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Friday, April 15, 2011

A Practical Checklist?

It seems like checklists are the "in" thing in patient safety right now.  It makes sense; follow this list of things and you won't hurt patients.  The problem is, they only work when you use them.  

While doing some background research on checklists in prehospital settings, I found this gem in the open access Scandinavian Journal of Trauma, Resuscitation, and Emergency Medicine.  The article is the print version of an oral presentation, so it isn't "science" but it is practical.  Prehospital airway management is a hotbed of controversy right now.  The data seem to point to worse outcomes, delays to definitive care, and decay of skills.  With all of these problems, anything to make the procedure safer is a welcome addition.  Enter the "checklist."

This group of prehospital providers created a novel approach to their airway management.  They took a disposable plastic sheet and printed it up with the following graphic:



Notice anything cool?  While it still has a text driven checklist (on left), the visual representations offer a rapid and convenient way to prepare for intubation.

Their checklist approach is broken into  the following areas:

Pre-anesthesia checklist
Monitoring:
Equipment:
Drugs
Staff

It would be easy to replace their text with the more familiar "P's" of intubation:

Preparation
Positioning
Preoxygenation
Pretreatment
Push the Drugs
Placement with Proof
Post-Intubation Management

On the far right you'll also notice a box for induction medications and maintenance medications. 

The thing I really like about this list is the visual representation of the equipment.  Just looking at it, I believe that it would really decrease the time in the "preparation" phase.  Look at what it includes:

Equipment for bag ventilation: oral and nasal airways

Drugs for the procedure (I would like to see these boxes include dosing guides for the common medications)

Equipment for intubation:
2 laryngoscope handles and blades
2 different sized endotracheal tubes
syringe
tube holder
qualitative end tidal CO2 detector with BVM connector

Backup Equipment: 

Bougie
LMA

This is HUGE.  How many of you out there really take the time and get your backup equipment out before you need it?  This demonstrates true foresight.

The only thing that I see missing is the suction.   

When working clinically by myself or with the residents, I'm constantly running through a little mental checklist that includes most items on the above list.  Being able to pull out a little plastic sheet that has the list already prepared would free my mind up to think ahead and address other important issues with the sick patient in front of me.  I can easily see how this has potential to really make both prehospital and emergency intubations safer.

Below is a video demonstration of the checklist in action:




Reference:

A pre-hospital emergency anaesthesia pre-procedure checklist

R Mackenzie emailJ FrenchS Lewis and A Steel
from Scandinavian Update on Trauma, Resuscitation and Emergency Medicine 2009
Stavanger, Norway. 23 – 25 April 2009
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2009, 17(Suppl 3):O26

Clip to Evernote

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