This document presents the findings of a study that tested the use of a checklist for rapid sequence intubations (RSI) in emergency situations. Eighteen anesthetists participated in a simulation where they prepared for an RSI with and without a checklist. The median score for preparation was higher when using the checklist. There was no significant difference in time taken. The checklist significantly reduced errors in preparation and appeared to do so regardless of experience level, suggesting that checklists can improve patient safety during emergency intubations.

1. (Oh no, not another checklist...)

2.  Emergency inductions in ICU and ED
are risky:
 Sicker patients
 Difficult airways
 Less time for preparation
 Pressure to intervene
 Human factors
 Less familiar environment & equipment
 Junior staff out of hours

4. Poor or incomplete planning
Inadequate provision of skilled staff and equipment
Lack of capnography

7.  Emergency Induction checklist
 Capnography for all intubations
 Discussion of difficult intubation plans

10.  Simulation – patient needing intubating
 Patient showing signs of sepsis and pneumonia
 Hypoxaemic and hypotensive
 Reduced level of conciousness
 Candidates asked to prepare for RSI
 1st time as normal
 2nd time using checklist
 Primary outcome = difference in score
 Secondary outcome = time taken to prepare

11.  Optimise position
 Connect oxygen and preoxygenate
 Request new bag of fluids
 Request vasopressor
 Capnography
 Suction
 Guedel airway
 LMA
 Bougie
 Propofol infusion (or alternative)
 Discussion of plan in case of failed intubation

12.  18 anaesthetists recruited
 7 consultants
 3 SAS grade
 8 trainees (CT2 and above)
Median Score (IQR) Mean Time (secs)
Without checklist 6 / 11 (4 to 7.25) 336.3
With checklist 10 / 11 (8 to 11) 378.2
P value 0.001* 0.097**
*Wilcoxon signed rank test score 150.5
**paired t-test

13.  The checklist significantly reduced errors in
preparation for induction
 This appeared to be regardless of experience
 There was not a significant difference in time
taken
 With practice time taken may even be
reduced

14.  No. You think you do.
 Chances are we all forget 1 or 2 things on the
list.
 We want everyone to use it – regardless of
grade and experience.

15.  No – there will be no paper copies
 It is not a box ticking exercise
 It is not a box ticking exercise
▪ It is not a box ticking exercise
 It is to be read out loud by the team leader
during pre-oxygenation.
 All team members must participate.
 Record in the notes that it was done.

16.  Yes
 it will reduce errors in preparing for RSI’s
 We have tested this.
 In a simulated RSI
▪ Median without checklist 6/11 (IQR 4 to 7.25), median
with checklist 10/11 (IQR 8 to 11). Wilcoxon signed rank
test score was 150.5, (P=0.001).

17.  It is unlikely to significantly prolong
preparation
 When done well it may reduce preparation
time
 It may also reduce stress
 It helps everyone work better as a team
 It will reduce the risk of errors
 It is time well spent

18.  All emergency inductions outside of theatre /
anaesthetic room.
 ED, ICU, HDU, Recovery
 ? On the wards
 Not in cardiac arrest situation.
 ie whenever drugs are given for induction
outside of theatres

19.  Much of intensive care is costly and based on
limited evidence. A checklist is free.
 Success on ICU is rarely based on one
intervention, but rather 100’s of interventions
that must all go right…
 Can a simple checklist help to make sure that
intubation goes right?

20.  With thanks to:
 Einir & Adam; Simulation co-
ordinators, Ysbyty Gwynedd, Bangor
 Ami, Farbod, Ifan, Eirian, Suzanne for acting
in the training video

21. Emergencyinductionchecklist.blogspot.com
“Better is possible. It
does not take genius.
It takes diligence”
Atul Gawande, author of “The checklist
manifesto” and the WHO checklist