Code Reader

Abstract

To the Editor: We would like to congratulate Burden et al1 for an important contribution to the literature on cognitive aids to improve performance in crisis situations, using both malignant hyperthermia and obstetric cardiac arrest scenarios. A previous research from the same group2 and other authors3 has shown that one of the most persistent barriers to the use of cognitive aids in medicine is that physicians often overlook them when faced with a crisis. The authors’ idea of a dedicated “reader” is an interesting technique to circumvent that problem. It is certainly novel in health care and seems to have similarities to role of a copilot in aviation. It will be fascinating to see if this form of redundancy, which is fairly uncommon in health care, has the potential to be transferable to other situations and to improve patients’ outcome. We think that the evaluation of Burden et al1 of the interaction between the reader and the leader is an important example of “clarification” research in medical education: looking beyond the question of “does it work?” and considering “how does it work best?”4 Randomized controlled trials (RCTs) are feasible in educational research, and a number of RCTs, not mentioned by Burden et al,1 have examined the effectiveness of cognitive aids in crisis situations. Berkenstadt et al5 used RCT methodology to investigate the effectiveness of an online cognitive aid to improve performance, also in a malignant hyperthermia scenario. They found that performance was better in the group randomized to the cognitive aid and that the aid was well used. Contrastingly, our group’s RCT on the use of cognitive aids in a neonatal resuscitation scenario showed no significant difference between the intervention group, which had access to an algorithm on a poster, and the control group, which did not.3 We also found that the cognitive aid was generally underused when present. Finally, Low et al6 investigated the use of a cognitive aid in the format of an application on a handheld computer (Apple iPhone) for an adult cardiac arrest scenario. The group randomized to the cognitive aid performed better, but there was no measurement of how well the cognitive aid was used. There are many factors that may affect how best to use cognitive aids in a crisis including the content, the format, human factors, and clinical factors such as the complexity and timing of the scenario/crisis. We would like to suggest that the most appropriate methodology for future investigations of the effectiveness of variations on these factors is the RCT, which can allow a “more robust understanding of the nature of change associated with the intervention.”7 Daniel J. Power, MD Department of Anesthesiology University of Ottawa The Ottawa Hospital Civic Campus Ottawa, ON, Canada Sylvain Boet, MD, MEd Department of Anesthesiology The Ottawa Hospital General Campus Ottawa, ON, Canada M. Dylan Bould, MBChB, MEd Department of Anesthesiology The Children’s Hospital of Eastern Ontario University of Ottawa Ottawa, ON, Canada