Increasing use of an endotracheal intubation safety checklist in the emergency department

Endotracheal intubation (ETI) is a high-risk procedure often performed in the emergency department (ED) in critically unwell patients. The fourth National Audit Project by The Royal College of Anaesthetists found the risk of adverse events is much higher when performing the intervention in this setting compared with a theatre suite, and therefore use of a safety checklist is recommended. This quality improvement project was set in a large teaching hospital in the North West of the UK, where anaesthesia and intensive care clinicians are responsible for performing this procedure. A retrospective baseline audit indicated checklist use was 16.7% of applicable cases. The project aim was to increase the incidence of checklist use in the ED to 90% within a 6-month period. The model for improvement was used as a methodological approach to the problem along with other quality improvement tools, including a driver diagram to generate change ideas. The interventions were targeted at three broad areas: awareness of the checklist and expectation of use, building a favourable view of the benefits of the checklist and increasing the likelihood it would be remembered to use the checklist in the correct moment. After implementation checklist use increased to 84%. In addition, run chart analysis indicated a pattern of nonrandom variation in the form of a shift. This coincided with the period shortly after the beginning of the interventions. The changes were viewed favourably by junior and senior anaesthetists, as well as operating department practitioners and ED staff. Limitations of the project were that some suitable cases were likely missed due to the method of capture and lack of anonymous qualitative feedback on the changes made. Overall, however, it was shown the combination of low-cost interventions made was effective in increasing checklist use when performing emergency ETI in the ED.