The implementation of the emergency manual (EM) as a perioperative medicine tool has been critical in improving patient safety during anesthesia administration. An EM indexes many resources to provide an anesthesia delivery plan that is synchronous between both the individuals of the anesthesia care team and other OR personnel (Cureus 2019;11:e4888; APSF Newsletter 2016;31:43-5; Anesth Analg 2013;117:1149-61; Anesth Analg 2016;123:641-9). The EM does not eliminate the importance of continuous knowledge acquisition, but rather serves as a memory aid during nonroutine critical events in patient care in order to minimize errors and optimize outcomes (Cureus 2019;11:e4888; Anesth Analg 2013;117:1149-61; Anesth Analg 2016;123:641-9).

The reliability of the EM as a patient safety tool has been extensively studied. Simulation-based studies from Harvard University have demonstrated that lifesaving processes of care were four to six times more likely to be implemented when EMs were utilized (N Engl J Med 2013;368:246-53). In the United States, most institutions have gradually achieved significant cultural acceptance to integrate EMs into their practice and training.

Although there is increasing international awareness of the advantages of EM utilization, the implementation of EMs in the clinical setting is challenging. Access to EMs within ORs has been implemented in China through free EM distribution and the introduction of protocols for EM placement (APSF Newsletter 2016;31:43-5; APSF Newsletter 2020;35:62-3). Anesthesia EMs that have been translated into Chinese and effectively adopted in anesthesia practice in China include the Stanford Emergency Manual, Harvard Ariadne Lab Operating Room Crisis Checklists, Society for Pediatric Anesthesia PediCrisis Critical Event Checklists, and Stanford Obstetric Emergency Manuals (APSF Newsletter 2016;31:43-5; APSF Newsletter 2017;32:53-4). All these manuals were published in the New Youth Anesthesia Forum, and new versions are translated and updated immediately.

This method of free downloads and access to anesthesia providers was an effective strategy to eliminate the barriers of cost and language in distributing EMs to a large audience (APSF Newsletter 2016;31:43-5). Over 125,000 copies were downloaded within the first six months of the first Chinese version of the Stanford EM publication. Thirty-eight thousand copies of the third Chinese version of EM were downloaded. These numbers do not include the large number of individuals who received their copies through email distribution lists and social networking (APSF Newsletter 2016;31:43-5).

Media platform promotion and education are other keys to successful implementation of EMs. Operating room EM education series were organized and broadcasted from 2017 to 2019 by the New Youth Anesthesia Forum, covering 22 critical events and attracting 130,000 views. A series of OB emergency management online lectures featuring 15 speakers was organized by the Chinese American Society of Anesthesiology and the New Youth Anesthesia Forum. To date, these lectures have attracted 2.51 million views (

One of the largest reported barriers to EM use during a critical event is a lack of sufficient simulation training programs ( In China, a simulation training competition was founded by the Zhongshan City Society of Anesthesiology (APSF Newsletter 2017;32:53-4). Finalists from seven hospitals competed in a half-day event that focused on crisis resource management skills using EMs (APSF Newsletter 2017;32:53-4). The event served as a catalyst to encourage facilities to organize simulation training for OR EM implementation. A study completed one year later found that among those who participated in the competition, 85% reported using EMs in at least one OR critical event, a statistically significant increase (Cureus 2018;10:e3188).

An Anesthesia Crisis Resource Management Workshop was organized by the Department of Anesthesiology, Peking University People's Hospital in Beijing, China, in 2017 to demonstrate the utility of EMs as a resource for education and clinical care (APSF Newsletter 2017;32:53-4). The participants could become qualified teachers to organize and teach simulations at their own institutions (APSF Newsletter 2017;32:53-4).

“The Chinese Association of Anesthesiologists and the Chinese Society of Anesthesiology, two of the top anesthesia societies in China, have encouraged anesthesiologists and OR personnel to incorporate the use of EMs while managing critical events and have supported the development of multidisciplinary training to facilitate successful EM utilization.”

Proponents of EM implementation in China realized that further awareness regarding EM use could be promoted by demonstration-based methods at anesthesiology conferences (APSF Newsletter 2017;32:53-4). An EM simulation demonstration was included in a regional anesthesia meeting by the Department of Anesthesia, Xiangyang Central Hospital (APSF Newsletter 2017;32:53-4). Participants found that expert demonstration appears to be similar to simulation participation and was superior to didactics for teaching tenets involving the application of teamwork skills (APSF Newsletter 2017;32:53-4).

“Training a trainer” is an efficient way to spread new medical practices, and having trained individuals at every hospital can eliminate the fees, travel costs, and time-consuming nature of simulation training workshops, which are often multiday events (APSF Newsletter 2018;33:60-1). During a Chinese Association of Anesthesiologists annual meeting, attendees were able to participate in a two-hour EM simulation instructor training course, where they became qualified teachers (APSF Newsletter 2018;33:60-1). Participants engaged in a series of three standardized simulation scenarios (APSF Newsletter 2018;33:60-1). A post-course evaluation survey found that 80% of participants felt that they obtained the basic skills of EM simulation training, and 97% of participants agreed that they would organize EM simulation training at their hospitals (APSF Newsletter 2018;33:60-1). This technique could be applied at various regional or national meetings to train more trainers.

The support of official organizations is imperative to successfully implement EMs. The Chinese Association of Anesthesiologists and the Chinese Society of Anesthesiology, two of the top anesthesia societies in China, have encouraged anesthesiologists and OR personnel to incorporate the use of EMs while managing critical events and have supported the development of multidisciplinary training to facilitate successful EM utilization.

Following the introduction of Chinese-translated EMs, a multi-institute study was conducted to assess the utilization of EMs during critical events in ORs (Simul Healthc 2018;13:253-60). The results of this study were consistent with data from EM utilization in the U.S. (Anesth Analg 2016;123:641-9). Results of the study demonstrated that more than 70% of respondents reported using EMs during at least one critical event within the past six months in China (Simul Healthc 2018;13:253-60); 88% of respondents reported participating in self-review or group study of EMs at least once within the past six months (Simul Healthc 2018;13:253-60). Nearly 70% reported participating in multidisciplinary simulation training (Simul Healthc 2018;13:253-60). EM has become an efficient and highly utilized tool for anesthesia providers to study and train and to use in the OR.

In summary, EMs have been well received by anesthesia professionals in China. Many of these professionals have access to an EM at each anesthesia station, and through multidisciplinary training, a great number of clinicians became proficient in the utilization of EMs. It is our hope that other countries will utilize similar methods to help encourage appropriate training to adopt the use of OR EMs. This training will allow anesthesiologists to optimize crisis management skills and further improve patient safety.