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Development of The Anaesthetic Crisis Manual (The ACM)


The concept of a more distinctive, easily recognizable, design oriented and functional manual for intra-operative crisis management began in 2006. Dr Borshoff, an anaesthesiologist with a diverse practice including paediatrics and cardiothoracic anaesthesia, as well as a background in recreational aviation, felt cognitive aids available at that time were inadequate and failed to achieve their purpose.

Like many guidelines and protocols created in academic institutions, they were often complicated, difficult to read and sometimes confusing with arrows and flow diagrams. On top of this, they were frequently in the format of laminated cards, inconsistently placed in the operating room. At best, they could be found as cards in a file – an unappealing format when trying to implement a culture of checklist and cognitive aid support.

Adopting an approach with emphasis on human factors, crew resource management and the power of good design to encourage clinician engagement, Dr Borshoff with the assistance of Graphic Source Design, created the now widely recognizable ACM. The orange cover, coloured tabs and the clearly formatted, bulleted directives, based on aviation checklist design, has encouraged widespread uptake by individuals and institutions worldwide.

In particular, the strong clinical orientation of the content has proven appealing to those who spend most of their time in the operating room or peri-operative environment. Anaesthesiologists who give thousands of anaesthetics a year were frequently consulted for suggestions and feedback until the final product was published in September 2011.

It continues to be the first commercially available checklist emergency manual for anaesthetic crisis management, including both Checklist Protocols for crisis management and a Crisis Prevention section to assist in diagnosis. The author has always been a strong advocate of the crisis prevention component, as under duress, incorrect diagnosis and the subsequent use of the wrong checklist is always possible. It is this that separates this manual from others currently available.
After first appearing on the market in 2011, The ACM has had significant influence on other organizations and emergency manuals. In 2012, The European Society of Anaesthesiology endorsed and extensively referenced The ACM as well as inviting Dr Borshoff to co-author their Emergency Operating Room Checklists. These became available as a free download from the ESA website, following the 2010 Helsinki Declaration on Patient Safety in Anaesthesiology. Both The 2013 Stanford Emergency Manual and the Harvard associated Ariadne Labs Operating Room Emergency Checklists, demonstrate one or more of The ACM features including spiral binding, the strategic use of colour, simpler design and formatting, bullet point directives and cross-referenced protocols.

The ACM e-Book released in July 2014 and the soon to be released diagnostic A-CAS app, continue to promote the cultural integration of cognitive aid use in the anaesthetic and peri-operative environment.

Indeed, Dr Michael Mulroy, Chairman of the Emergency Manual Implementation Collaborative in the USA, after reviewing The Anaesthetic Crisis Manual in 2011 stated:

"This concept is a great step forward for our profession in providing safe and effective care for all our patients, and we owe a debt of gratitude to Dr. Borshoff for helping us along this path."