Impact of Checklist Implementation on Endotracheal Intubation-Related Complications in Critically Ill Adults-A...

Endotracheal intubation is a common procedure in the intensive care. However, it is associated with a high incidence of complications, primarily hypotension and hypoxia. Although guidelines advocate the use of checklists for intubation, studies on their effectiveness are limited. The aim was to investigate whether the implementation of a checklist for intubation in an intensive care unit is associated with a reduction in immediate intubation-related complications.

We conducted an observational before and after study, implementing an intubation checklist before the second period. Adult patients intubated between December 2022 and August 2024 at Karolinska University Hospital were included. Data regarding intubations were collected from a quality registry. The primary outcome was a SpO₂ < 90% by pulse oximetry or systolic arterial pressure (SAP) < 90 mmHg within 5 min of intubation. Chi-square or Fisher's exact test was used for the comparison of proportions.

A total of 97 patients were included. There was no significant difference in the primary outcomes of SpO₂ < 90% (30% vs. 21%, p = 0.29) or SAP < 90 mmHg (34% vs. 32%, p = 0.80) before and after checklist implementation. There was no difference in the secondary outcomes of lowest median SpO₂ from intubation until up to 5 min after, surgical airway intervention, cardiovascular collapse, cardiac arrest, oesophageal intubation, severe arrhythmia, or death between the periods. Apnoeic oxygenation, either by standard nasal cannula or high-flow nasal cannula, was used more frequently after checklist implementation (7% vs. 36%, p = 0.005). Preoxygenation with non-invasive ventilation was used in 33% of cases in the standard period compared to 48% in the checklist period (p = 0.19).

In this study on implementing a checklist for intubation of critically ill adults, we could not demonstrate a reduction in immediate intubation-related complications. However, the use of apnoeic oxygenation increased in the checklist period, highlighting the checklist's value as a cognitive aid when preparing for this common yet perilous procedure.

This time interrupted series analysis looked at implementation of a checklist for preparing and planning intubation of ICU patients, where it is recognized that there is risk for respiratory or circulatory adverse events. The findings here from one center showed that implementation of new, detailed checklist-based preparation can affect practice, and that when advanced non-invasive positive pressure ventilatory support is routinely applied, hypoxia can be less frequent then before these were routinely implemented.

Clinicaltrials.gov identifier: (NCT06791317).