Videographic Assessment of Preintubation Checklist Use in Pediatric Emergency Departments: A NEAR4PEM Checklist Feasibility Study

Abstract

OBJECTIVES: Cognitive aids are widely used in pediatric emergency departments (PEDs), yet real-world use is difficult to assess via self-report or the medical record. We used video review to assess whether (adoption) and how (fidelity) the NEAR4PEM Preintubation Checklist was used during tracheal intubations (TIs) in PEDs. METHODS: Prospective observational study at 2 tertiary PEDs with continuous multivideo camera recording in resuscitative areas. Four independent reviewers used a standardized video abstraction tool to evaluate checklist use in checklist item verbalization, completion, timing, and efficiency (time spent on the checklist). RESULTS: Among 47 TIs, the checklist was used in 34 (72%). Thirty (88%) cases (22 medical, 8 trauma) were available for video review. Inter-reviewer concordance on all data elements was 96%. Verbalization of all 26 checklist items occurred in only 10% of cases. For most items, verbalization occurred in >80% of TIs and completion in ≥70%. Lower rates were observed for "limit on attempts/duration discussed" (verbalized in 33%, completed in 23%) and for "rescue devices identified/prepared" (verbalized in 63%, completed in 47%). Several preparation and equipment tasks were typically completed before checklist verbalization, whereas anticipatory-planning elements-such as difficult airway considerations, limits on attempts, and postintubation planning-were more often addressed after checklist prompting. Median checklist completion time was 2 minutes (IQR: 1 to 3min). Reviewers reported that the checklist was used effectively for patient preparation and enhanced team communication in 28 cases (93%). CONCLUSIONS: While checklist adoption was high, checklist item completion varied widely, potentially highlighting which elements function as true cognitive aids versus those reflecting routine practice. Video review provides a feasible and uniquely informative method to measure real-world implementation and identify opportunities to improve ED cognitive aid use.