Using Checklists and Bundles to Reduce Adverse Events Surrounding Endotracheal Intubation: A Systematic Review
CCCF ePoster library. Soliman D. 10/02/17; 198142; 20
Dr. Daniel Soliman
Dr. Daniel Soliman
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Using Checklists and Bundles to Reduce Adverse Events Surrounding Endotracheal Intubation: A Systematic Review

Soliman, Daniel1; Wilson, Brock2; Cardinal, Pierre1

1Division of Critical Care, Department of Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Canada


Introduction:  Endotracheal intubation (ETI), is a high-risk intervention especially when performed in critically ill patients with tenuous physiologic reserve1-3. ETI is associated with a 3% mortality rate and severe complication rates reported as 24%, 28% and upwards of 50% 4-7. Recent consensus guidelines recommended that a standardized approach to ETI be implemented to improve first-attempt ETI success while reducing serious complications of hypotension, prolonged hypoxia, and airway deterioration1
Objective: We devised to systematically review the literature to ascertain whether checklists or bundles reduce complication rates surrounding ETI with the following parameters: Population: critically ill patients requiring ETI; Intervention: intubation checklist or bundle; Control: standard of care; Outcome: intubation performance and safety.
Methods: A literature search with the following terms returned 143 references from CINAHL, EMBASE, Medline and Cochrane central databases: airway; intubation; respiratory failure; bundle; checklist; difficult airway; complications; case-control; randomized control; cohort; observational; retrospective; prospective. We excluded neonatal studies, studies not published in English, and studies in which no control data was available. The abstracts were reviewed and three studies met our criteria and were included in the analysis 8-10.
Results: A total of 999 intubations were performed, with 472 control or pre-intervention, and 527 performed post-checklist or bundle implementation. The majority of patients were intubated for traumatic or neurological (i.e. seizure, decreased LOC, CVA) presentations. With a checklist or bundle introduced, the calculated odds ratios are as follows: desaturation 0.53 (95% CI = 0.37 -0.77), hypotension 0.49 (95% CI = 0.30-0.82), cardiac arrest 0.27 (95% CI = 0.07 - 0.97), esophageal intubation 0.34 (95% CI = 0.14-0.82), and less than 3 ETI attempts 0.42 (95% CI = 0.28 - 0.63). All three studies documented an implementation period in which medical staff were trained in use of the bundle or checklist for ETI. However, the bundles and checklists differed in pre-oxygenation technique, devices used for ETI, location ETI was performed (ICU versus emergency department), and the amount of experience ETI proceduralists had prior to study initiation.
Conclusion: An intubation checklist or bundle when well implemented in an emergency department or ICU can decrease the incidence of adverse events peri-intubation through continuing education, improved communication, frequent recognition of airway challenges, and ample team and patient preparation.

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