The EMCrit call/response checklist offers tips to prepare patients and ED teams, gather equipment needed to perform safe, successful intubations

The Case

A 63-year-old male with severe sepsis from pneumonia is brought to the emergency department. The monitor shows blood pressure of 72/48 mm Hg and a blood oxygen saturation (SpO2) of 92 percent. The decision is made to intubate the patient for predicted worsening clinical course as well as poor mental status. What now? Just jump into rapid sequence intubation (RSI), right? But it’s pretty disappointing to realize that the patient’s blood pressure has dropped even lower after you push the meds, and he has turned out to be an unanticipated difficult airway. You yell for the necessary equipment and meds, but nobody seems to understand the seriousness of the situation.

Wouldn’t it be better to make sure everything was prepared to give you optimal success every time whether the intubation is smooth or difficult? This is a situation ripe for a checklist.

Not Everyone Respects Checklists

From a doctor on a critical-care mailing list, regarding a checklist: “This is so over the top! Instead of using a checklist, I just intubate. Sorry for sounding gung ho. Many of the items on the checklist are required to be on standby 24-7 in every ED. No point to go through them. Briefing is clearly superfluous and a waste of time. The checklist obsession just got worse!”

You may think a checklist is unnecessary, but think again. In 2001, Peter Pronovost, MD, PhD, introduced an intensive-care checklist protocol for central venous catheter insertion.¹ In the first three months of use after the launch of the Keystone ICU project, the median rate of infections at a typical ICU dropped from 2.7 per 1,000 patients to 0.² An estimated 1,500 lives and $175 million were saved over the first 18-month period.¹ Since this landmark study showing the efficacy of a checklist, medicine has begun to embrace the idea of integrating these cognitive aids into clinical practice. Most checklists have been adopted in elective procedures, where the controlled and stable setting allows for the time and patience to run through the list. However, we can likely gain similar safety and cognitive benefits from checklists for ED intubations.

Every time the decision is made to intubate, we are putting patients at risk. It is imperative to consider and prepare for predictable dangers, especially when intubating in an adrenaline-charged environment like the ED. The EMCrit call/response intubation checklist is designed for use in such a situation.

How to Use the EMCrit Call/Response Intubation Checklist

The checklist (Figure 1) is available at emcrit.org/podcasts/emcrit-intubation-checklist. Print the checklist double-sided on a single piece of paper. Fold it in half along the dotted line on the front page; only the top portion of the page is the actual checklist to be used while intubating. The bottom of the front page is an aid for commonly needed doses and reminders for the peri-intubation period. The back (inside the fold) includes instructions for the use of the checklist—these should only be used for review or to teach others in nonclinical situations.