In the interests of patient safety, many have turned to peri-procedural checklists. Rather than,
essentially, “winging it”, a standardized protocol is followed each time, reducing the chance of an important omission.
These authors describe a checklist intervention for, as they describe, the high-risk procedure of endotracheal intubation in the setting of trauma. The checklist involves, generally, assignment of roles, explicit back-up airway planning, and adequate patient positioning. The authors used a before-and-after design using video review of all intubation events to compare steps performed.
In the six-month pre-checklist period, 7 of 76 intubation events resulted in complications – 6 desaturations, 2 emesis, and 2 hypotension. In the post-intervention period, using the checklist, events were reduced to a single episode of desaturation in 65 events. So, success?
As with every before-and-after study, it is hard to separate the use of the checklist to the educational diffusion associated with checklist exposure. Would another, less intrusive, intervention been just successful? Will the checklist lose effectiveness over time as it is superseded by newer safety initiatives? And, most importantly, what did operators actually do differently after checklist implementation?
Only 4 of 15 checklist elements differed from the pre-checklist period: verbalization of backup intubation technique (61.8% vs. 90.8%), pre-oxygenation (47.3% vs. 75.4%), team member roles verbalized (76.4% vs. 98.5%), and optimal patient positioning (80.3% vs. 100%). If only four behaviors were substantially changed, are they responsible for the outcomes difference – which, technically, is solely episodes of hypoxia?
Their intervention seems reasonable, and the procedure is likely high-risk enough to warrant a checklist. However, I probably would not implement their specific checklist, as some refinement to the highest-yield items would probably be of benefit.
“A Preprocedural Checklist Improves the Safety of Emergency Department Intubation of Trauma Patients”
http://www.ncbi.nlm.nih.gov/pubmed/26194607
Hello,
You comment on their specific checklist, however I have not been able to actually find the checklist. Do you have a link to the checklist they use?
1) Pre-Arrival Checklist
All items must be verbalized by physician responsible for intubation
1. Oxygen mask and nasal cannula available and connected to oxygen
2. Oral airway available
3. Suction available and running
4. Laryngoscope blade and handle available and functional
5. Tube/stylet available and shaped appropriately
6. Extra tubes and stylet available
7. Bougie available
8. Backup devices available (including laryngeal mask airway, King Airway
System, cricothyrotomy kit)
9. Monitors and video laryngoscope screen positioned appropriately
10. Bag-valve mask with ETCO2 attachment available
11. IV fluid available
12. Individual designated to hold cervical spine stabilization
13. Airway plan verbalized
2) Pre-Induction Checklist
All items must be verbalized by the Nurse Scribe and confirmed by the physician responsible for intubation
1. Pre-arrival checklist completed
2. Airway plan confirmed between Trauma and ED attending physicians
3. IV line functioning
4. Rapid sequence intubation medication and doses confirmed and drawn up
5. Cervical spine inline stabilization initiated (if necessary)
6. Pre-oxygenation underway with mask at 15 liters/min and nasal cannula at 5 liters/min
7. Patient positioning optimized
8. Blood pressure cuff placed on opposite arm of IV line and pulse oximetry probe