Implementing the Quick Reference Handbook (QRH)

Implementing the QRH into your department can be challenging. We recommend following the process below. 

We also recommend joining the Emergency Manuals Implementation Collaborative for online community-based support in implementation.

1. Assemble a team to organise and champion the QRH:

• Select a team leader. This will usually be an anaesthetist, but could be any team member
• Get the support and co-operation of the theatre nursing co-ordinator or equivalent
• Secretarial and/or admin support can be useful, especially initially when the QRH needs to be printed and assembled
• Other useful members to have in the implementation team are:
  • Colleagues experienced in training and/or simulation
  • The College Tutor
  • A trainee representative
  • A representative from the surgical body
  • Risk manager
  • Other educators

2. Decide which locations will have a copy:

• The QRH should be immediately available in all locations where anaesthesia takes place; this may mean one copy per anaesthetic machine or one copy per theatre. 
• Departments should make sure the QRH is available in remote locations, such as CT or MRI suites and emergency departments. If anaesthesia is only occasionally provided in these locations, it may be necessary to take a QRH along each time (for instance with the anaesthetic machine or in a 'grab bag') rather than leaving one there all the time. Be aware it's harder to police QRHs in such locations and they are more likely to disappear
• Print extra copies for training and for simulation, as appropriate to your unit

3. Decide where you'll display the QRH:

• The QRH should have a highly visible and dedicated storage point in each location
• The QRH should ideally be displayed in a wall mounted holder, marked clearly with a sign as the location for the QRH. You can download a ready-made template sign for the QRH holder
• Alternatively, keep the QRH with the anaesthetic machine

4. Decide how you'll print and assemble the QRH:

• Print the QRH in colour if possible
• Individual guidelines will change over time and will need to be removed and substituted. Guidelines may also be added or removed. The QRH needs to be assembled in a way which anticipates this
• The simplest way to assemble the QRH is to use A4 hole-punched polypockets in a simple clear-fronted plastic prong folder
• The guidelines can also be professionally printed, for example on laminated paper. Individual departments can evaluate the cost vs benefit of this
• We don't recommend spiral binding or other more elaborate binding methods, unless they allow removal and substitution of individual guidelines

5. Decide whether you’ll use the 'out of the box' version or modify the guidelines locally:

• The PDF version of the QRH has been designed to be printed off, assembled and implemented right away
• Some units will wish to modify some or several of the guidelines by downloading the Word version
• While we support this, there are caveats:

i. You must understand and accept the licensing terms
ii. You are responsible for checking the entirety of any guideline once you begin to modify it, not just the portions you modify

6. Pre-publicise the introduction:

• Make sure everyone knows the QRH is being implemented
• Make sure colleagues understand the intent, extent and limitations of the QRH
• Use departmental and clinical governance meetings to preview the QRH
• Make sure your risk managers, Trust Board and CEO know about it!

7. Roll out the introduction

8. Practice and re-practice using the QRH:

• Regular multi-disciplinary practice of crisis management should take place
• In remote locations, regular multi-disciplinary practice of crisis management should take place and should include special focus on an any location-specific limitations or impediments that exist
• The mere presence of a QRH won't help in a crisis; it's a tool like any other and teams must practice using it
• The QRH is not a substitute for learning and practicing the skills required to manage a crisis
• Effective practice doesn’t need high fidelity simulation; simpler forms of simulation can be more effective
• 'Table top' practice can be just as effective at familiarising users with the guidelines. This simply involves an informal 'walk through' of the guidelines with the relevant team members, but in a non-immersive environment, i.e. without simulation of any kind. It can be undertaken anywhere
• Having a timetable for 'crisis of the day' can be a useful way of stimulating in theatre discussion and informal practice. Each day or week has a nominated crisis (rotated daily or weekly) and during any down time, at their convenience, theatre teams can work their response to that crisis and refresh their knowledge. This retains team familiarity with the QRH
• Local circumstances will dictate exactly where, when and how the practice takes place
• Remember: Clinicians should be familiar with what's in the QRH and be practiced in its use. Reaching for it in a crisis should be automatic

9. Maintain the QRH:

• Ensure you have the most up to date version
• Periodically check the presence, integrity and completeness of all the handbooks
• Replace any missing handbooks promptly

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