Having done a bit of reading about checklist design, and the challenge-response style, I’ve reconfigured the resus time out checklist. I was actually working on this the other night after finished a late shift up in Darwin, and was on-call for the ED overnight. Sure enough I was asleep for about an hour when the phone rang at 03:15am. Groan…. “Two patients from a high-speed MVA, one was ejected and is agitated and combative, I think we’ll need to tube him” said the Registrar.
15 minutes later I enter the resus room to hear the words “pass me the bougie” from the head of the bed. I’d missed the party, and the tube went in uneventfully. As soon as this happened though, I stood back to watch what the assembled and very capable senior ED, Surgical, Anaesthetic and ICU Registrars and nursing staff would do. In true night-shift fashion, everyone started doing their own thing! The tasks they were doing weren’t wrong, but they lacked direction or focus, and there were a couple of glaring omissions. I’m sure if I suddenly blindfolded them all and asked what each of the other people in the room were doing, they’d have had no idea. Which of course is completely normal for people who are operating in a state that’s been proven to be the same as working when you’re drunk.
“Perfect time for the checklist” I thought, so I made the time out announcement, and ran through it.
The effect it had was interesting, and very productive. Some of the positive effects included:
- Everyone stopped, which allowed everyone to catch up on where we were up to
- It provided clear points for the scribe nurse to document, and double check those that she’d already written
- I could see that the A/B/C structure was familiar, and it was evident that this was an easy sequence for the group to follow
Potential omissions/errors/efficiency points that were picked up included:
- Sedation and paralytics were drawn up and administered immediately – these had not been pre-prepared prior to intubation
- A bite block was inserted
- The switchover from bagging circuit to the ventilator occurred sooner, freeing up the Anaesthetic Reg to obtain the 2nd IV access
- 2nd IV access established, as the patient had been too combative to get two in before intubation
- Blood gas checked & signed
- Two registrars fixated on establishing an arterial line were (after two unsuccessful attempts) diverted to preparing staff, equipment & drugs for transport to CT
- Prior to departure disposition direct to ICU from CT was arranged (which changed to theatre once the scan was done – see below)
- It also gave me something to focus on, as I was exhausted having already worked a busy 11-hour shift, and having been woken so soon after entering deep sleep (a well-recognised mechanism for maximal brain scrambling).
Overall I really felt that use of the checklist provided a clear structure for the group to work within, and made the resus process more orderly, calm, and definitely more efficient. Instead of performing time-consuming or unnecessary tasks, or falling into “night shift attention drift”, we managed to get the essentials done, and get the patient out of the ED in well under 30 minutes from my arrival. About the only negative effect was that we got the patient stabilised, ready for transport and out the door so quickly, that the ED Reg hadn’t written any notes! Perhaps a sub-heading for version 3.0 could be “DOCUMENTATION”
Anyway, here’s the checklist: Resus Time Out Checklist: Version 2.0
And in this case, the sooner we got this patient out of ED, the better.
Yep, two separate extradurals, with midline shift. Time really was of the essence.
As usual, comments are welcome. Feel free to download, copy, modify and adjust as you see fit. It’s still a work in progress, so any suggestions are welcome.