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Medical crisis checklists in the emergency department: a simulation-based multi-institutional randomised controlled trial
  1. Eric Dryver1,2,3,
  2. Jakob Lundager Forberg4,
  3. Caroline Hård af Segerstad5,
  4. William D Dupont6,
  5. Anders Bergenfelz2,3,
  6. Ulf Ekelund1,2
  1. 1 Department of Emergency and Internal Medicine, Skåne University Hospital Lund, Lund, Sweden
  2. 2 Department of Clinical Sciences, Lund University, Lund, Sweden
  3. 3 Practicum Clinical Skills Centre, Office for Medical Services, Region Skåne, Sweden
  4. 4 Department of Emergency Medicine, Helsingborg Hospital, Helsingborg, Sweden
  5. 5 Department of Emergency Medicine, Ystad Hospital, Ystad, Sweden
  6. 6 Department of Biostatistics, Vanderbilt University, Nashville, Tennessee, USA
  1. Correspondence to Dr Eric Dryver, Department of Emergency and Internal Medicine, Skåne University Hospital Lund, Lund 22185, Sweden; eric.dryver{at}med.lu.se

Abstract

Background Studies carried out in simulated environments suggest that checklists improve the management of surgical and intensive care crises. Whether checklists improve the management of medical crises simulated in actual emergency departments (EDs) is unknown.

Methods Eight crises (anaphylactic shock, life-threatening asthma exacerbation, haemorrhagic shock from upper gastrointestinal bleeding, septic shock, calcium channel blocker poisoning, tricyclic antidepressant poisoning, status epilepticus, increased intracranial pressure) were simulated twice (once with and once without checklist access) in each of four EDs—of which two belong to an academic centre—and managed by resuscitation teams during their clinical shifts. A checklist for each crisis listing emergency interventions was derived from current authoritative sources. Checklists were displayed on a screen visible to all team members. Crisis and checklist access were allocated according to permuted block randomisation. No team member managed the same crisis more than once. The primary outcome measure was the percentage of indicated emergency interventions performed.

Results A total of 138 participants composing 41 resuscitation teams performed 76 simulations (38 with and 38 without checklist access) including 631 interventions. Median percentage of interventions performed was 38.8% (95% CI 35% to 46%) without checklist access and 85.7% (95% CI 80% to 88%) with checklist access (p=7.5×10−8). The benefit of checklist access was similar in the four EDs and independent of senior physician and senior nurse experience, type of crisis and use of usual cognitive aids. On a Likert scale of 1–6, most participants agreed (gave a score of 5 or 6) with the statement ‘I would use the checklist if I got a similar case in reality’.

Conclusion In this multi-institution study, checklists markedly improved local resuscitation teams’ management of medical crises simulated in situ, and most personnel reported that they would use the checklists if they had a similar case in reality.

  • checklists
  • crisis management
  • simulation
  • team training

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Footnotes

  • Contributors ED is a specialist and educator in emergency medicine. He contributed to the conception of the study, the acquisition, analysis and interpretation of data, drafting and revising the manuscript and approving the current version submitted for publication. JLF and CHS are specialists in emergency medicine and contributed to the acquisition of data, revising the manuscript and approving the current version submitted for publication. WDD is a Professor of Biostatistics and Preventive Medicine and contributed to the analysis and interpretation of data, revising the manuscript and approving the current version submitted for publication. AB is a Professor of Practical Medical Education and contributed to the conception of the study, the interpretation of data, revising the manuscript and approving the current version submitted for publication. UE is a Professor of Emergency Medicine and Associate Professor of Physiology. He contributed to the conception of the study, the analysis and interpretation of data, revising the manuscript and approving the current version submitted for publication.

  • Funding This study was funded by Region Skåne (ALF 2018-0152, REGSKANE-627931, REGSKANE-814271).

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval The study was approved by Lund’s Regional Ethics Committee (Dnr 2013/858) and the heads of the four emergency departments, and all study participants gave written consent.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available in a public, open access repository. All data relevant to the study are included in the article or uploaded as supplementary information. The data collected for this study and the programs that analysed these data are publicly available. The data for this study are posted athttps://www.dropbox.com/sh/u1xfkz2s7fyjxsc/AAD3l3ZL1mHqoeRkNDkTCKr0adl=0inanExcelspreadsheetnamed Checklists_ED_interventions.xlsx.It is freely available to anyone. To make a copy of this file, go to this URL, pull down the Open box next to Checklists_ED_interventions.xlsx and select 'Open in Excel'.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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