Cognitive aids improve performance in oral and maxillofacial surgery outpatient anesthesia emergency simulations: a pilot study
Ryan C. Seeley1
, Leslie Donoghue Seeley2, Patrick J. Louis1, Kathlyn K. Powell1
Contributions: (I) Conception and design: RC Seeley; (II) Administrative support: PJ Louis, KK Powell; (III) Provision of study materials or patients: All authors; (IV) Collection and assembly of data: RC Seeley, LD Seeley; (V) Data analysis and interpretation: RC Seeley, LD Seeley; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.
Background: Outpatient anesthesia complications for the oral and maxillofacial surgeon (OMS) are rare events; however, successful management is critical for minimizing patient morbidity and mortality. The purpose of this pilot study was to determine if the use of cognitive aids during office-based anesthesia emergency simulation improves performance.
Methods: The authors implemented a randomized pilot study. Eight teams, each including a resident OMS, a surgical technician, and a registered nurse were randomized to one of two groups to complete 3 mock emergency drills using either cognitive aids or no aids in the outpatient setting at the University of Alabama at Birmingham OMS clinic. Group 1 completed 3 emergency scenarios for laryngospasm, anaphylaxis, and airway fire using cognitive aids while group 2 completed the same scenarios without aids. The primary predictor variable was the use of the cognitive aid. The main outcome variables were time to correct diagnosis (seconds), time to notify emergency medical services (EMS) (seconds), simulation duration (seconds), and task completion (yes/no). Performance was evaluated based on time to complete key steps and overall task completion. Statistical analysis performed using a Mann-Whitney test.
Results: A total of 8 surgical teams participated in a total of 24 simulated outpatient office-based anesthesia emergency simulation scenarios. Key timed measures include time to diagnosis, time to EMS notification, and total simulation time. While cognitive aids reduced the time to EMS notification, the reduction was not statistically significant (P>0.05). However, significant decreases in total simulation time were observed in the anaphylaxis (P=0.03) and airway fire scenarios (P=0.03). Cognitive aids improved scores in the laryngospasm (P=0.03) and airway fire simulations (P=0.03), but not in the anaphylaxis simulation (P=0.09), Additionally, cognitive aid use reduced the interquartile range of performance scores, indicating more consistent outcomes.
Conclusions: In this pilot study, our results demonstrated that cognitive aids potentially could improve performance during office-based outpatient anesthesia emergency scenarios for OMSs. These findings suggest that cognitive aids have the potential to help improve patient outcomes during adverse events and emergency scenarios encountered during office-based outpatient anesthesia provided by OMSs.
Keywords: Outpatient anesthesia; emergency simulations; cognitive aids; anesthesia; oral and maxillofacial surgery anesthesia
Received: 10 May 2025; Accepted: 10 December 2025; Published online: 17 December 2025.
doi: 10.21037/joma-2025-17
Highlight box
Key findings
• Cognitive aids could be associated with improved performance scores during office-based outpatient anesthesia emergency scenarios for oral and maxillofacial surgeons.
What is known and what is new?
• Other fields of medicine have demonstrated beneficial outcomes of utilizing cognitive aids while managing emergency scenarios.
• This paper demonstrates the possible benefit of utilizing cognitive aids while managing office-based outpatient oral and maxillofacial surgery emergency scenarios.
What is the implication, and what should change now?
• Future studies should research cognitive aids in outpatient oral and maxillofacial surgery.
Introduction
The administration of office-based outpatient anesthesia by oral and maxillofacial surgeons (OMSs) has been a topic of discussion amongst the medical community and the general public despite published studies documenting the safe administration of outpatient sedation (1,2). Previous papers have highlighted how safety improvements in aviation can inform improvements in medicine (3). Similar to the aviation industry, oral and maxillofacial surgery continues to make improvements to ensure the safe delivery of office-based outpatient anesthesia by the OMS with the American Association of Oral and Maxillofacial Surgeons (AAOMS) offering courses like Office Based Emergency Airway Management (OBEAM) and Office Crisis Management (OBCM). Additionally, programs like the Dental Anesthesia Assistant National Certification Exam (DAANCE) have been created to help provide structured review and anesthesia training for the office-based team. Lastly, an additional significant contribution to the safe administration of outpatient anesthesia is dependent on the appropriate screening and risk stratification of patients. Despite the proven safety record, utilization of cognitive aids during office-based outpatient oral and maxillofacial surgery emergencies offers an additional opportunity for improving safety measures.
In oral and maxillofacial surgery office-based anesthesia, potential emergencies can arise, including airway obstruction or compromise, hypotension or hypertension, hypoxia, allergic reactions, anaphylaxis, arrhythmias, aspiration, and local anesthetic toxicity (4). Airway compromise is the most common mechanism of injury in patients undergoing office based sedation (5). Although adverse events in office-based outpatient anesthesia are rare, they are high-stakes events in which critical decisions and coordinated teamwork are essential for successful patient outcomes. It has been documented in aviation that teams involving highly trained professionals can fail due to missing key details at critical moments (6). Studies analyzing the performance of advanced cardiac life support demonstrate a rapid loss of knowledge and poor retention after training (7). Additionally, previous studies in medicine have shown that it is common to deviate from guidelines during times of stress (8,9). A structured approach is recommended, and when properly applied, it can result in earlier recognition and better management of patient emergencies (10). The foundational principles of airway management and preparation for emergency scenarios can decrease morbidity and mortality from adverse events associated with office-based outpatient anesthesia provided by the OMS (4).
In the midst of an aviation emergency, pilots utilize their training and follow emergency procedure checklists to assist with the safe configuration of the aircraft and identify solutions for any malfunctioning equipment (11). Manufacturers of aircraft have meticulously crafted these procedure checklists to include critical steps that must be performed for a successful outcome. These do not serve as exhaustive lists of information, nor do they function to replace the knowledge or skill required to operate an aircraft successfully. However, these have been shown to help reduce pilot error, improve decision making, and help the flight team navigate these times of high stress (11). Similarly, multiple studies have demonstrated the success of cognitive aids in managing emergencies during general anesthesia in an operating room setting (12-14). Additionally, research has suggested that using an emergency cognitive aid improves teamwork, facilitates coordination, decreases stress, and enables improved patient care (12). Other fields of medicine, including pediatric anesthesia as well as other dental specialties, have performed studies that demonstrate beneficial outcomes of utilizing cognitive aids while managing emergency scenarios (15,16). To our knowledge, no literature describes the use of cognitive aids in office-based outpatient anesthesia administered by OMSs. The purpose of this study was to create novel cognitive aids for emergencies encountered during office-based outpatient anesthesia provided by OMSs and to assess performance during three unique emergency scenario simulations. We present this article in accordance with the CONSORT reporting checklist (available at https://joma.amegroups.com/article/view/10.21037/joma-2025-17/rc).
Methods
Novel cognitive aids were developed for three clinical scenarios with existing simulation scripts and outlines utilized in the oral and maxillofacial surgery training program at our institution: laryngospasm (Appendix 1), anaphylaxis (Appendices 2,3), and airway fires (Appendices 4,5). These simulation scenarios were developed and adapted from The American Association of Oral and Maxillofacial Surgeons Emergency Protocols (4,5,17). The development of the cognitive aid was constructed based on the fundamental components outlined by Burian’s recommendations for medical checklists (18,19). This includes a title, condition statement with descriptions, symptom list highlighting diagnostic criteria, immediate action items, header sections, consider items, go-to items (when applicable), and checklist end (19).
Participants included resident OMSs post graduate year one through post graduate year four at a single academic institution. They were enrolled through sign-up sheets and a random selection of staff members who were already scheduled to work on the study dates. Teams consisted of a resident surgeon, a surgical assistant, and a nurse. Eight teams were created, and each team was given a unique five-digit identification number.
Participants were randomized into two equal groups via block randomization based on post graduate year training level. All resident participants had successfully completed clinical coursework in outpatient anesthesia for the OMS at the University of Alabama at Birmingham. Additionally, all resident surgeons were certified in basic life support, advanced cardiac life support, and advanced trauma life support. Before the emergency simulations, no review material or preparation was provided to participants.
Variables
Each team underwent a simulation session in an oral and maxillofacial surgery operatory consisting of outpatient emergency scenarios. They were presented with a series of three scenarios and assessed for their performance based on evidence-based guidelines. Four teams performed each emergency scenario without the use of cognitive aids, while the other four teams performed the same emergency scenarios with the use of cognitive aids.
Data collection methods
The simulation administrator evaluated each team using a performance score sheet unique to each simulation (Appendices 6-9). A list of items utilized to score the performance during each simulation is summarized in Table 1. Audio recordings of the emergency scenarios were utilized to record the accurate timing of key actions performed during the emergency simulations as determined by the simulation administrator.
Table 1
| A: Laryngospasm: 14 tasks | B: Anaphylaxis: 8 tasks | C: Airway fire: 9 tasks |
|---|---|---|
| Surgical site packed | EMS notified | EMS notified |
| Attempted jaw thrust, reposition | Oxygen administration | Discontinue oxygen |
| Attempt to break spasm with bag mask | Correct dose of epinephrine | Saline or water to fire |
| Consider placement oral/nasal airway | Consider to stop allergen | Extent of fire evaluated |
| Attempt to break spasm with propofol | Additional fluids administered | Airway re-assessed |
| Correct dosage of propofol | Vitals monitored every 2 minutes | Intubation considered |
| Attempt to break spasm with succinylcholine | Alternative diagnosis considered | Steroids administered |
| Correct spasm dose of succinylcholine | Secondary medications considered | Vitals monitored every 2 minutes |
| Correct intubation dose of succinylcholine | Additional fluids administered | |
| EMS notified after succinylcholine | ||
| Intubation or mask after succinylcholine | ||
| Vitals monitored every 2 minutes | ||
| Alternative diagnosis considered | ||
| Secondary medications considered |
EMS, emergency medical services.
The simulations involved an adult manikin in an oral and maxillofacial surgery clinic setting, outpatient based emergency medications, and emergency airway equipment. A simulated video monitor was utilized to provide real time vital sign monitoring of heart rate, 5-minute interval blood pressures, oxygen saturation, end tidal carbon dioxide, respiratory rate, and a three-lead electrocardiogram waveform. The simulation administrator provided verbal interaction with the simulation team. To accommodate session time, the simulation administrator would provide prompts when tasks or decisions were delayed or missed. The simulation concluded when all interventions and tasks had been completed. Audio recording of the simulations was utilized to aid with measuring the time of key actions performed during the scenarios.
This pilot study was part of a quality improvement project implemented at an outpatient oral and maxillofacial surgery clinic at the University of Alabama at Birmingham.
Data analysis
A normality test was performed on the data using Graph Pad by Prism. A Mann-Whitney Test was used to compare the performance of the surgical teams with and without the cognitive aid. Descriptive statistics are presented as median and interquartile range (IQR) unless otherwise specified. P value set at <0.05.
Ethics
The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the institutional review board at the University of Alabama (protocol IRB-300012937) and informed consent was obtained from all individual participants.
Results
Eight surgical teams participated in 24 simulated outpatient office-based anesthesia emergency simulation scenarios. Participants were paired based on their level of residency training, which varied from post-graduate years 1 through 4. Six participants were male, and two were female.
A total simulation score was calculated for each simulation, ranging from 0 to 1. This total simulation score correlated with the percent of correct actions associated with the scenario’s performance score sheet (Appendices 6-9). In all simulations, using cognitive aids increased the participant’s average score (Figures 1-3). Cognitive aids increased median total simulation scores in the laryngospasm simulation by 0.32 points (P=0.03), the anaphylaxis simulation by 0.38 points (P=0.09), and for the airway fire simulation by 0.33 points (P=0.03). A perfect score of 1.0 was only achieved with participants using a cognitive aid. Furthermore, the total simulation score medians and IQRs were narrowed using cognitive aids across all simulations: laryngospasm without aid score 0.5 (0.27–0.63) vs. with aid score 0.82 (0.73–0.96); anaphylaxis without aid score 0.56 (0.41–0.88) vs. with aid score 0.94 (0.88–1.0); airway fire without aid score 0.61 (0.47–0.67) vs. with aid score 0.94 (0.89–1.0). Together, cognitive aid resulted in higher performance scores and greater consistency of scores in the oral and maxillofacial surgery anesthesia simulations (Tables 2-4).
Table 2
| Simulation tasks | Without aid, n (%) | With aid, n (%) |
|---|---|---|
| Surgical site packed | 1 (25.0) | 3 (75.0) |
| Attempted reposition, Jaw thrust | 3 (75.0) | 4 (100.0) |
| Attempt to break spasm with bag mask | 3 (75.0) | 4 (100.0) |
| Consider placement of oral/nasal airway | 2 (50.0) | 1 (25.0) |
| Attempt to break spasm with propofol | 2 (50.0) | 4 (100.0) |
| Correct dosage of propofol | 0 (0) | 4 (100.0) |
| Attempt to break spasm succinylcholine | 2 (50.0) | 4 (100.0) |
| Correct spasm dose succinylcholine | 2 (50.0) | 4 (100.0) |
| Correct intubation dose succinylcholine | 3 (75.0) | 4 (100.0) |
| EMS notification after succinylcholine | 4 (100.0) | 4 (100.0) |
| Intubation or mask after succinylcholine | 4 (100.0) | 4 (100.0) |
| Vitals monitor every 2 minutes | 0 (0) | 2 (50.0) |
| Alternative diagnosis considered | 0 (0) | 2 (50.0) |
| Secondary meds considered | 0 (0) | 3 (75.0) |
EMS, emergency medical services.
Table 3
| Simulation tasks | Without aid, n (%) | With aid, n (%) |
|---|---|---|
| EMS notified | 4 (100.0) | 4 (100.0) |
| Oxygen administered | 4 (100.0) | 4 (100.0) |
| Correct dose of epinephrine | 0 (0) | 3 (75.0) |
| Consider to stop allergen | 0 (0) | 3 (75.0) |
| Additional fluids administered | 1 (25.0) | 3 (75.0) |
| Vitals monitored every 2 minutes | 0 (0) | 4 (100.0) |
| Alternative diagnosis considered | 1 (25.0) | 2 (50.0) |
| Secondary medications considered | 1 (25.0) | 4 (100.0) |
EMS, emergency medical services.
Table 4
| Simulation tasks | Without aid, n (%) | With aid, n (%) |
|---|---|---|
| EMS notified | 4 (100.0) | 4 (100.0) |
| Discontinue oxygen | 4 (100.0) | 4 (100.0) |
| Saline or water to fire | 3 (75.0) | 4 (100.0) |
| Extent of fire evaluated | 3 (75.0) | 4 (100.0) |
| Airway re-assessed | 3 (75.0) | 4 (100.0) |
| Intubation considered | 3 (75.0) | 3 (75.0) |
| Steroids administered | 1 (25.0) | 4 (100.0) |
| Vitals monitored every 2 minutes | 0 (0) | 3 (75.0) |
| Additional fluids administered | 0 (0) | 4 (100.0) |
EMS, emergency medical services.
Consistent timed parameters in all three simulations (laryngospasm, anaphylaxis, and airway fire) included time to diagnosis, time to notify emergency medical services (EMS), and total simulation time (Figures 4-6). Diagnosis time was unaffected by the use of cognitive aid or the type of simulation. All participants made a correct diagnosis in under 23 seconds or less. The time to notify EMS was reduced in all scenarios of participants using a cognitive aid, however this reduction was not statistically significant (laryngospasm P=0.69, anaphylaxis P=0.06, and airway fire P=0.2). Critical intervention steps unique to the type of simulation were also assessed, but the use of cognitive aid was not statistically significant. The critical intervention for laryngospasm, the time to suction the airway or bag-mask ventilate did not change. The critical intervention anaphylaxis, the time to administer epinephrine was unaffected using cognitive aids. Although all participants administered epinephrine during this emergency scenario, the correct dosage were administered 100% of the time in the cognitive aid group versus 0% of the time in participants without using the cognitive aid. Lastly, the critical intervention for airway fire simulation’s discontinuing oxygen was unaffected by the use of the aid. Notably, the total simulation time was significantly reduced in the anaphylaxis (P=0.03) and airway fire simulations (P=0.03) but not in the laryngospasm simulation (P=0.99).
Discussion
The purpose of this pilot study was to create a novel cognitive aid for emergencies encountered during office-based outpatient anesthesia provided by OMSs and assess whether the aid improved performance in emergency scenario simulation.
A cognitive aid is a tool designed to assist medical professionals during emergencies by providing an outline and supplemental critical information (20). Cognitive aids can vary and include manuals, checklists, posters, or digital platforms (21). Cognitive aids are not meant to replace clinical judgment and are not a substitute for advanced knowledge and training (17). Their purpose is to ensure that critical steps are not overlooked and to decrease the reliance on memory in stressful scenarios. Additionally, cognitive aids can help the team avoid anchoring and confirmation bias by providing a potential list of diagnoses to rule out during the emergency scenario (22). Lastly, in addition to improving performance during stress, studies have demonstrated improved teamwork and communication (23). Regular training, preparation, and adherence to established protocols can help mitigate the risks associated with emergencies in office-based anesthesia administered by the OMS (24).
While many textbooks focus on the management of these potential complications, no comprehensive collection of cognitive aids is available for the use of OMSs during office-based outpatient anesthesia. The American Association of Oral and Maxillofacial Surgeons offers courses like the Office-Based Emergency Airway Management (OBEAM). While some of these course contain some cognitive aids for emergencies like laryngospasm, they do not publish a comprehensive set of cognitive aids for OMSs.
The limitations of this study include a small number of participants, participants only included those still in residency training, and the study was conducted in a single institution. Other limitations include subjectivity of the study introduced by the simulation administrator. Some limitations of the pilot study include the cognitive aids, while attempting the create a novel aid for the use of OMSs to exist on a single page, some formatting required two pages.
Conclusions
This pilot study found that using a cognitive aid could be associated with improved performance scores during office-based outpatient anesthesia emergency scenarios for the OMS. Furthermore, the use of a cognitive aid significantly reduced overall average simulation time in the anaphylaxis and airway fire simulations. Lastly, surgeons utilizing cognitive aids resulted in a greater consistency of scores, evident in reducing the standard deviation compared to those without a cognitive aid. These findings suggest that cognitive aids have the potential to help improve patient outcomes during adverse events and emergency scenarios encountered during office-based outpatient anesthesia provided by the OMS.
The current authors are in the process of finalizing a comprehensive cognitive aid for reference in the most common clinical emergency scenarios. Future research with larger sample sizes and the participation of experienced OMSs will continue to be needed to validate the initial findings of this study (25). These documents will be reviewed using the cognitive aids in medicine assessment tool (CMAT) and then tested in simulations (26).
Acknowledgments
The authors would like to thank the resident surgeons and clinical staff at the University of Alabama at Birmingham who participated in this pilot study.
Footnote
Reporting Checklist: The authors have completed the CONSORT reporting checklist. Available at https://joma.amegroups.com/article/view/10.21037/joma-2025-17/rc
Data Sharing Statement: Available at https://joma.amegroups.com/article/view/10.21037/joma-2025-17/dss
Peer Review File: Available at https://joma.amegroups.com/article/view/10.21037/joma-2025-17/prf
Funding: None.
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://joma.amegroups.com/article/view/10.21037/joma-2025-17/coif). P.J.L. has received the consulting fees from BioHorizon Implants. The other authors have no conflicts of interest to declare.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the institutional review board at the University of Alabama (protocol IRB-300012937) and informed consent was obtained from all individual participants.
Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
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Cite this article as: Seeley RC, Seeley LD, Louis PJ, Powell KK. Cognitive aids improve performance in oral and maxillofacial surgery outpatient anesthesia emergency simulations: a pilot study. J Oral Maxillofac Anesth 2025;4:21.
