A preprocedural checklist to improve patient safety during prehospital rapid sequence intubation

Background: major traumatic injuries or severe medical conditions are life-threatening circumstances that may require the establishment of a definitive airway prior to hospital arrival to provide optimal oxygenation and ventilation, being the indicated procedure in most of these circumstances rapid sequence intubation (RSI). The prehospital setting encompasses several predisposing factors that make difficult intubation more likely to occur compared to in-hospital intubations (7.4-13% vs 5.8%), performing more intubation attempts that lead to an increased RSI complication incidence (16-30%). Those predisposing factors comprise patient biophysics, challenging environments and experience of the physician and the team who perform the procedure, including technical (TS) and non-technical skills (NTS), which can be reinforced by the use of a preprocedural RSI checklist. Justification: prehospital airway management is more susceptible to entail an increased adverse event rate and a decrease in patient safety, leading to greater morbidity and mortality. The use of a RSI checklist is widely recommended in the existing literature, and mandatory in some countries. In Catalonia’s prehospital setting, RSI is not standardized and entails a high interpersonal variability due to personal preferences rather than adherence to evidence-based guidelines and recommendations. A preprocedural RSI checklist was developed in 2016 by the medicalized helicopter crew from Girona and has been used by this unit since then, but its impact on the RSI complication rate has never been assessed. Objectives: the main objective of this project is to assess whether the application of the preprocedural RSI checklist decreases the incidence of major adverse events during the RSI procedure in critically ill or injured patients of all ages in Catalonia’s prehospital setting. Furthermore, this study aims to study the following unknown information of Catalonia’s prehospital setting: determine the incidence of the prehospital RSI procedure, the first-pass intubation rate (FPS), the global RSI- complication incidence (and its occurrence by intubation attempts) and assess if the checklist application increases the FPS rate, lowers complications in all kind of patients and causes any harmful delays in patient care. Methodology: this study is designed as a quasi-experimental before-and-after evaluation of an intervention to improve the quality of the RSI procedure in Catalonia’s prehospital setting. This intervention is the application of a preprocedural RSI checklist, which will be implemented through formation and training under simulation. A non-probabilistic consecutive sampling method will be performed, including all patients who will undergo RSI in Catalonia’s prehospital setting from May 2019 to March 2022. Thus, 1,456 patients will be required to carry out this project, 728 patients will be recruited for each period (pre- and postchecklist). The complications exhibited in both periods will be assessed and compared to determine the impact of the intervention ​
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