events 
from memory alone.12 Indeed, three recent editorials make the 
same plea as Babcock did in 1924, concluding it is time to adopt 
the use of emergency routines during the perioperative period.11 
Several studies demonstrate healthcare providers perform poorly 
when relying solely on memory to manage simulated critical 
events.8,13-16 For instance, Smith et al found a rapid decline in 
Advanced Cardiac Life Support (ACLS) skills among nurses 
after 3 and 12 months post-training, (30% and 14% of nurses, 
respectively).13 Similarly, 6 months after advanced life support 
training, Semeraro et al found a 36% reduction in the number 
of anesthesiologists who passed a multiple-choice test, a 1-min 
increased time to first defibrillation, and other delayed or 
forgotten interventions.14 Berkenstadt et al reported a decay in 
knowledge and skills during simulated cardiac arrest in obstetric 
patients, with only 0–4% of anesthesia providers removing fetal 
monitors, 44–68% positioning the patient with left uterine 
displacement, 48–78% maintaining cricoid pressure during 
ventilation, and 40–83% delivering the fetus by caesarean in 5 
min or less.15 Henrichs et al found that although anesthesiologists 
performed better than CRNAs in eight simulated perioperative 
critical events, both groups performed poorly overall, completing 
only 66.6% and 59.9% of key tasks, respectively.16 In a simulated 
malignant hyperthermia scenario, Harrison et al found that not 
all teams needed a cognitive aid to perform well. However, the 

teams that performed well often used an aid, whereas the teams 
that performed the most poorly did not use an aid.8 It may 
be impossible to prospectively determine whether a team will 
perform well in a crisis situation but may be prudent to train all 
teams on the use of cognitive aids and ensure aids are readily 
available during unfamiliar or life-threatening situations. 
PICOT QUESTION & MODEL

The target institution for this project performed approximately 
10,000 operations per year.  In 2014-2015, there were several 
incidents of low-frequency, high-risk, critical events that 
challenged anesthesia providers to make accurate, evidence-based 
decisions while under a high level of stress and during hours 
when additional staff may not be available. As a countermeasure 
to these situations, our team developed the following PICOT 
question: Would the use of high-fidelity simulation training using 
EMs conducted over one week with practicing CRNAs produce 
both increased performance in key tasks and positive satisfaction 
scores related to the use of the emergency manual during critical 
events now and in the future? 
The change strategy adopted for this project developed by 
Goldhaber-Fiebert and Howard called for a four-step process 
to achieve success within an institution when implementing an 
EM.17 The first step was to create or adapt an EM on the local 
level to meet the specific needs of the institution. Second, training 
was incorporated to increase CRNA familiarity with the EM. 
Third, it was ensured that the EM was accessible and effectively 
used. Finally, integrating the EM was integrated as a part of the 
institution’s quality and safety culture. Utilizing this strategy and 
adapting it to the specific constraints of our facility, our team 
sustained a change in practice among our anesthesia providers 
and better outcomes for our patients when faced with critical 
events.
TRAINING PROGRAM
After receiving exempt status from the Institutional Review 
Board, the project was conducted at an Army community 
hospital over a 5-day period in April 2017. Data collection and 
training were carried out in a manner similar to that described 
by Goldhaber-Fiebert et al.9  Twenty CRNAs were divided into 
teams of two, and pre-training data collection, training, and post-
training data collection and subjective evaluation were completed 
within a 150-min session. For pre-training data collection, the 
number of key tasks completed by groups were counted during 
a high-fidelity simulation of a perioperative critical event (eg, 
anaphylaxis). CRNAs were then trained on the use of the 
selected EM through a trigger film on severe bradycardia. The 
EM chosen for this project was the Stanford Emergency Manual 
version 3.1 that included validated algorithms for twenty-
five different perioperative emergencies and anesthesia crisis 
resource management (ACRM) resources.18 For post-training 
data collection, CRNAs used the EM during two additional 
simulations of perioperative critical events (eg, intraoperative 
hemorrhage and ventricular fibrillation/cardiac arrest), and 
the numbers of key tasks completed were counted. For each 
simulation, one CRNA served as the primary provider or “leader”, 
and the other served as the emergency consult or “reader”. The 



Educated Hand Publishing LLC 
“The Science Behind the Art” 
Volume 10 - No.1 2022 

 Anesthesia eJournal - Online
ISSN 2333-2611

Page 3

simulations were conducted as described by Arriaga et al and 
video-recorded for data collection purposes.19

The simulated critical events were conducted using the Human 
Patient Simulator (HPS) with optional HPS equipment (CAE 
Healthcare). The HPS is the only human patient simulator that 
supported the modeling of potent inhalational anesthetics and 
exchanges oxygen and carbon dioxide gases to replicate patient 
physiology,20 and it also integrated with clinical monitoring 
equipment. The HPS allows CRNAs to administer medications, 
indicated or contraindicated, during the scenario, with a 
subsequent automatic natural physiologic response.  In essence, 
the HPS replicates human physiology in a response manner 
analogous to real patients enhancing the fidelity of the simulation 
experience.
The effectiveness of the training was assessed by tallying the 
proportion of key tasks completed during the post-training 
scenarios. Each simulated critical event was evaluated by two 
project team members who observed the scenarios in real time. In 
cases of discrepancy between team members, the video recording 
was used to confirm the observations. CRNAs’ perceptions of 
the usefulness and clinical relevance of the EM were assessed 
using a questionnaire immediately after completing the first (eg, 
pre-training) and third (eg, post-training) scenarios to evaluate 
likelihood of adopting the EM in future practice. CRNAs were 
additionally surveyed to assess opinions on the quality of the 
overall session, EM checklists, and scenarios.
TRAINING RESULTS
Twenty CRNAs participated in the three high-fidelity simulated 
critical events; one scenario was delivered before EM training, 
and two scenarios were delivered after EM training. In the first 
scenario (anaphylaxis), CRNAs completed 46.05% of key tasks 
on average without EM use (Figure 1). The most common missed 
actions included failing to call for the code cart, continuing a 
volatile agent, not considering additional intravenous access, 
not administering a histamine-2 receptor antagonist, and not 
performing five additional actions related to post-anaphylaxis care 
and referrals.
In the second scenario (hemorrhage), CRNAs completed 80.56% 
of key tasks on average while using the EM. The most common 
missed actions included failing to call for the code cart, not 
placing the patient in Trendelenburg position, not confirming 
or placing a Foley catheter, and failing to call for the cell saver 
system. In the third scenario (ventricular fibrillation), CRNAs 
completed 94.02% of key tasks on average while using the 
EM. No major key actions were missed, with the exception of 
one instance of failing to consider antiarrhythmic medications. 
Administration of magnesium sulfate for Torsade de Pointes, and 
concurrent administration of calcium chloride, insulin, glucose, 
and sodium bicarbonate for hyperkalemia, were omitted as key 
actions because this scenario did not include either condition as a 
potential cause of ventricular fibrillation.
A questionnaire was provided to participating CRNAs after the 
first pre-training and third post-training scenarios (Table 1). 
The greatest change in score was for CRNAs’ perception that 
they learned something new (+0.92) and feeling that they did 
things during the training day they never would have been able to 
practice otherwise (+0.64). The vast majority of CRNAs (98.8%) 

believed that EM use supported safer care and allowed them 
to be better prepared when confronted with anesthesia-related 
crises. CRNAs also believed that all operating room staff should 
be trained on EM use (97.8%), that the EM did not hinder 
clinical flow (97.8%), and that they would want the EM used if 
they were the patient (97.8%).
After the session, CRNAs were asked additional questions about 
the quality of the overall session, EM checklists, and scenarios; 
willingness to repeat the simulations and attend training again 
if it were provided off-site; feelings of overall stress while using 
the EM; and intention to use what was learned in future practice. 
CRNAs were also asked where in the operating room they felt 
would be most appropriate to place the EM after being fully 
implemented into local practice. CRNAs expressed satisfaction 
with the quality of the simulation, EM checklists, and scenarios. 
CRNAs also expressed an unwillingness to attend off-site 
trainings and general feelings of less stress when using the EM. 
The majority of CRNAs (71%) wanted the EM placed on the 
wall in the operating room in clear view using a document holder. 
DISCUSSION
Consistent with the findings of Goldhaber-Fiebert et al and 
Arriaga et al, the authors observed EM training increased the 
proportion of key tasks completed during simulated critical 
events, from 46.05% after the first scenario to 94.04% after the 
final scenario.9,10 This analysis was limited by the design of the 
training session and the small number of CRNAs completing the 
training.  The large change in task completion rate led the authors 
to believe future implementation of the EM into CRNA practice 
at other facilities could yield significant improvements in response 
to low-frequency, high-risk perioperative critical events. Full 
implementation of EM training and practice among all anesthesia 
providers and operating room staff should be considered.  It 
must be noted that the design of this project was intended to 
deliver the most complete training experience for the CRNAs 
by having them participate in all three clinical scenarios. Formal 
statistical analysis was not applied due to the lack of controls 
between scenarios or for repeated training effect. Regardless of 
these issues, the drastic change in key task performance proved 
invaluable when demonstrating the importance of using an EM 
for the management of critical anesthesia events.
Types of emergent high-fidelity simulation scenarios, selected for 
this project, produced some unexpected patterns of performance. 
The first scenario (anaphylaxis) yielded an appropriate acute 
response for all CRNAs involved (ie, call for help, increase 
FIO2, epinephrine or albuterol administration), Overall rates 
of task completion ranged between 80–100%. Weaknesses in 
performance were observed in post-acute event care, including 
failure to administer histamine-2 antagonists and/or steroids, 
perform laboratory evaluation, consult the allergy service, 
and continue further observation, with completion rates 
ranging between 0–50%. Such weaknesses in post-acute event 
performance highlighted the need for CRNAs to use a cognitive 
aid, such as an EM. 
The hemorrhage management noted deficiencies in four key 
tasks: calling for a code cart, placing the patient in Trendelenburg 
position, placing a Foley catheter, and calling for a cell saver 
system. The participants indicated they would have called for the 



Educated Hand Publishing LLC 
“The Science Behind the Art” 
Volume 10 - No.1 2022 

 Anesthesia eJournal - Online
ISSN 2333-2611

Page 4

code cart if the scenario had been perceived as leading to cardiac 
arrest as opposed to an isolated massive resuscitation effort. 
Trendelenburg positioning was frequently not considered in lieu 
of focusing on other key actions. In some cases, pre-placement 
of a Foley catheter was assumed due to the nature of the open 
abdominal surgery scenario, and cell saver capability was not 
available at the location where training was taking place. These 
shortfalls highlighted the need to tailor the scenarios and EM to 
increase relevance to the practice setting. More thorough briefing 
to address scenario key factors would have added clarity.  
The ventricular fibrillation scenario demonstrated the highest 
levels of performance. No specific deficiencies were noted. 
Whether this improvement in performance across the three 
scenarios is the result of greater training effect within the 
simulation exercises and use of the EM, or experience and 
comfort in managing certain types of critical events, was difficult 
to ascertain within the scope of this project. However, this issue 
pointed toward potential areas for future research on training 
CRNAs to respond to critical events. Furthermore, it could have 
been possible that the highest rates of completion of key tasks in 
the ventricular fibrillation scenario were related to the frequency 
of training received on this event through ACLS recertification 
every two years.

CONCLUSION
Utilizing an EM during simulated critical events can increase 
the completion of key tasks by CRNAs, thereby enhancing 
the quality of care delivered to patients during perioperative 
critical events. Feedback shows positive trends that the training 
was perceived as both valuable and well-constructed. These 
findings are encouraging and justify expansion and inclusion of 
similar simulation-based EM training to include all disciplines 
of the perioperative healthcare team. Furthermore, widespread 
implementation of similar simulation-based training programs 
and ensuring the availability of EMs should be encouraged 
throughout all training and patient care arenas. The use of 
standardized EMs is relatively new within medical and nursing 
disciplines, and the best method of implementation is yet to 
be determined. However, with proper training, EMs have the 
potential to make a positive, enduring impact on care provided 
during low-frequency, high-risk critical events.21

SUMMARY OF KEY POINTS

• Cognitive aids in the form of emergency manuals have been shown to increase the performance of individuals and teams when 
faced with low-frequency, high-risk, critical events. Despite this evidence, culture within many medical disciplines still endorses 
working from memory alone.

• Some low-frequency, high risk, critical events are so rare that a provider may not encounter them throughout their career.

• Memory degrades over time and as such performance degrades as well. This is demonstrated by studies that have investigated 
the performance of practitioners in cardiac arrest management at after training. At six to nine months after training, most 
practitioners would fail a Basic Life Support or Advanced Cardiac Life Support test if taken without refreshments of knowledge 
and skills.

• The use of high-fidelity simulation provides a realistic platform for institutions to implement and sustain the use of an emergency 
manuals. Examination of the providers improved performance using the manual without patient risk can be convincing even to 
providers with the long-held belief that they need to remember everything.

• Emergency manuals when coupled with proper team dynamics such have the potential to greatly enhance patient outcomes to 
low-frequency, high-risk, perioperative critical events.



REFERENCES

1. Hogan P, Seifert RF, Moore CS, Simonson BE. Cost effectiveness analysis of anesthesia providers. Nursing Economic$. June 
2010;28(3):159-169.

2. Webb RK, Currie M, Morgan CA, et al. The Australian Incident Monitoring Study:  an analysis of 2000 incident reports. 
Anaesthesia and Intensive Care. 1993;21(5):520-528.

3. Charuluxananan S, Punjasawadwong Y, Suraseranivongse S, et al. The Thai Anesthesia Incidents Study (THAI Study) of 
anesthetic outcomes. Journal of the Medical Association of Thailand=Chotmaihet thangphaet. 2005;88:S14-S29.

4. O’Neill ES, Dluhy NM, Chin E. Modeling novice clinical reasoning for computerized decision support system. Journal of 
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5. Diehl MR, Sanders KK. Anesthesia Complications. In: Nagelhout JJ, Plaus KL eds. Nurse Anesthesia. 5th ed St Louis, MO: 
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6. Neal JM, Hsuing RL, Mulroy MF, Halpern BB, Dragnich AD, Slee A. ASRA checklist improves trainee performance during 
a simulated episode of local anesthetic toxicity. Regional Anesthesia and Pain Medicine. 2012;37(1):8-15.

7. Augostides JG, Atkins J, Kofke WA. Much ado about checklists. Anesthesia & Analgesia. 2013;117(5):1037-1038.

8. Harrison TK, Manser T, Howard SK, Gaba DM. Use of cognitive aids in a simulated anesthetic crisis. Anesthesia & Analgesia. 
2006;103(3):551-556.

9. Goldhaber-Fiebert S, Lei V, Nandagopal K, Bereknyei S. Emergency manual implementation: Can brief simulation-based OR 
staff trainings increase familiarity and planned clinical use? The Joint Commission Journal on Quality and Patient Safety. May 
2015;41(5):212-220.

10. Arriaga AF, Bader AM, Wong JM, et al. Simulation-based trail of surgical crisis checklists. New England Journal of Medicine. 
January 2013;368(3):246-253.

11. Babcock WW. Resuscitation During Anesthesia. Anesthesia & Analgesia. 1924;3(6):208-213. http://journals.lww.com/
anesthesia-analgesia/Citation/1924/12000/

Resuscitation_During_Anesthesia_.3.aspx. Accessed December 10, 2016.

12. Stiegler MP, Neelankavil JP, Canales C, Dhillon A. Cognitive errors detected in anesthesiology. British Journal of Anesthesiology. 
2012;108(2):229-235.

13. Smith K, Gilcreast D, Pierce K. Evaluation of staff ’s retention of ACLS and BLS skills. Resuscitation. 2008;78:59-65.

14. Semeraro F, Signore L, Cerchiari EL. Retention of CPR performance in anaesthetists. Resuscitation. 2006;68:101-108.

15. Berkenstadt H, Ben-Menachem E, Dach R, et al. Deficits in the provision of cardiopulmonary resuscitation during simulated 
obstetric crises: Results from the Israeli Board of Anesthesiologists. Anesthesia & Analgesia. 2012;115(5):112-1126.

16. Henrichs BM, Avidan MS, Murray DJ, et al. Performance of certified registered nurse anesthetists and anesthesiologists in a 
simulation-based skills assessment. Anesthesia & Analgesia. 2009;108(1):255-262.

17. Goldhaber-Fiebert SN, Howard SK. Implementing emergency manuals: Can cognitive aids help translate best practices for 
patient care during acute events? Anesthesia & Analgesia. 2013;117(5):1149-1161.

18. Stanford Anesthesia Cognitive Aid Group. Emergency Manual: Cognitive Aids for Perioperative Clinical Events. Creative 
Commons BY-NC-ND; 2016. http://emergencymanual.stanford.edu. Updated 2016. Accessed October, 2016.

19. Arriaga AF, Bader AM, Wong JM, et al. Simulation-based trial of surgical crisis checklists. New England Journal of Medicine. 
2013;368(3 Suppl.).

20. Human patient simulator (HPS): physiology you can count on. CAE Healthcare. http://www.caehealthcare.com/images/
uploads/brochures/HPS.pdf. Published 2015. Accessed January 5, 2017.

21. Morrell RC, Cooper JB. APSF sponsors workshop in implementing emergency manuals. APSF Newsletter. February 
2016;30(3):68-71.

Educated Hand Publishing LLC 
“The Science Behind the Art” 
Volume 10 - No.1 2022 

 Anesthesia eJournal - Online
ISSN 2333-2611

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http://journals.lww.com/anesthesia-analgesia/Citation/1924/12000/
http://journals.lww.com/anesthesia-analgesia/Citation/1924/12000/
http://emergencymanual.stanford.edu
http://www.caehealthcare.com/images/uploads/brochures/HPS.pdf
http://www.caehealthcare.com/images/uploads/brochures/HPS.pdf


Figure 1. Percentage of Key Tasks Completed During Simulated Critical Event Scenarios Before and After EM Training.

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 Anesthesia eJournal - Online
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Table 1. CRNA Perceptions Before and After EM Training. 

                                                                                                    Average Scores

Question Before EM After EM Score Difference

The scenario was realistic. 4.75 4.89 4.89

The scenario was appropriately challenging. 4.55 5.00 +0.45 

This scenario will help me provide safer patient care. 4.65 4.94 +0.29

This scenario prompted realistic response from me. 4.58 4.83 +0.25

I felt I did things during this training day that I 
never would have had a chance to practice otherwise 3.80 4.44 +0.64

The knowledge gained will be helpful to me in my 
practice. 4.60 4.89 +0.29

I enjoyed the training session. 4.75 4.94 +0.19

I learned something new. 3.75 4.67 +0.92

This training session should be taken by all OR staff 4.50  4.89 +0.39

1=Strongly Disagree, 2=Slightly Disagree, 3=Neutral, 4=Slightly Agree, 5=Strongly Agree. 

The questionnaire was adapted from that used by Arriaga et al.19

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“The Science Behind the Art” 
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 Anesthesia eJournal - Online
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