The Triad Approach was presented at the Australian Society of Anaesthetists and the New Zealand Society of Anaesthetists Combined Scientific Congress in Darwin on September 13th, 2015
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Dr Nicholas Chrimes FANZCA, Consultant Anaesthetist |
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What is a "High Acuity Implementation Tool"?
Clinical crisis management frequently requires key priorities to be initiated in a time critical fashion to avoid significant morbidity or mortality to patients. This can be a stressful situation and, even in the hands of highly competent and experienced staff, this stress can result in time critical interventions not being implemented in an appropriate time frame and important priorities being delayed or overlooked, thereby compromising patient care. The use of properly designed cognitive tools to prompt clinicians to perform these basic tasks, could improve management of these situations but the amount of information that can be processed by stressed individuals in the initial phases of managing a crisis may be very low.
Whilst algorithms & clinical guidelines usually present information that is technically correct regarding how to manage a medical crisis, they tend to be text based, information dense documents. Whilst such documents have an important part to play in preparing clinicians to deal with a crisis prior to a crisis occurring they are less suited to use during the initial phase of a crisis, when clinicians may have limited information processing ability due to stress. The term "High Acuity Implementation Tool" was coined by emergency & retrieval physician Dr Peter Fritz and anaesthetist Dr Nicholas Chrimes, in relation to the Vortex Approach, to refer to a tool which is designed specifically for use during time critical emergencies. In order to achieve this, not only must the content of the tool address the technical factors required to manage the crisis, but the design of the tool must address the human factors aspects that will allow it to be used in "real time" during a crisis. A High Acuity Implementation Tool must therefore be simple enough to be used by teams of potentially highly stressed clinicians during the initial stages of managing a time critical emergency and flexible enough that the same tool can be consistently applied to any context in which a particular crisis might arise. The purpose of a High Acuity Implementation Tool is to act as a prompt to facilitate implementation of prior training & planning, in order to allow clinical teams to perform under pressure.
Whilst algorithms & clinical guidelines usually present information that is technically correct regarding how to manage a medical crisis, they tend to be text based, information dense documents. Whilst such documents have an important part to play in preparing clinicians to deal with a crisis prior to a crisis occurring they are less suited to use during the initial phase of a crisis, when clinicians may have limited information processing ability due to stress. The term "High Acuity Implementation Tool" was coined by emergency & retrieval physician Dr Peter Fritz and anaesthetist Dr Nicholas Chrimes, in relation to the Vortex Approach, to refer to a tool which is designed specifically for use during time critical emergencies. In order to achieve this, not only must the content of the tool address the technical factors required to manage the crisis, but the design of the tool must address the human factors aspects that will allow it to be used in "real time" during a crisis. A High Acuity Implementation Tool must therefore be simple enough to be used by teams of potentially highly stressed clinicians during the initial stages of managing a time critical emergency and flexible enough that the same tool can be consistently applied to any context in which a particular crisis might arise. The purpose of a High Acuity Implementation Tool is to act as a prompt to facilitate implementation of prior training & planning, in order to allow clinical teams to perform under pressure.
High Acuity Implementation Tool...
"simple enough to be used by teams of potentially highly stressed individuals... flexible enough that the same tool can be consistently applied to any context in which a particular crisis might arise"
"a prompt... to allow clinical teams to perform under pressure"
It is well documented in emergency airway management that even experienced clinicians are vulnerable to making significant, fundamental errors when they are under pressure and that such errors can lead to serious adverse patient outcomes. The Vortex Approach was conceived by Dr Nicholas Chrimes as a High Acuity Implementation Tool to assist in addressing these issues during management of the unanticipated difficult airway.
Rationale for the Triad Approach
Although the issues relating to airway emergencies apply to the management of other clinical crises, adapting the principles of the Vortex Approach for use beyond airway management poses some additional challenges. In general, clinicians engaged in independent advanced airway management can be assumed to have a baseline level of competence with the requisite technical skills (where this is not the case the issue should be addressed by improving training, not via use of a cognitive tool). These skills tend to be well maintained even in situations of stress, provided clinicians are provided with appropriate cues to implement them using prompts to remind the team of the available options and to improve situational awareness. In contrast to difficult airway management, other clinical emergencies may require significant information recall, complex decision making and tracking of multiple parallel processes in order for to be managed effectively. The amount of information which needs to be provided by a cognitive tool to enable clinicians manage a crisis effectively may vary widely according to their level of training, experience and exposure – all of which contribute to their level of familiarity with management of that crisis. Even for a particular individual managing a specific crisis, information recall may vary widely in different contexts according to their level of stress. The factors which may induce stress in a clinical situation are numerous but include forseeablility, complexity, availability of assistance, urgency to intervene, severity of potential harm, feelings of responsibility for causing the crisis, fatigue, prior emotional state and familiarity with the crisis itself. The dynamic nature of many of the factors which contribute to the stress produced by a particular clinical circumstance means, that there is potential for a clinician, no matter how experienced and familiar with a clinical event, to be become stressed to the point that cognition becomes significantly compromised.
Traditionally, cognitive aid design has addressed the above issues by creating tools with detailed technical content that cater to the "lowest common denominator" in terms of knowledge and cognitive capacity. The rationale is that provision of exhaustive instructions ensures that even someone with limited familiarity or information recall will have access to sufficient technical information to successfully manage the crisis. Conversely it is assumed that more experienced, well functioning clinicians who do not need to access this detail can "skip over" it, selecting only the information they need. Whilst this may intuitively seem to make sense, this approach ignores the fact that stress can not only impair a clinician’s ability to access their own existing knowledge but can also interfere with their ability to process the information presented to them in a cognitive aid. Thus these information laden tools do not address the cognitive challenges produced by stress, diminishing their utility in “real time” management of clinical crises.
To be effective, a High Acuity Implementation Tool tool needs to provide prompts pitched at a level which is appropriate to the both familiarity and cognitive capacity of the clinicians involved in a particular clinical circumstance. This balance can be difficult to achieve, with the greatest discordance arising when a clinician is presented with a clinical situation with which they have limited familiarity (resulting in a requirement for high information content) in a situation which is also highly stressful (resulting in a limited capacity for information processing). Whilst this is the situation in which it is most difficult to devise an effective cognitive aid, it is also the situation in which it is most needed.
Traditionally, cognitive aid design has addressed the above issues by creating tools with detailed technical content that cater to the "lowest common denominator" in terms of knowledge and cognitive capacity. The rationale is that provision of exhaustive instructions ensures that even someone with limited familiarity or information recall will have access to sufficient technical information to successfully manage the crisis. Conversely it is assumed that more experienced, well functioning clinicians who do not need to access this detail can "skip over" it, selecting only the information they need. Whilst this may intuitively seem to make sense, this approach ignores the fact that stress can not only impair a clinician’s ability to access their own existing knowledge but can also interfere with their ability to process the information presented to them in a cognitive aid. Thus these information laden tools do not address the cognitive challenges produced by stress, diminishing their utility in “real time” management of clinical crises.
To be effective, a High Acuity Implementation Tool tool needs to provide prompts pitched at a level which is appropriate to the both familiarity and cognitive capacity of the clinicians involved in a particular clinical circumstance. This balance can be difficult to achieve, with the greatest discordance arising when a clinician is presented with a clinical situation with which they have limited familiarity (resulting in a requirement for high information content) in a situation which is also highly stressful (resulting in a limited capacity for information processing). Whilst this is the situation in which it is most difficult to devise an effective cognitive aid, it is also the situation in which it is most needed.
"a High Acuity Implementation Tool tool needs to provide prompts pitched at a level which is appropriate to the both familiarity and cognitive capacity of the clinicians involved in a particular clinical circumstance"
Overview of the Triad Approach
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The Triad Approach addresses the above challenges by providing a hierarchy of resources of increasing complexity which can be accessed according to a clinician’s information needs and cognitive capacity. The first tier (the Triad) simply presents management priorities, the second tier (the Task List) identifies tasks needed to address these priorities and the third (the Intervention Guide) provides more detailed background information on the specific interventions required to complete the tasks. The intention is that each tier provides prompts at an appropriate level of detail for the cognitive capacity of the clinicians involved in managing the crisis. The simpler prompts of the upper tiers ensure time critical interventions are recognised and initiated, even by highly stressed individuals. This not only provides urgent therapy to the patient in a timely fashion but the sense of achievement in progressing management of the crisis will hopefully decrease the level of stress ("success to destress"), thereby improving their cognitive capacity so that they can process the more detailed information presented in the lower tiers. Thus to achieve the desired balance between maintaining simplicity and providing the varying level of technical information required by a clinician to manage any crisis, the Triad Approach is designed so as to provide increasingly detailed information that can be accessed according to the requirements of a specific situation. The role of each of the 3 tiers of the Triad Approach is outlined below.
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Generic Triad
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Triad Purpose:
The first tier of the Triad Approach consists of the Triad itself. This provides three immediate priorities, specific to the management of a particular crisis. The Triad is a low content, predominantly graphic tool which allows clinicians to recognise management priorities but does require them to process information in order to be utilised. As such it has been tailored to meet the needs and cognitive capacity of potentially highly stressed clinicians during the initial stages of managing a high-stakes, time-critical situation. Whilst the Triad cognitive tool would ideally be physically accessible in the clinical environment, the expectation is that clinicians should commit to memory the three priorities of each Triad for the specific crises relevant to their practice, and know them well enough that they can be recited at any given time. The Triad is analagous to the "boldface" concept in aviation, whereby pilots must commit to memory the few immediate, essential steps to manage certain in-flight emergencies so as to ensure that in circumstances where the pilot might otherwise become overwhelmed, these time-critical interventions are still implemented rapidly. |
Triad "...three immediate priorities, specific to the management of a particular crisis"
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Triad Presentation:
Rather than present the Triad as a simple written list, it is displayed as a graphic image in an attempt to facilitate its use by clinicians who may be cognitively overwhelmed. Clinicians have described that when under stress they are able to use visual memory to recall graphic elements of a cognitive tool more easily than text based elements. The term "conceptual imprinting" was coined by Nicholas Chrimes in relation to the Vortex Approach to describe the incorporation of colours, images and other graphic metaphors into the design of cognitive tools, to be used as cues which could convey additional concepts without explicit reference needing to be made to them. These visual cues allow the tool to reinforce these concepts whilst still maintaining a simple, low content interface which is accessible to the stressed clinician. Whilst in the generic Triad depicted above, the three circular elements of the graphic are all grey, in the Triads for specific crises these elements displaying the priorities are brightly coloured. The colour of each of these graphic elements has been selected to make a cognitive link with the priority to which it refers, in the hope that this will assist with memory & recall. The nature of these links is explained in relation to each individual Triad in the subsequent webpages. |
Cardiac Arrest Triad
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The colour of the text of the lower tiers of the Triad Approach (see below), which provide a more specific articulation of actions, is also coded to match the colour of the priorities in the initial Triad with which those actions are thematically linked. The theme uniting each priority with subsequent items in the associated task list is not specified in the Triad itself but is explained to clinicians as part of their training in use of the Triad Approach. The intention is that this represents another level of conceptual imprinting to assist clinicians to recall actions, other than those specifically included in the Triad.
The graphic presentation of the Triad also aims to reduce the cognitive load by not specifying a particular sequence in which the Triad priorities should be implemented. Whilst there may be a preferred sequence in which given priorities might best be implemented, this may vary according to the specific context and can be decided at the time. The principle of the Triad is that irrespective of the desired sequence, ensuring that time critical aspects of care can be rapidly implemented requires them all to be declared at from the outset. As such Triad simply reminds clinicians to declare the three immediate management priorities as soon as the crisis itself is declared.
Interventions to manage any clinical crisis can be broadly divided into those which are supportive and (these are specific components of supporting airway, breathing and/or circulation) and those which are therapeutic (these treat the underlying cause of the problem). One further cue provided by the Triad graphic is the outline seen around the "Priority" text in some elements. This "text outline" formatting delineates these priorities as being related to therapeutic rather than supportive interventions and is present in all Triads. For example, the “text outline” is seen around the "Rhythm Check" in the Cardiac Arrest Triad above because this item leads to a series of events that are ultimately needed to restore spontaneous circulation. The remaining items “CPR” and “Adrenaline” simply support the circulation until this can occur. In sub-acute conditions, first responders are often involved in providing supportive care which “buys time” for other clinicians to initiate the therapeutic interventions at a later time (for example antibiotics for a septic patient or surgery for a patient with a bowel obstruction). The types of crises to which the Triads apply, however, require the therepeutic options to be implemented urgently. This additional prompt reminds clinicians which of the priorities is responsible for rectifying the problem. It is deliberately subtle so that it does not clutter the graphic but is available as an additional cue to aid memory if desired.
Triad Content:
Considerable thought has gone into selecting the three priorities for each Triad. To maximise their general acceptance, the technical content determining the Triad priorities has been derived from established guidelines for management of the relevant clinical emergencies. Whilst some experienced clinicians may occasionally feel that a particular context requires deviation from accepted conventional practice and may elect to omit or alter a particular priority in this situation, the Triad at least ensures that in this circumstance this is a conscious decision, rather than an omission or error.
The priorities of the Triads have been articulated according to the following principles to maximise their utility as prompts:
The graphic presentation of the Triad also aims to reduce the cognitive load by not specifying a particular sequence in which the Triad priorities should be implemented. Whilst there may be a preferred sequence in which given priorities might best be implemented, this may vary according to the specific context and can be decided at the time. The principle of the Triad is that irrespective of the desired sequence, ensuring that time critical aspects of care can be rapidly implemented requires them all to be declared at from the outset. As such Triad simply reminds clinicians to declare the three immediate management priorities as soon as the crisis itself is declared.
Interventions to manage any clinical crisis can be broadly divided into those which are supportive and (these are specific components of supporting airway, breathing and/or circulation) and those which are therapeutic (these treat the underlying cause of the problem). One further cue provided by the Triad graphic is the outline seen around the "Priority" text in some elements. This "text outline" formatting delineates these priorities as being related to therapeutic rather than supportive interventions and is present in all Triads. For example, the “text outline” is seen around the "Rhythm Check" in the Cardiac Arrest Triad above because this item leads to a series of events that are ultimately needed to restore spontaneous circulation. The remaining items “CPR” and “Adrenaline” simply support the circulation until this can occur. In sub-acute conditions, first responders are often involved in providing supportive care which “buys time” for other clinicians to initiate the therapeutic interventions at a later time (for example antibiotics for a septic patient or surgery for a patient with a bowel obstruction). The types of crises to which the Triads apply, however, require the therepeutic options to be implemented urgently. This additional prompt reminds clinicians which of the priorities is responsible for rectifying the problem. It is deliberately subtle so that it does not clutter the graphic but is available as an additional cue to aid memory if desired.
Triad Content:
Considerable thought has gone into selecting the three priorities for each Triad. To maximise their general acceptance, the technical content determining the Triad priorities has been derived from established guidelines for management of the relevant clinical emergencies. Whilst some experienced clinicians may occasionally feel that a particular context requires deviation from accepted conventional practice and may elect to omit or alter a particular priority in this situation, the Triad at least ensures that in this circumstance this is a conscious decision, rather than an omission or error.
The priorities of the Triads have been articulated according to the following principles to maximise their utility as prompts:
- Open rather than closed ended: wherever possible, priorities have been phrased so as to trigger a cascade of actions rather a single "dead end" action. As an example, in the cardiac arrest Triad, the prompt "Rhythm Check" is characterised as "open ended". Performing a rhythm check provides the clinical team with information which it should automatically trigger a subsequent series of actions. Recognition of a "shockable rhythm" should lead to an attempt at defibrillation whilst a "non-shockable rhythm: should lead to consideration of reversible causes. In contrast, had the priorities been structured differently such that one was "defibrillate" then, whilst prompting an important action for a "shockable rhythm", this would not necessarily imply any further interventions beyond that single action and is therefore characterised as "closed ended".
- Compound rather than simple: wherever possible, priorities which represent readily understood "compound concepts" have been used. As an example in the cardiac arrest Triad, the prompt "CPR" triggers initiation of a clearly understood constellation of actions including external cardiac compressions, ventilation, provision of 100% oxygen, compression/ventilation ratio, etc. In contrast, the prompt "external cardiac compressions", whilst highlighting the most crucial component of CPR, risks overlooking implementation of these other actions. The Triad Approach takes the perspective that it is the role of prior training to teach clinicians that cardiac compressions are the most time critical component of CPR so that during the crisis they can respond to this prompt accordingly. The goals of the Triad Approach are therefore best served by prompting several compound actions with a single priority which inflicts the same cognitive load on the clinician as a more restrictive simple priority.
The above principles are in keeping with the intention that the Triads express broad management priorities rather than the first three steps in a checklist of specific actions. Sometimes, however, simple closed ended actions are so crucial to the immediate management of a crisis that it is felt that they must be specifically articulated as a Triad priority.
Use of the Triad:
The Triad provides the initial interface between the stressed clinician and the cognitive tool, in the "real time" management of a high-stakes, time critical emergency. For both cultural & practical reasons the initial steps of clinical emergency management have tended to be based on taking immediate action without prior consultation of a checklist or other cognitive aid. By providing a simple, graphic which can be easily referred to in real time or recalled from visual memory, the Triad bridges the gap between these instinctive initial steps of management and the less familiar process of consulting the more conventionally structured Task List and Intervention Guide tiers of this High Stakes Cognitive Tool.
The combination of open/compound priorities, colour coding and thematic links with the more detailed information provided in the lower tiers is therefore intended to improve the cognitive efficiency of the Triad, such that prompting three priorities may lead to several additional interventions, even before lower tiers of the cognitive tool have been accessed.
2. The Task List
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The task list presents a simple set of items directed towards achieving the priorities highlighted by the parent Triad. Items in the task list are colour coded to link thematically to the Triad priority to which they relate. This is intended to facilitate initial role allocation as team members who are assigned by the coordinating clinician to oversee implementation of each triad priority can then lead sub-teams of individuals, each delegated responsibility for an item in the task list of that colour. Colour coding of the task list items to the Triad priorities may also assist with recall, though it is not intended that items in the task list should be memorised. In contrast to a checklist, the items in the task list are less specific and not necessarily intended to be implemented in a specific sequence.
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3. The Intervention Guide
The Intervention Guide provides more detailed, background information on the technical aspects of managing the crisis such as drug doses, descriptions of specific techniques & criteria for more complex decision making. For easy reference the Intervention Guide is colour coded according to the Triad priority and task list item to which it relates.
The Triad Approach thus allows information to be accessed according to the familiarity and cognitive capacity of the clinicians in that clinical circumstance.
The Triad Approach thus allows information to be accessed according to the familiarity and cognitive capacity of the clinicians in that clinical circumstance.
- For expert clinicians with extensive technical knowledge of the clinical event & training in behavioural aspects of crisis management, who are operating under conditions of minimal stress, use of the TRIAD to prompt the PRIORITIES of therapy may be all that is required, as the TASKS (both technical & behavioural) necessary to achieve these may already be familar.
- Clinicians comfortable with the technical aspects of managing the event but less experienced in the behavioural aspects may additionally utilise the Task List to assist with role allocation (see below).
- Junior staff or experts exposed to unfamilar clinical events (eg. Malignant Hyperthermia) may need to additionally access the Intervention Guide. The principles described above for the design and content of the Triad graphic mean that its priorities should be a sufficient prompt that even inexperienced staff are likely to be able to initiate some of the more specific interventions to achieve the priorities stated by the Triad, prior to consulting the Task List. These staff are likely to need to consult the 2nd or 3rd tiers of the tool, however, in order to comprehensively manage the crisis. As junior staff become more experienced over time it would be expected that they increasingly rely only on the more superficial tiers of the triad when dealing with more familiar crises.
- For clinicians of all levels the Task List and Intervention Guide should remain valuable resources to be consulted to confirm specific pieces of information and ensure vital steps in management have not been overlooked.
Focus of the Triad Approach
The Triad Approach restricts itself to highlighting the specific priorities required to manage a particular provisional diagnosis. As such it deliberately does not address the following:
Undifferentiated Problems
No Triads have been developed for undifferentiated physiological abnormalities such as hypoxia, hypotension, tachycardia or high airway pressures which have not yet been associated with a particular provisional diagnosis of the underlying pathology responsible for causing them. The reason for this is that tailoring management specifically towards a specific physiological problem risks causing fixation which might impair recognition of other co-existent abnormal physiology. Identifying other physiological abnormalities is important not only so that urgent empirical therapies to address them can be implemented but also because pattern recognition of different constellations of physiological abnormalities may be important in forming a provisional diagnosis of the underlying pathology. Hypoxia that is associated with tachycardia, hypertension and hypercapnia conjures up a different set of differential diagnoses than that associated with bradycardia, hypotension and hypocarbia. Undifferentiated physiological abnormalities should be addressed using an approach which involves repeated evaluation & optimisation of airway, breathing, circulation & disability – a process which should continue even once a provisional diagnosis has been made. Even though the Triads do not address the approach to managing undifferentiated problems via evalution and management of ABCD, for some crises the evaluation and optimisation of airway, breathing, circulation &/or disability is so critical to the specific management of a particular crisis that addressing one or more of these elements has been included within the priorities of the initial Triad.
Generic Aspects of Crisis Management
There are a number of important actions common to the effective management of any crisis. These include non-technical aspects such as declaring the crisis, calling for help and role allocation as well as technical interventions such as establishing intravenous access, considering the need to escalate the intensity of monitoring and sourcing specialised equipment such as the crash cart, difficult airway trolley, malignant hyperthermia kit, etc. As with the Vortex Approach, in the interests of maintaining the simplicity & clarity, these aspects of care are not addressed by the High Stakes Cognitive Tool itself. Since these elements can be consistently applied to the management of any crisis – whether resulting from undifferentiated physiological problems or associated with a specific provisional diagnosis - they are best addressed by a separate simple tool which is always implemented in parallel with the Triad Approach.
Effective “real world” use of the Triad Approach thus requires that it is implemented within a broader generic framework for crisis management which includes aspects of management common to the management of any crisis as well as initial evaluation & optimisation of undifferentiated physiological abnormalities - with the Triad Approach only being invoked once a provisional diagnosis has been made, in parallel with ongoing repeated re-evaluation of airway, breathing, circulation & disability. Such a framework, specifically designed to integrate with the Triad Approach, has been developed. For clarity this template has not been included here but will be presented as an appendix to the forthcoming free Triad Approach e-book.
Crisis Selection
There should only be a limited number of crises for which a given clinician needs to commit a Triad of priorities to memory. With this in mind, the Triads developed so far have been restricted to crises for which rapid execution of the initial steps of management is critical to minimise the risk of patient morbidity/mortality. Furthermore, care has been taken to keep the definitions of the crises broad. Thus "Haemorrhage" refers equally to post-partum haemorrhage, intraoperative bleeding or ruptured aortic aneurysm. Similarly no distinction has been made between adult, paediatric and maternal cardiac arrest. Whilst there may be differences in the specific interventions to achieve the priorities between the different manifestations of these crises, the broad priorities remain constant. The strategy adopted by the Triad Approach has been to reduce cognitive load by emphasising the similarities which predominate in the management of different manifestations of a given crisis, whilst highlighting the limited number of important distinctions in the Task List and Intervention Guide.
Triad Approach Crisis List
Triads and associated Task Lists for the above crises will be published on this site in the future.
Universal Approach
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By providing a standardised set of key priorities for a limited number of crises the Triad Approach offers the potential to offer a universal approach to the initiation of management of these crises across all clinical disciplines, specialties and contexts. Whilst the ability of clinicians to achieve these priorities and the specific interventions by which they do so may vary according to level of training, experience and the environment - the Triad of priorities always remains constant. The priorities for the management of anaphylaxis are the same for a nurse in a local doctor's clinic, a junior resident on the ward or a senior critical care clinician in the Emergency Department.
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Whilst individual clinicians will no doubt have their own opinions on what the three Triad priorities should ideally be for each crisis, it is hoped that consideration of the above principles along with an appreciation of the benefits of creating a universally accepted template for crisis management, will encourage clinicians to accept the merits of the stated priorities. By the same token, the author is happy to receive communication from clinicians who feel strongly that the utility of the tool could be improved if the priorities in a particular Triad were altered, provided this is in keeping with the above stated principles. |
Requirement for Training
Whilst the cognitive tool provides a simple interface designed to be accessible to during the “real time” many of the underlying principles of the Triad Approach require detailed explanation to be useful. As such effective use of the Triad Approach to manage a crisis requires prior inter-professional training of clinical teams in use of the cognitive tool. It is unrealistic to expect that information recall and complex decision making can be facilitated by a tool simple enough to be used in "real time" during a crisis by teams of highly stressed clinicians, without prior training. Achieving this will not be possible using a cognitive tool which is utilised "off the shelf", sight unseen, for the first time during a crisis. It is the effective prior instruction of clinicians in both the use of the High Acuity Implementation Tool itself and the underlying technical & behavioral aspects of managing the relevant crises that enables a simple cognitive aid to prompt the recall & implementation of complex actions. The purpose of a High Acuity Implementation Tool is to facilitate implementation of appropriate prior training & planning, not to compensate for its inadequacies.
The purpose of a High Acuity Implementation Tool is to facilitate implementation of appropriate prior training & planning, not to compensate for its inadequacies.