A Cognitive Aid Improves Adherence to Guidelines for Critical Endotracheal Intubation in the Resuscitation Room: A Randomized Controlled Trial With Manikin-Based In Situ Simulation.

Abstract

Emergency endotracheal intubation (ETI) is a high-risk procedure. Some of its adverse events are life-threatening, and guidelines emphasize the need to anticipate complications by thorough preparation. The emergency department (ED) can be an unpredictable environment, and we tested the hypothesis that a cognitive aid would help the emergency practitioners better follow guidelines. The main objective of this study was to determine whether the use of a cognitive aid focusing on both preintubation and postintubation items could improve ETI preparation and implementation in the ED resuscitation room regarding adherence to guidelines. The secondary objective was to measure and describe procedure times. We conducted a single-blind randomized controlled trial with manikin-based in situ simulation. The participants were not aware of the purpose of the study. The cognitive aid was developed using national guidelines and current scientific literature. The most relevant items were the preparation and implementation of a rapid sequence induction for ETI followed by mechanical ventilation. Emergency department physician-nurse pairs were randomized into a "cognitive aid" group and a "control" group. All pairs completed the same scenario that led to ETI in their own resuscitation room. An adherence to guidelines score of 30, derived from the 30 items of the cognitive aid (1 point per item), and preparation and intubation times were collected. Seventeen pairs were included in each group. Adherence to guidelines scores were significantly higher in the cognitive aid group than in the control group (median = 28 of 30, interquartile range = 25-28, vs. median = 24 of 30, interquartile range = 21-26, respectively, P < 0.01). Preparation, intubation, and total procedure times were slightly longer in the cognitive aid group, but these results were not significant. In an in situ simulation, a cognitive aid for the preparation and implementation of an emergency intubation procedure in the ED resuscitation room significantly improved adherence to guidelines without increasing procedure times. Further work is needed in a larger sample and in different settings to evaluate the optimal use of cognitive aids in critical situations.