RSI checklists

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Lets be honest, Emergency Medicine clinicians don’t like checklists. They’re slow, organised and deliberate tools that get in the way of our fast, impulsive and dynamic resuscitation and they’re just not cool!

But what’s the background to checklists, is there much uptake and what have we got to gain by using them?

Background

In England and wales nearly 130,000 surgery related events in 2007 were reported. The WHO checklist was subsequently established and has been implemented in theatres to ensure that all staff are aware of plans and the major steps that are planned and anticipated. The institution of these checklists lead to a 47% reduced rate of death and a 36% reduction of inpatient complications.

NAP4 commented on the higher complication rates of intubations that happen in ICU and ED when compared to anaesthsisa and a need to focus on ways to minimize this risk, with a major complication rate of 0.06%.

What’s been the uptake of checklists so far?

Introducing checklist for sedation and intubation into the Emergency Department; a challenge worth rising to? R I Galloway,1 F Swann2. 1Emergency Medicine, Brighton and Sussex University Hospital NHS Trust, East Sussex, United Kingdom; 2Brighton and Sussex Medical School, Brighton, United Kingdom. 10.1136/emermed-2013-203113.13

Galloway published some work in 2013 looking at this, he found (via telephone surveys) that in England 49% of EDs use a RSI checklist and 58% using a sedation checklist. He then went on to review a single centre and showed 21.5% compliance with RSI checklist and 57.8% with sedation checklists

Interviews showed barriers including problems of implementing the changes across multiple specialties and staff’s pre-concieved attitudes towards checklists.

So this demonstrates a pretty poor application of checklists throughout the country, is this justified or are we failing to use a really powerful and effective tool?

What evidence exists on ED checklists?

Impact of checklists on peri-intubation care in ED trauma patients; American Journal of Emergency Medicine. Conroy (effectively a retrospective data trawl of intubated patients)

A retrospective review of trauma patients at a level 1 centre in the US over a 2 year period getting endotracheal intubation which included 187 patients. A checklist was instituted in November 2011 and they used patients prior to this as a pre-checklist cohort vs the patients after as the checklist cohort. Data was collected for a load of information including demographics, vital signs, LOS and mortality, they also collected a number of characteristics. Compliance with the checklist in the second group was 93%. They found no difference in the number of ETI attempts, haemodynamic parameters, number of intubation attempts etc and also no differences in the length of ED stay, length of ITU stay or in mortality. The positive effect they did see was an improved post intubation analgesia from 14.4 to 27.8% (statistically insignificant)

This obviously doesn’t show the most powerful results but is a relatively small study with low level evidence. What else exists out there in a setting similar to ED?

An intervention to decrease complications related to endotracheal intubation
in the intensive care unit: a prospective, multiple-center study. Jaber S. Intensive Care Med (2010) 36:248–255

This was a Prospective multicenter study in French in ICUs. Data from all ICU intubations excluding tohse in cardiac arrest were analysed over a 6 month period prior to the implementation of any protocol being used. There was then a 4 week period in which all staff received formal education and clinical training on the use of a ten point bundle of management;

1. Presence of two operators

2. Fluid loading (isotonic saline 500 ml or starch 250 ml) in absence of cardiogenic pulmonary edema

3. Preparation of long-term sedation

4. Preoxygenation for 3 min with NIPPV in case of acute respiratory failure (FiO2 100%, pressure support ventilation level between 5 and 15 cmH2O to obtain an expiratory tidal volume between 6 and 8 ml/kg and PEEP of 5 cmH2O)

5. Rapid sequence induction: etomidate 0.2–0.3 mg/kg or ketamine 1.5–3 mg/kg combined with succinylcholine 1–1.5 mg/kg in absence of allergy, hyperkaliemia, severe acidosis, acute or chronic neuromuscular disease, burn patient for more than 48 h and medullar trauma

6. Sellick maneuver

7. Immediate confirmation of tube placement by capnography

8. Norepinephrine if diastolic blood pressure remains \35 mmHg

9. Initiate long-term sedation

10. Initial ‘‘protective ventilation’’: tidal volume 6–8 ml/kg of ideal body weight, PEEP \5 cmH2O and respiratory rate between 10 and 20 cycles/min, FiO2 100% for a plateau pressure \30 cmH2O

They then collected data during a 6 month intervention phase and then recorded complications cataegorised as life threatening or mild or moderate complications for such things as cardiac arrest, cardiovascular collapse, difficult intubation etc. They has 121 patients in the control and 123 in the intervention arm with similar groups at baseline.

They found a the complication rates dropped significantly following institution of the checklist with

  • Life threatening 21 vs 34% (p= 0.03)
  • Mild to moderate 9 vs 21% (p=0.01)

Severe hypoxaemia and cardiovascular collapse were the main lifethreatening complications after intubation.

So what does it mean for us?

Well we don’t seem to like it but checklists have been well implemented in a number of areas with some extremely significant benefit. Whilst they may not be really proven in the ED in the specific case of RSI they do make sense and why should we be resistant to something so simple that could make such a huge difference to a number of our patients. One thing is for sure they are staying on our airway trolley…apart from when we pick them up to fill them in, everytime!

 References

Editorials Surgical safety checklists. BMJ 2009; 338 doi: http://dx.doi.org/10.1136/bmj.b220 (Published 21 January 2009)

Introducing checklist for sedation and intubation into the Emergency Department; a challenge worth rising to? R I Galloway,1 F Swann2. 1Emergency Medicine, Brighton and Sussex University Hospital NHS Trust, East Sussex, United Kingdom; 2Brighton and Sussex Medical School, Brighton, United Kingdom. 10.1136/emermed-2013-203113.13

An intervention to decrease complications related to endotracheal intubation
in the intensive care unit: a prospective, multiple-center study. Intensive Care Med (2010) 36:248–255

NAP4 recommendations

 

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