The Emergency Induction Checklist

(Oh no, not another checklist...)

Introduction

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

NAP 4

Poor or incomplete planningInadequate provision of skilled staff and equipmentLack of capnography

“Avoidable Deaths”

NAP4 - ED

Capnography on ICU

Recommendations

Emergency Induction checklist

Capnography for all intubations

Discussion of difficult intubation plans

Does it work?

Method

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

Scoring (out of 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

Results

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**

18 anaesthetists recruited

7 consultants 3 SAS grade 8 trainees (CT2 and above)

*Wilcoxon signed rank test score 150.5**paired t-test

Conclusion

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

“I do all this all the time anyway...”

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.

“More paperwork...”

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.

“Will this make a difference?”

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).

“We don’t have time to do it...”

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

“When should we use it?”

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

Discussion

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?

Acknowledgements

With thanks to:

Einir & Adam; Simulation co-ordinators, Ysbyty Gwynedd, Bangor

Ami, Farbod, Ifan, Eirian, Suzanne for acting in the training video

“Better is possible. It does not take genius. It takes diligence”

Atul Gawande, author of “The checklist manifesto” and the WHO checklist

Emergencyinductionchecklist.blogspot.com