When a patient can’t breathe by themselves, healthcare staff may decide to intubate them to make it easier to get air into and out of the lungs. A tube goes down the throat and into the windpipe, and a machine called a ventilator pumps in air with extra oxygen. It can be life-saving, but life-threatening complications can also occur during a significant number of these procedures.
Sam Goodhand is a registrar in the Sussex region, specialising in anaesthetics and intensive care medicine. In this interview for Patient Safety Learning he tells us how and why he developed an accessible checklist for staff involved in intubation processes.
What are the safety challenges of intubation?
Intubation is a highly committing procedure. After we induce anaesthesia, our patient stops breathing, and we must rapidly secure the airway and establish ventilation in order to maintain oxygen levels. If oxygen levels drop major organs are rapidly unable to function, in particular the heart, which will stop within minutes.
Particularly for our critically ill patients, forward planning and communication are crucial. Anaesthetic drugs and mechanical ventilation are life-saving, but do come at an immediate cost to the overall stability of our patient, who may already be compromised.
Environmental and human factors play a huge part in the safety and success of these interventions too, and are arguably easier to optimise beforehand.
This involves making clear plans which we share with the whole team, good ergonomics of space and equipment, and just the right number of aide memoirs/checklists to make error harder to occur. It’s also about being aware of your own limitations and surroundings – being mindful of your own level of experience, tiredness, stress, and whether it’s the best time and place to do what you’re about to do.
Can you tell us about the intubation safety checklist you developed?
As a novice anaesthetist, I became aware that pre-procedure checklists for intubation weren’t always available. My training would emphasise their use, but often it was during highly pressured situations in the farthest corner of the hospital that the checklist was unavailable. The fear of forgetting an essential drug or piece of kit was very real.
When, finally, I forgot to prepare a drug to maintain blood pressure during a remote intubation, I resolved to produce a solution for myself and my colleagues.
It started with a home-printed sticker, which stuck to the ID card holder. My whole team loved it, so I proceeded to make a plastic card using the DAS emergency intubation guideline checklist. This way, it’s always on your person - avoiding a whole host of potential issues around availability and departmental (dis)agreement on a specific checklist. It seemed a no-brainer, but I’d never have believed there would now be 10,000 cards in circulation worldwide!
What feedback have you had from staff who have used it?
The feedback has been overwhelmingly positive. And it’s not just a tool for doctors – they’re really popular with Intensive Care and A&E nurses, and operating department practitioners. They can really help bring the team together in a shared mental approach before an intubation, and hopefully help bridge gaps in knowledge too.
How can staff get hold of the checklist card?
If you’re lucky, you might have grabbed one as a freebie at a DAS conference. A handful were also sent to every trust in the UK in 2019, funded by DAS.
If you would like to order a pack of intubation checklist cards for your team, simply complete the attached form.
What have you learnt personally in this quality improvement journey?
A few things really stand out. Firstly, if you’re passionate about an idea and its potential to improve things, it shouldn’t feel like hard work. Secondly, a concept won’t succeed without the support of your colleagues, but I would caution against asking everybody’s opinion! This sounds controversial, but particularly as a more junior doctor, it can cause awkwardness to not include everybody’s ideas.
Be persistent and don’t let your juniority hold you back – you may actually have a sharper eye for cracks in the system, which the familiarity of experience unconsciously bridges.
You also need a bit of luck; I’m lucky to have worked in brilliantly supportive departments and to have had a couple of fortuitous introductions.
You're now developing a paediatric version, can you tell us a bit more?
After the success of the adult checklist card, a lot of people were asking about a version for emergency airway management in kids. I’ve now developed this with the support of my colleagues at The Alex Children’s Hospital in Brighton.
Aside from the intubation checklist, I’ve tried to include elements which may not be second nature to paediatric non-specialists in a district general hospital, such as emergency drug dosing and airway kit sizing. Caring for a critically ill baby or child can be unsettling, but I hope this tool provides an extra layer of safety and confidence until definitive paediatric teams take over.
You can use the attached form if you would like to order a pack of paediatric checklist cards.
Do you have any other ideas up your sleeve for improving patient safety?
I have a couple of ideas. I feel the way we store our equipment doesn’t always integrate with our meticulous approach to sick patients, or work well with the limitation of space in hospitals. So I’m working on something…watch this space!
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About the Author
I’m currently a specialist registrar in anaesthetics and ICU. In the past, I spent eighteen brilliant months as an A&E doctor in Western Australia, and enjoyed a more recent stint working as a Flying Doctor in the rural Outback. These experiences broadened my perspective on different methods of delivering care- both inside and outside of the hospital.
Aside from clinical work, I’m interested in how simple tools can transform patient safety and reduce mental workload – what people would generally call “human factors”. When I have the time and inspiration, I also to write for more mainstream publications, in the past this has included The Independent and New Statesman. Away from work I love kitesurfing, reading, travelling and good whisky (in moderation of course..!).