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Should real resuscitationists use airway checklists?

Three Part Question

In [critically ill patients requiring endotracheal intubation] does [the use of a preprocedural checklist] reduce [the incidence of adverse events].

Clinical Scenario

Your trauma patient rolls through the door. The blood pressure looks good and there does not appear to be any chest injuries. Disappointed, you put your new thoracotomy shears back in your pocket. You brighten up when you realise the patient has sustained a serious head injury and will need intubating. As you brandish your prefilled syringes of ketamine and rocuronium towards the patient the anaesthetist on the trauma team starts reading from the rapid sequence induction (RSI) checklist. Rolling your eyes, you point out that this is major trauma, not a Friday morning elective cholecystectomy and demand that they proceed with the intubation immediately. Anyway, you have already given the ‘ROCKET’ induction while you have been talking, so they better start doing something fast…

Later, while pulling on your lycra shorts and downing a seventh can of Monster energy drink, you reflect on the case. Initially, you are clear that the SpO2 of 65% for a few minutes was unavoidable. Then you remember that the suction was found not to be working initially, the first laryngoscope failed and your plan B consisting of ‘get out of my way and let me do it’ seemed a surprise to everyone. You experience an unfamiliar twinge of self-doubt, and decide to read up on this checklist business after crossfit later…

Search Strategy

A literature search of EMBASE, MEDLINE and CINAHL was conducted via NHS Evidence. Reference lists of relevant articles were also hand searched.








(prehospital OR emergency OR critical OR intensive)ti.ab


(intubation OR induction).ti,ab



1 OR 2 OR 3 OR 4 OR 5 OR 6 OR 7 OR 8

9 OR 10

11 OR 12

13 AND 14 AND 15

The Cochrane Library Issue 3 of 12 March 2016

MeSH descriptor: [Checklist] explode all trees AND MeSH descriptor: [Intubation] explode all trees OR intubation ti, ab, kw 0 results

Search Outcome

184 articles were found and abstracts reviewed for inclusion. Four articles were directly relevant to the three part question and are presented below

Relevant Paper(s)

Author, date and country Patient group Study type (level of evidence) Outcomes Key results Study Weaknesses
Kerrey et al,
Critically ill children undergoing RSI in a paediatric ED, before and after institution of 4 quality improvement measures, including a checklist. Retrospective 'before and after' unmatched cohort studyIncidence of desaturation (SpO2 <90%) during RSIDesaturation occurred in 33% of historical controls vs 16% of intervention cohort. ARR 17% (95% CI 4-28%)Retrospective design. Multiple interventions studied at once, making if difficult to assess effect of checklist alone. Airway interventions restricted to certain operators as one aspect of the QI measures.
Smith et al,
Major trauma patients undergoing RSI in the ED before and after introduction of a pre-procedural checklistProspective observational 'before and after' unmatched cohort studyComplications (composite outcome)Overall complication rate 1.5% in intervention group, 9.2% in control. ARR 7.7% (CI 0.5-14.8%) No power calculation. Composite outcome - individual outcome measures show no significant difference. Incomplete compliance with checklist in treatment cohort. Significant likelihood of Hawthorne effect contributing to improved outcome measure.
Paralysis to intubation timeMedian 92 seconds pre checklist, compared to 82 seconds post.
Adherence to recognised safety measures17.1% adherence pre checklist, improved to 69.2% post checklist
Conroy et al,
Major trauma patients undergoing RSI in the ED before and after checklist was institutedRetrospective 'before and after' unmatched cohortVital signs post intubationNo significant differenceNo data proportion of patients that received intervention (all intubations after institution of checklist were assumed to have used it). Outcome measures not specified in plan. 67% of intubations in comparison group were performed by ED doctors, 99% in intervention group.
Complications during intubationNo significant difference
Mortality No significant difference
Shanmugasundaram et al,
Patients undergoing intubation in the ED or ICU before (n=47) and after (n=52) a quality improvement initiative including use of a checklist. Retrospective 'before and after' unmatched cohortMajor adverse incidents as defined by NAP4 criteria10.8% incidence of MAI pre intervention, compared to 0% post intubation.closed loop audit (conference abstract). Intervention comprised several changes, unable to clarify effect of checklist individually. Difficult to gauge proportional use of checklist during the intervention period.


Rapid sequence intubation in the critically ill patient is a high-risk procedure. Adverse events are common and can precipitate underlying injury, delay effective care and occasionally result in catastrophic patient outcome (Cook et al 2011, Fogg et al 2012). The use of checklists to reduce error rates in acute settings has been the subject of much debate. The WHO surgical checklist has been widely adopted as standard procedure in UK operating theatres. The use of checklists for emergency situations outside of the operating theatre is more variable. In 2011, the UK Royal College of Anaesthetists carried out a national audit regarding complications of airway management in the UK (NAP4). High adverse event rates were noted within an ED/critical care setting and some of these complications were attributed to action teams with limited experience working in unfamiliar territory. As such one of the ensuing recommendations was the use of a checklist to facilitate a shared mental model and optimise the chance of first pass success. The level of evidence to directly support this recommendation is weak; most studies before or after NAP4 addressing the issue of airway checklists are observational, unmatched, before and after quality improvement measures comprising multifaceted interventions. As such they are prone to significant Hawthorne effect and confounding (Goodacre 2015).

When recommending the use of a checklist the authors of NAP4 cite a prospective multicentre-controlled cohort study (Jaber et al 2010) suggesting a significant decrease in life-threatening complications after introduction of an intubation management protocol. This study assessed the effectiveness of a bundled intervention including mandatory capnography, dual operator, positive pressure preoxygenation and other features now considered to be routine elements of emergency airway management, rather than the benefit of the checklist itself.

Despite the dearth of high-quality evidence airway checklists have become increasingly adopted, usually as part of local Quality Improvement initiatives designed to reduce adverse event rates. Indeed, evidence exists to support their benefit regarding information exchange, teamwork and perception of safety. Use of checklists is intuitive and likely to be of benefit, providing regular educational update and review within a robust governance structure.

Clinical Bottom Line

Current evidence suggests there may be a potential reduction in adverse events with the use of preprocedural checklists, during intubation of the critically ill patient outside a theatre environment. However, this evidence is level 3 at best and should be considered hypothesis generating. Further evidence is required before airway checklists can be considered a standard of care.

Level of Evidence

Level 3 - Small numbers of small studies or great heterogeneity or very different population.


  1. Kerrey BT, Mittiga MR, Rinderknecht AS et al. Reducing the incidence of oxyhaemoglobin desaturation during rapid sequence intubation in a paediatric emergency department. BMJ Qual Saf 2015;24:709–17.
  2. Smith KA , High K , Collins SP , et al . A Preprocedural Checklist Improves the Safety of Emergency Department Intubation of Trauma Patients. Acad Emerg Med 2015;22:989–92.
  3. Conroy MJ , Weingart GS , Carlson JN. Impact of checklists on peri-intubation care in ED trauma patients. Am J Emerg Med 2014;32:541–4.
  4. Shanmugasundaram P, Wilson G and Parke T. Improving intubation safety in critically ill patients. J Intensive Care Soc 2014;15(Suppl 1):1751–437.
  5. Fogg T , Annesley N , Vassiliadis J . Prospective observational study of the practice of endotracheal intubation in the emergency department of a tertiary hospital in Sydney, Australia. Emerg Med Australas 2012;24:617–24.
  6. Cook TM , Woodall N , Harper J , Benger J . Fourth National Audit Project. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Br J Anaesth 2011;106:632–42.
  7. WHO surgical safety checklist and implementation manual. (accessed 20 Feb 2016).
  8. Goodacre S. Uncontrolled before-after studies; discouraged by Cochrane and the EMJ. Emerg Med J 2015;32:507–8.
  9. Jaber S , Jung B , Corne P , et al. An intervention to decrease complications related to endotracheal intubation in the intensive care unit: a prospective, multiple-center study. Intensive Care Med 2010;36:248–55.
  10. Tscholl DW , Weiss M , Kolbe M , et al An anesthesia preinduction checklist to improve information exchange, knowledge of critical information, perception of safety, and possibly perception of teamwork in anesthesia teams. Anesth Analg 2015;121:948–56.