Compliance and Attitudes of Critical Care Transport Providers Regarding a Prehospital Rapid Sequence Intubation Checklist


David Olvera, BA, NRP; Michael J. Lauria, MD, NRP, FP-C; Jennifer Noce, NRP, CCEMTP, FP-C, CCP-C; William B. Weir, MD, FAAEM, FACEP, FAEMS


Human factors engineering innovations, such as checklists, have been adopted in various acute care settings to improve safety with reasonable compliance and acceptance. In the air medical industry, checklists have been implemented by different teams for critical clinical procedures such as rapid sequence intubation. However, compliance and attitudes toward these human factors engineering innovations in the critical care transport setting are not well described. In this institutional review board-exempt, retrospective review of checklist usage, we assessed rapid sequence intubation checklist compliance and surveyed providers with 5 questions based on Rogers’ theory of diffusion of innovation to examine why or why not there was compliance. Our results indicated that compliance with checklist implementation was excellent. The survey questions were consistent with process improvement factors that enhance the spread and acceptance of innovation.

In 1936, Boeing and the US Army developed the first series of comprehensive operational checklists for operating the B-17 Flying Fortress in the wake of a disastrous test flight crash.1,2 Since then, checklists have been a quintessential part of aviation operations. The development and implementation of human factors engineering (HFE) concepts such as clinical checklists have steadily been incorporated into clinical practice to improve patient safety in both emergent and nonemergent circumstances.3,4,5 They have been described in the literature to improve surgical safety,6,7 promote compliance with evidence-based sepsis interventions,8,9 lower catheter-related bloodstream infections,10 reduce complications during rapid sequence intubation (RSI),11 and enhance guideline compliance in prehospital emergency care.12

However, as with any practice change, it is often challenging to gain organizational compliance with instituting new safety measures. Understanding and assessing compliance are important because no safety intervention can be successful if it is not implemented at the point of care. Tan et al13 surveyed operating room staff in 138 Chinese hospitals and found overall compliance with the World health Organization Surgical Safety Checklist to be 79.8%. Vohra et al14 surveyed 6,269 medical professionals from 69 countries and found that only 57.5% used the World Health Organization Surgical Safety Checklist perioperatively. Compliance with checklists for other clinical operations, such as intensive care unit rounding, has also been investigated in the literature and found to be low.15

Assessing attitudes and beliefs about HFE interventions, such as checklists, is also important. Understanding how safety innovations are adopted can identify barriers to implementation that can be addressed, facilitating process improvement.16 Rogers17 explored the spread or “diffusion” of innovations. He identified several factors that explained the rate and extent of innovation adoption. He determined that the attributes of the innovation itself, including compatibility with current practices, complexity, and observability of how the innovation helps, are crucial in determining whether or not individuals implement a new tool or process. Applications of this theoretical framework to the clinical environment have helped assess interventions and improve patient care.18,19,20

In the air medical industry, checklists have been implemented by different teams for critical procedures, including RSI.21,22 However, in this setting, compliance and attitudes toward these HFE innovations are not well described. This investigation assessed the compliance of a novel RSI checklist for critical care transport (CCT) teams and applied Rogers’ theory of innovation17 to survey questions that assessed attitudes toward the checklist.

Click below to read the full research paper published by the Air Medical Journal, Volume 41, Issue 1, January 01, 2022, Page 82-87