LO34: Does utilization of an intubation safety checklist reduce dangerous omissions during simulated resuscitation scenarios?

Abstract

Introduction: One of the most high-risk tasks regularly performed by emergency medicine (EM) physicians is airway management. Many studies identify an increase in adverse events associated with airway management outside of the operating theatre. Errors of omission are the single most common human error type. To address this risk, the checklist is becoming a common pre-intubation tool. Simulation is a safe setting in which to study the implementation of a new airway checklist. The purpose of this study was to determine if a novel airway checklist decreases practitioners rates of omission of important tasks during simulated resuscitation scenarios. Methods: This was a dual-centre, randomized controlled trial of a novel airway checklist utilized by EM practitioners in a simulated environment. The 29-item peri-intubation checklist was derived by experienced EM practitioners following a review of airway checklists in published and gray literature. Participants were EM residents or EM physicians who work more than 20 hours/month in an emergency department. Volunteers were recruited from two academic health centres to complete three simulated scenarios (two requiring intubation, one cricothyroidotomy), and were randomized to either regular care or checklist use. A minimum of two assessors documented the number of omitted tasks deemed important in airway management and the time until definitive airway management. Discrepancies between assessors were resolved by single-assessor video review. Results: Fifty-four EM practitioners participated. There was no significant difference in baseline characteristics between the two study groups. The average percentage of omitted tasks over the three scenarios was 45.7% in the control group (n=25) and 13.5% in the checklist group (n=29) an absolute difference of 32.2% (95% CI: 27.8%, 36.6%). Time to intubation (normally distributed) was significantly longer in the checklist group for the first two scenarios (mean difference 114.10s, 95% CI: 48.21s, 179.98s and 76.34s, 95% CI:31.35s ,121.33s), but there was no statistical difference in the third scenario where cricothyroidotomy was required (mean difference 33.75s, 95% CI: -28.14s, 95.65s). Conclusion: In a simulated setting, use of an airway checklist significantly decreased the omission rate of important airway management tasks, however it increased the time to definitive airway management. Further study is required to determine if these findings are consistent in a clinical setting and how they impact the rate of adverse events.

Cognitive aids in the management of clinical emergencies: a systematic review

“…In all, 13 randomised controlled trials were included and their findings were reported in 16 publications [20–35]. Details of the screening process are illustrated in Fig.…”

“…2. Two of the trials were assessed to be at overall low risk of bias [27, 33, 34], nine to have some concerns [22–26, 28–32, 35] and two were at high risk of bias [20, 21]. In the 13 instances where clarification of trial methodology or missing data was needed, seven authors responded with the required information [22, 25, 27, 29–34].…”

“…The development process of the cognitive aid differed between trials and included: consideration of the design and format in two trials [20, 27]; literature review, publication guidelines and/or international recommendations in 10 trials [20–24, 26, 27, 31–35]; iterative revision until consensus was reached in five trials [20, 23, 24, 27, 31, 32]; and testing in four trials [27, 31–34]. The included cognitive aids consisted of three algorithms [20, 21, 27], seven checklists [22–25, 31–35], one hybrid checklist and guideline [29, 30] and two in which the type was not specified [26, 28]. Seven cognitive aids were presented on paper [21–25, 27, 33–35], five electronically [20, 28–32] and one electronically and on paper [26].…”

“…The included cognitive aids consisted of three algorithms [20, 21, 27], seven checklists [22–25, 31–35], one hybrid checklist and guideline [29, 30] and two in which the type was not specified [26, 28]. Seven cognitive aids were presented on paper [21–25, 27, 33–35], five electronically [20, 28–32] and one electronically and on paper [26]. In seven trials, the participating clinicians had the opportunity to familiarise themselves with the cognitive aid before use [21–24, 27, 29–32] and in three trials, the process of familiarisation was not specified [20, 26, 33, 34].…”

“…Seven cognitive aids were presented on paper [21–25, 27, 33–35], five electronically [20, 28–32] and one electronically and on paper [26]. In seven trials, the participating clinicians had the opportunity to familiarise themselves with the cognitive aid before use [21–24, 27, 29–32] and in three trials, the process of familiarisation was not specified [20, 26, 33, 34]. The cognitive aid was tested in a simulated environment in most trials [21–32, 35].…”