SPEEDBOMB: a simple and rapid checklist for Prehospital Rapid Sequence Induction

The creation, implementation, and harmonisation of medical standard operating procedures and checklists of Finnish Helicopter Emergency Medical Service units

INTRODUCTION

The purpose of this study was to investigate the creation, implementation, and harmonisation of medical Standard Operating Procedures (SOP) in Finnish Helicopter Emergency Medical Services (HEMS). The research questions are: (1) What factors influence the creation and implementation of medical SOPs for Finnish HEMS units? and (2) What can be done to harmonise the medical SOPs of Finnish HEMS units?

METHODS

The research was conducted as a qualitative interview study with HEMS physicians who worked full-time in Finnish HEMS units or had worked in HEMS for more than five years. Three HEMS physicians from each of the six HEMS units in Finland participated in the study (n = 18). The thematic interviews (average duration 32 min) were transcribed (70,176 words in Finnish) and analysed using inductive content analysis.

RESULTS

The results of the first research question formed three main categories: (1) Background to developing medical SOPs and checklists (CLs), (2) Creation of medical SOPs in Finnish HEMS units, and (3) Implementation of medical SOPs and CLs. The main categories were divided into eight upper categories and twelve subcategories. The results of the second research question formed four main categories: (1) Prerequisites for harmonising procedures, (2) System-level changes needed, (3) Integrating common medical SOPs into HEMS, and (4) Cultural change. The main categories were divided into nine upper categories and nine subcategories.

CONCLUSIONS

Medical SOPs and CLs are an integral part of Finnish HEMS. Each unit creates its own SOPs and CLs; their development, implementation, and follow-up are relatively unstructured. Harmonising existing SOPs would be possible, but developing common SOPs would require structural changes in HEMS and a stronger sense of community belonging among HEMS physicians.

Implementation of a Rapid Sequence Intubation Checklist Improves First-Pass Success and Reduces Peri-Intubation Hypoxia in Air Medical Transport

OBJECTIVE

Rapid sequence intubation (RSI) is a critical skill commonly performed by air medical teams in the United States. To improve safety and reduce potential patient harm, checklists have been implemented by various institutions in intensive care units, emergency departments, and even prehospital air medical programs. However, the literature suggests that checklist use before RSI has not shown improvement in clinically important outcomes in the hospital. It is unclear if RSI checklist use by air medical crews in prehospital environments confers any clinically important benefit.

METHODS

This institutional review board-approved project is a before-and-after observational study conducted within a large helicopter ambulance company. The RSI checklist was used by flight crewmembers (flight paramedic/nurse) for over 3 years. Data were evaluated for 8 quarters before and 8 quarters after checklist implementation, spanning December 2014 to March 2019. Data were collected, including the self-reported use of the checklist during intubation attempts, the reason for intubation, and correlation with difficult airway predictors (HEAVEN [Hypoxemia, Extremes of size, Anatomic disruption, Vomit, Exsanguination, Neck mobility/Neurologic injury] criteria), and compared with airway management before the implementation of the checklist. The primary outcome was improved first-pass success (FPS) when compared among those who received RSI before the checklist versus those who received RSI with the checklist. The secondary outcome was a definitive airway sans hypoxia improvement noted on the first pass among adult patients as measured before and after RSI checklist implementation. Post-RSI outcome scenarios were recorded to analyze and validate the effectiveness of the checklist.

RESULTS

Ten thousand four hundred five intubations were attempted during the study. FPS was achieved in 90.9% of patients before RSI checklist implementation, and 93.3% achieved FPS postimplementation of the RSI checklist (P ≤ .001). In the preimplementation epoch, 36.2% of patients had no HEAVEN predictors versus 31.5% after RSI checklist implementation. These data showed that before RSI checklist implementation, airways were defined as less difficult than after implementation.

CONCLUSION

The implementation of a standardized RSI checklist provided a better identification of deterring factors, affording efficient and accurate actions promoting FPS. Our data suggest that when a difficult airway is identified, using the RSI checklist improves FPS, thereby reducing adverse events.

Predictors for Prehospital First-Pass Intubation Success in Germany

(1) Background: Endotracheal intubation in the prehospital setting is an important skill for emergency physicians, paramedics, and other members of the EMS providing airway management. Its success determines complications and patient mortality. The aim of this study was to find predictors for first-pass intubation success in the prehospital emergency setting. (2) The study was based on a retrospective analysis of a population-based registry of prehospital advanced airway management in Germany. Cases of endotracheal intubation by the emergency medical services in the cities of Tübingen and Jena between 2016 and 2019 were included. The outcome of interest was first-pass intubation success. Univariate and multivariable regression analysis were used to analyse the influence of predefined predictors, including the characteristics of patients, the intubating staff, and the clinical situation. (3) Results: A total of 308 patients were analysed. After adjustment for multiple confounders, the direct vocal cord view, a less favourable Cormack–Lehane classification, the general practitioner as medical specialty, and location and type of EMS were independent predictors for first-pass intubation success. (4) Conclusions: In physician-led emergency medical services, the laryngoscopic view, medical specialty, type of EMS, and career level are associated with FPS. The latter points towards the importance of experience and regular training in endotracheal intubation.

Does utilization of an intubation safety checklist reduce omissions during simulated resuscitation scenarios: a multi-center randomized controlled trial

Objectives

Checklists have been used to decrease adverse events associated with medical procedures. Simulation provides a safe setting in which to evaluate a new checklist. The objective of this study was to determine if the use of a novel peri-intubation checklist would decrease practitioners’ rates of omission of tasks during simulated airway management scenarios.

Methods

Fifty-four emergency medicine (EM) practitioners from two academic centers were randomized to either their usual approach or use of our checklist, then completed three simulated airway management scenarios. A minimum of two assessors documented the number of tasks omitted and the time until definitive airway management. Discrepancies between assessors were resolved by single assessor video review. Participants also completed a post-simulation survey.

Results

The average percentage of omitted tasks over 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 definitive airway management was longer in the checklist group in the first two of three scenarios (difference of 110.0 s, 95% CI 55.0 to 167.0; 83.0 s, 95% CI 35.0 to 128.0; and 36.0 s, 95% CI −18.0 to 98.0 respectively).

Conclusions

In this dual-center, randomized controlled trial, use of an airway checklist in a simulated setting significantly decreased the number of important airway tasks omitted by EM practitioners, but increased time to definitive airway management.

Electronic supplementary material

The online version of this article (10.1007/s43678-020-00010-w) contains supplementary material, which is available to authorized users.

An Unusual Cause of Failure to Ventilate

We report an unusual case of endotracheal tube failure. It was due to a manufacturing defect in the internal white plastic piece that is normally depressed by the luer-lock syringe within the blue pilot balloon. Prior to use, the endotracheal tube was tested and functioned normally. A 64-year-old patient in the intensive care unit with a history of hypertension was being mechanically ventilated after uneventful abdominal surgery. After several hours in the intensive care unit, he was noted to be suddenly no longer receiving adequate tidal volumes from the ventilator. It was found that the cuff on the endotracheal tube was not retaining air when it was filled with air from a syringe. This lead to a large "leak" around the endotracheal tube such that the intended tidal volumes set on the ventilator were not delivered to the patient. The patient was uneventfully reintubated and did well. Subsequent investigation revealed the cause to be a manufacturing defect in the internal white plastic piece that is normally depressed by the luer-lock syringe within the blue pilot balloon. Other mechanisms of cuff failure are reviewed in this case report. This case is an unusual reason for cuff failure. Illustrations supplied alert the reader how to identify the appearance of this manufacturing defect in a pilot balloon. This case illustrates the potential device malfunctions that can develop during a procedure, even when the equipment has been tested and previously functioned well. Even small defects developing in well-engineered products can lead to critical patient care emergencies.

Development and Testing of a Neonatal Intubation Checklist for an Air Medical Transport Team

OBJECTIVE

We developed a Neonatal Intubation Checklist for Airlift Northwest. Our goal was to improve the preparation, technical proficiency, and safety of neonatal intubation without increasing the time required to perform the procedure.

METHODS

The Neonatal Intubation Checklist, a "call and response" checklist for neonatal intubation, was developed. Its effectiveness was evaluated during a baseline assessment and 2 practice sessions after a checklist orientation. Intubation proficiency was evaluated using a validated assessment tool that included a proficiency score, a global rating scale (GRS) score, and time to perform the procedure.

RESULTS

Significant improvements in intubation proficiency and time to intubation were noted when teams used the intubation checklist (proficiency score: 29 [7] at baseline vs. 57 [1] with checklist, P < .001; GRS 2 [2, 2.5] at baseline vs. 5 [3, 5] with checklist, P < .001; baseline intubation time 626 [93] seconds vs. 479 (44) seconds with checklist, P < .001). These changes were associated with a large effect on proficiency (ƞ2 = 0.89), GRS (ƞ2 = 0.6), and time to successful intubation (ƞ2 = 0.52).

CONCLUSION

The use of the Neonatal Intubation Checklist improved transport team performance during simulated neonatal intubations and decreased the time required to successfully perform the procedure.

Effectiveness of interventions to improve medication use during rapid-sequence intubation in a pediatric emergency department

PURPOSE

Results of a study to determine whether checklist-based interventions improved the selection and administration of rapid-sequence intubation (RSI) medications in a pediatric emergency department (ED) are reported.

METHODS

A retrospective study of data collected during a quality-improvement project was conducted. Data sources included the electronic health record and video review. The central intervention was use of a 21-item RSI checklist, which included guidance for the physician team leader on medication selection and timing. A quick-reference card was developed to guide staff in preparing RSI medications. The main outcomes were (1) standard selection, defined as administration of indicated medications and avoidance of medications not indicated, and (2) efficient administration, defined as an interval of <30 seconds from sedative to neuromuscular blocker (NMB) infusion.

RESULTS

A total of 253 consecutive patients underwent RSI during 3 consecutive periods: the historical (preimprovement) period (n = 136), the checklist only period (n = 68), and the checklist/card period (n = 49). The rate of standard selection of 3 RSI medications (atropine, lidocaine, and rocuronium) did not improve. The rate of efficient sedative and NMB administration improved from 56% in the historical period to 88% in the checklist period (p = 0.005). The median duration of RSI medication administration decreased from 28 seconds (interquartile range [IQR], 23-44 seconds) in the historical period to 19 seconds (IQR, 15-25 seconds) in the checklist/card period (p = 0.004).

CONCLUSION

In a quality-improvement project in a pediatric ED, a checklist-based intervention improved RSI medication administration technique but not selection.

Use and implementation of standard operating procedures and checklists in prehospital emergency medicine: a literature review

OBJECTIVES

This review aimed to analyze published literature to introduce the use and implementation of standard operating procedures (SOPs) and checklists in prehospital emergency medicine and their impact on guideline adherence and patient outcome.

METHODS

An English literature search was carried out using the Cochrane Library, MEDLINE, EMBASE, Springer, Elsevier, and ProQuest databases. Original articles describing the use and implementation of SOPs or checklists in prehospital emergency medicine were included. Editorials, comments, letters, bulletins, news articles, conference abstracts, and notes were excluded from the analysis. Relevant information was extracted relating to application areas, development of SOPs/checklists, educational preparation and training regarding SOPs/checklists implementation, staff attitudes and the effects of SOPs/checklists use on guideline adherence and patient outcomes.

RESULTS

The literature search found 2187 potentially relevant articles, which were narrowed down following an abstract review and a full text review. A final total of 13 studies were identified that described the use and implementation of SOPs (9 studies) and checklists (4 studies) in different areas of prehospital emergency medicine including prehospital management of patients with acute exacerbated chronic obstructive pulmonary disease and acute coronary syndrome, prehospital airway management, medical documentation, Emergency Medical Services triage, and transportation of patients.

CONCLUSIONS

The use and implementation of SOPs and checklists in prehospital emergency medicine have shown some benefits of improving guidelines adherence and patient outcomes in airway management, patient records, identification and triage, and other prehospital interventions. More research in this area is necessary to optimize the future use and implementation of SOPs and checklists to improve emergency personnel performance and patient outcomes.