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Should We Ditch Preintubation Checklists?

October 20, 2017

Spoon Feed
Calling out a verbal pre-intubation checklist to make sure equipment was present and that the intubation and backup plans were in place did not result in improved lowest oxygen saturation.  Read on to see why we shouldn’t ditch the checklist just yet.

Why does this matter?
Surgical safety checklists have been embraced by the World Health Organization because they have repeatedly been shown to improve surgical outcomes and patient safety.  Airline pilots and other professionals use checklists routinely, and I’m glad they do.  There’s no place for hubris when it comes to a procedure that results in death if you mess up.  This study sought to determine whether a pre-intubation checklist would impact outcomes during intubation, specifically desaturation and hypotension.

Check yourself before you wreck yourself
This was a multicenter RCT of 262 ICU patients, some of whom received usual care and some of whom had a written checklist that was verbally called out prior to intubation.  This study was brought to you by the same group that did the FELLOW trial on apneic oxygenation and head-up intubation.  In fact, this was part of the same study which looked at head-up intubation, called CHECK UP.  The checklist consisted of ten items: ensuring suction was present and functional, pre-oxygenation underway, equipment and difficult airway adjuncts on hand, assessment of difficult airway obtained, and more.  There was no difference in the primary outcome, lowest SpO2, or any secondary outcome, such as time to intubation, number of attempts, etc.  The biggest issues with this study were that it was unblinded; there was significant cross-contamination between control and intervention groups and penetrance of checklist items into usual care; and some sites had many of the checklist items as part of usual care.  All these would make the outcome tend toward the null.  The authors referenced 7 studies that demonstrated the effectiveness of checklists in improving outcomes and patient safety.  Clearly, checklists work.  Despite this negative trial, I don’t think the take home point should be not to do a pre-intubation checklist of some kind.  If anything, the use of a checklist may have improved care in both groups via cross contamination, leading to the null effect on the outcome measures.  It just makes sense to make sure you have everything prepped and ready prior to chemically inducing a coma and flaccid paralysis… that’s kind of a big deal.  For years, before we formalized a checklist process in our ED, I had used the SOAP mnemonic – Suction, Oxygen, Airway, Pharmacy: suction on and accessible, pre-ox/bag valve mask prepped, tube/equipment/adjuncts at the ready, and drugs/doses chosen.

A multicenter, randomized trial of a checklist for endotracheal intubation of critically ill adults.  Chest. 2017 Sep 13. pii: S0012-3692(17)32685-5. doi: 10.1016/j.chest.2017.08.1163. [Epub ahead of print]

Another Spoonful
If you want a great airway checklist, download this free one from 5minuteairway.

Peer reviewed by Thomas Davis, MD

What are your thoughts?