Simulation-Based Rapid Plan-Do-Study Act Cycles for Airway Management Checklist Development and Quality Improvement

Objective

Intubation of critically ill patients is a high stakes procedure. Across the healthcare industry, procedural checklists have been recognized as a successful tool for improving patient safety and outcomes. While intubation checklists may improve patient outcomes and reduce complications, the content comprising a checklist is not standardized and varies widely. This novel approach to intubation checklist development embeds quality improvement Plan-Do-Study-Act (PDSA) cycles within healthcare team-based intubation simulations to efficiently elicit feedback and garner buy-in from relevant stakeholders.

Methods

Plan: A multidisciplinary group of critical care transport (CCT) providers drafted the initial intubation checklist using a modified Delphi process reviewing checklists from external CCT transport programs.

Do

This draft checklist was then trialed in two simulation-based educational sessions for CCT providers at a single institution. During each session, four groups of CCT providers rotated through an intubation workshop. During each workshop, providers utilized the intubation checklist in three brief simulated intubation scenarios of escalating complexity.

Study

After each intubation scenario, the participants provided semi-structured feedback regarding content and use of the checklist.

Act

Between intubation workshops, this feedback informed serial modifications to the checklist. This iterative process of refining, trialing, and soliciting feedback repeated over eight cycles.

Results

Feedback from providers addressed multiple components of the checklist, including both its functionality and clinical implications. Changes were made to simplify wording in order to improve clarity and length of the checklist. Participant feedback also informed resequencing of checklist items to produce a more natural flow within clinical scenarios. The visual characteristics of the checklist, including color and font, were modified to improve visual tracking and flow. The clinical and operational implications of including certain checklist items were discussed, including the use of specific equipment and medications.

Conclusion

Integrating quality improvement processes into educational simulation facilitated efficient intubation checklist development. Utilizing PDSA cycles embedded within simulation, rapid iterative adjustments were made over two 3 hour sessions based on end-user feedback from CCT providers. Additionally, soliciting provider feedback promoted team engagement and buy-in for future implementation of this intubation checklist in patient care.