The Association of Anaesthetists Quick Reference Handbook: past, present and future 

My task is to tell the story of the Association’s Quick Reference Handbook for Anaesthesia Emergencies, or as it is usually known, “the QRH”. I’m going to explain how it came into being, its current status, and where it is headed.  

A QRH is not a new idea. They have existed for decades as cognitive aids for pilots and for others working in high-stakes industries. Ours was not even the first in anaesthesia, but it was the first written for a UK audience, and I believe it is still the most comprehensive. I will explain my role and why the Association was the natural home for this project. 

The Association has long been known for its role in patient safety and is well known for its clinical guidelines. Once, the guidelines were physical handbooks, known as ‘glossies’ because of their glossy covers, but now, of course, they exist in the digital universe, ready for download. They are consistently one of the Association’s most valued outputs at home and overseas. 

Long before I was elected to the Association’s board, I already had a substantial interest in patient safety. Back in 2007, and again in 2010 with its revision, I was part of the team that wrote the Association’s safety guideline for the management of severe local anaesthetic toxicity, the first national guideline published anywhere for this. The Association was already home to the national guidelines on malignant hyperthermia and anaesthesia-related anaphylaxis, so it was the natural home for the LA toxicity guideline. But also, I was hooked…  

Meanwhile, in my own hospital at that time, each theatre had its ‘red folder’, a well-intentioned, but random jumble of emergency protocols hidden amongst other non-emergency information, different in each theatre and of little use in an emergency. I set about creating a local QRH, a simple folder including the Association’s emergency guidelines and a few others, such as the national adult and paediatric advanced life support guidelines. This meant that each theatre now had an identical QRH containing all available relevant emergency protocols. We mounted holders for them on the wall so they were visible, obvious and immediately accessible.  

I should confess I did this as much for my own needs as anyone else’s. I had long held that it was wrong to expect clinicians to memorise emergency protocols and recall every item faultlessly in the throes of a crisis. I certainly knew I couldn’t. Subsequent human factors science supports this, but it seemed self-evident to me. I assembled a resource that would ensure my colleagues and I had the right cognitive aid immediately to hand if the worst happened. 

Next, I started looking for gaps in the QRH and quickly identified management of sudden, unexpected hypoxia, desaturation, cyanosis, or raised airway pressure during anaesthesia as a gap. There was no published systematic protocol or cognitive aid for this, so I wrote one and presented it at the Association’s 2012 Winter Scientific Meeting. I proposed working with the Association to develop and refine the hypoxia guideline, and to create a free online resource on their website so others could easily download and assemble a QRH, just like the ones in my hospital. 

Things became much easier in 2014 when I was elected to the Association board, and we assembled a working party, which I joined, comprising a small but brilliant group of colleagues with diverse clinical interests and expertise in cognitive aids. But things got a lot harder, too, as we realised and accepted that we could not just assemble the existing cognitive aids; we would have to develop a format, expand the topic list, and create new content. Ariadne Labs, which had published an OR crisis checklist in the USA, kindly allowed us to adopt their format, and in 2018, we launched our Quick Reference Handbook. 

We launched two versions: first, an ‘as is’ PDF version, which anyone can download and implement in the time it takes to print, and second, an editable Word version, which users can adapt to their needs. To allow this, the QRH is published under a Creative Commons CC BY-NC-SA 4.0 license. Our website includes a very detailed implementation plan. We know that successful implementation and maintenance require a whole-team approach, including educating all potential users about what’s in the QRH and, crucially, practising its use. The QRH will not leap magically off the wall in a crisis to save the day. It is a tool that requires skills to use, just like any other. 

The QRH covers 26 different scenarios, divided into four sections: a ‘key basic plan’ for stabilising the situation in an overwhelming crisis of unclear cause; situations where a crisis manifests as discreet signs or symptoms but without a clear cause and diagnosis and management are simultaneous, situations where the diagnosis is known or suspected and so management is the key focus; and finally, other environmental crises that could pose risk. 

Updates are promoted when necessary through our social media and member communications channels. The need for updates is usually obvious, for example, when the national advanced life support or anaphylaxis guidelines are updated. We are constantly ‘horizon scanning’ for this. Sometimes members have reported important errors or omissions, prompting us to issue updates.  

We chose not to develop an electronic version in 2018 for several reasons. First, at the time, it would have required a significant five-figure outlay, which was not budgeted. But also, the key principle of the QRH was that it be immediately available and portable to the site of the crisis, and we wanted a ‘lo-fi’ solution. Each page is designed to be viewed in its entirety rather than piecemeal, and a smartphone screen would not be large enough to do so.  

The Obstetric Anaesthetists Association has now published its own QRH for out-of-theatre obstetric emergencies, following the same format (including an electronic version). The Emergency Manuals Implementation Collective (EMIC) has a resource that compiles a large number of QRHs and other emergency manuals. 

The QRH is now seven years old. It is worth noting its success. Most UK departments have adopted it or adapted it for their own use; trainees value the QRH as a learning aid and as a support aid in a crisis; overseas colleagues have taken the editable version and created a QRH for their local audience, including translation into other languages. But it’s also time to reflect on what we do next. 

We are planning a review and update of the QRH. In particular, we need to incorporate some of the lessons from the work on unrecognised oesophageal intubation. We will add new steps to some pages to prompt clinicians to consider and exclude oesophageal intubation, and we will integrate the PUMA (Project for Universal Management of Airways) guide to reassureand non-reassure capnograph traces. We need to improve the generic paediatric content, and there will be a parallel project led by the Association of Paediatric Anaesthetists of Great Britain and Ireland to write a more specialised paediatric version for paediatric units. We will revisit the idea of an electronic version; technology has changed, and with the advent of AI, this may be achievable more efficiently than before. 

Finally, we are beginning work with the Royal College of Anaesthetists to develop a national scheme of mandatory, career-long periodic updates for clinicians in the management of life-threatening crises. The QRH is likely to figure in this work as it effectively provides a syllabus. Right now, some centres already offer this kind of update, but others do not. All too often, it relies solely on the existence of a local enthusiast. But this is too important to be left to chance. Pilots have to undergo regular currency training in the management of critical incidents in the cockpit. In aviation, it is understood and accepted that staying current is part of the job. It is in everybody’s interests – patients, clinicians and employers – that we begin to embrace this understanding in medicine. 

Succession planning means that, not too far off, someone else will have to take over what has been a very personal project for me for over a decade. I will be very sad when that day comes. I am incredibly proud of my role and the Association’s role in developing the QRH and making it a component of everyday anaesthesia in the UK. If I am remembered for one thing, I would like it to be this!  

Author: Tim Meek, President, Association of Anaesthetists of Great Britain and Ireland 

QRH in wall-mounted holder 

QRH cover 

Example guideline page from QRH

Contents page