Welcome to the emergency intubation / rapid sequence intubation checklist blog

In 2012, in response to the findings of the 4th national audit project of the Royal College of Anaesthetists of Great Britain (NAP4), Ysbyty Gwynedd in Bangor, North Wales developed a checklist to be used by staff prior to all emergency intubations / rapid sequence inductions in the ICU / ITU and emergency department (ER).

We have validated and audited the checklist and have it is now a standard practice in Ysbyty Gwynedd.  We have developed some training presentations and a training video (on you tube) which we are happy to share freely through this blog.  The checklist is adapted from one published in NAP4.  The checklist we use is also available on this blog.  Please feel free to browse and use these. 

No matter how experienced or senior you are, you are human and prone to lapses and error.  We all forget basic things occasionally under duress.  Most of the time the consequences are insignificant but during an emergency intubation the consequences of forgetting to consider a back up plan, or forgetting the capnograph could result in disaster.  A simple checklist is free and simple to follow.  It doesn't need to be time consuming or patronising.  In fact we spent a lot of time working on the checklist to make sure it was user friendly.  (The version we adopted was about the 10th version.)

If your hospital / department are not currently using any form of verbal checklist for emergency intubations - why not?  Are you confident that all your emergency intubations are perfect?  Do you think there could be room for improvement?  To quote Atul Gawande "Better is possible.  It doesn't take genius, it takes diligence"

Take our checklist - adopt it for your own hospital / department and start using it.

Abstract published in Anaesthesia 2013, 68, 655-661.

Our emergency induction checklist is now a standard practice for all emergency intubations in the emergency department and HDU / ITU here at Ysbyty Gwynedd in Bangor, North Wales.

A recent audit found that most users find that it is very helpful and does not significantly delay the intubations.

I am also glad to hear that it the you tube video that we made has been used for mandatory training in the Gold Coast Hospital, Queensland, Australia (where oddly enough I used to work in 2002).  Great minds think alike!

We have also had an abstract published after our poster was shortlisted at the DAS conference last November.  The abstract can be accessed via the anaesthesia online website:

http://onlinelibrary.wiley.com/store/10.1111/anae.12174/asset/anae12174.pdf?v=1&t=hhwfr0i7&s=e9b27535df47c3657d67c6502595391ba7941fa0

Poster for Difficult Airway Society Conference

Poster for presentation of our emergency induction checklist study at the annual conference of the Difficult Airway Society, Cardiff  (21st-23rd November 2012) by Dr Farbod Babolhavaeji (ACCS CT2 trainee in Emergency Medicine)

Teaching presentation

Find our teaching presentation here

2nd Prize at Welsh Intensive Care Society

The Emergency Induction Checklist was well received at the annual summer scientific meeting of the Welsh Intensive Care Society in Saundersfoot, Pembrokeshire.

Congratulations to Dr Ifan Rees who won 2nd prize in the Ed Major prize competition for his excellent presentation of his study on the effectiveness of the checklist in reducing errors.

We should be humble enough to realise that we are human and will not get it perfectly right every time. The checklist is just a tool to assist us.  It's free. It's harmless. It works.

Quote of the day: We need to get away from the idea that "I don't need to use a checklist because I'm a good doctor" to "I'm a good doctor therefore I will use a checklist" 

Ysbyty Gwynedd Emergency Induction Checklist - click on image to enlarge

EIC Training Video

This training video was filmed on the high dependency unit at Ysbyty Gwynedd, Bangor, North Wales (Betsi Cadwaladr University Health Board) in May 2012.  The staff were asked to intubate a patient with respiratory failure and sepsis secondary to pneumonia.

The team leader was asked to deliberately forget a few things in the first take (fluids, capnography, suction and failed intubation plan).  In the second take, the emergency induction checklist was used.

The emergency induction checklist at Bangor has been adapted from the one recommended in the appendix of the 4th National audit project of the Royal College of Anaesthetists (NAP4).

The purpose of this training video is to illustrate how easily things can get missed when a team are under pressure to intervene with a sick patient.  This happens frequently with no significant consequences, because it rarely matters when things go well.  Every now and again, however, things will not go to plan and without proper preparation the consequences can be severe.  The NAP4 project identified a disproportionate number of complications of airway management arise from intensive care patients.  This is not surprising as they are often sicker patients, with multiple comorbidities, there is often less time for preparation and often the equipment is not as good as we are used to in the operating theatre. What is not known is how many patients suffer harm from transient hypotension and hypoxia as a result of poorly managed inductions.

The purpose of the checklist is to ensure that the team is well prepared for potential difficulties.  It is not intended as a step by step guide to a rapid sequence intubation.  That is what the staff are trained for.  Neither is it a box ticking exercise.  We do not keep a paper record of it.   It is all about getting the team together and communicating in a structured, organised way, making sure that important equipment and drugs are available, and that the patient is as good as they can be before commencing.

The checklist is a cheap, simple solution.  It is easy to follow and does not take up a significant amount of time.  We have tested it in a short simple study and it has been shown to be effective in reducing errors in preparing for a rapid sequence induction.  Our staff are now trained to use the checklist for all emergency RSI's in critical care and the Emergency department.  Feedback from anaesthetists who have used the checklist has been overwhelmingly positive.

We hope that you find the video educational (and entertaining).

The simulator is a standard Laerdal SimMan.  The video was filmed with a HD video camera and an iPhone 4.  It was edited using iMovie.

Many thanks to Eirian, Ifan, Suzanne, Ami, Farbod, Einir, Adam, Phil.