# Creation of an Implementation Blueprint for the National Emergency Airway Registry for Pediatric Emergency Medicine (NEAR4PEM) Pre-Intubation Checklist

## TL;DR

This paper describes the creation of a detailed plan to implement a pre-intubation checklist in pediatric emergency departments to improve patient safety.

## Contribution

The study provides a collaborative, evidence-based blueprint for implementing a pediatric airway checklist in clinical settings.

## Key findings

- Six barriers to checklist adoption were identified as high impact and high feasibility.
- Nineteen implementation strategies were prioritized and detailed in a blueprint for clinical use.
- The blueprint was developed through interprofessional collaboration and implementation science methods.

## Abstract

The National Emergency Airway Registry for Pediatric Emergency Medicine (NEAR4PEM) developed an evidence-based pre-intubation checklist, however its successful integration to clinical practice in the Pediatric Emergency Department (PED) requires attention to implementation. Given the complex conditions influencing checklist use, it is essential to work with key informants to understand multilevel determinants and identify the most effective strategies for implementation. The objective of this study was to systematically identify barriers to checklist adoption and to prioritize and detail targeted strategies as an implementation blueprint to support successful checklist integration into clinical practice.

NEAR4PEM recruited Airway Champion (AC) teams composed of physicians, nurses, pharmacists, and respiratory therapists at each PED. Our methodology consisted of a five-step modified conjoint analysis. In Step 1, a mixed-methods formative evaluation was conducted, utilizing focus groups and surveys for identification of barriers and facilitators to checklist implementation. In Step 2, key informants prioritized the identified barriers according to feasibility and impact quantitatively via survey. In Step 3, the prioritized barriers were matched with implementation strategies from a published compilation (Expert Recommendations for Implementation Change, ERIC) via virtual facilitated sessions. In Step 4, these strategies were ranked for feasibility and impact by Advisory Board (AB) members. In step 5, the AB detailed the prioritized implementation strategies in an implementation blueprint.

In Step 1, ACs from 13 sites completed 45 surveys, which, together with focus groups, identified 16 unique barriers. For Step 2, these key informants prioritized 6 barriers of high impact and high feasibility. For Step 3, an implementation science team assisted ACs with selection of 24 ERIC strategies. In Steps 4 and 5, the AB prioritized 19 ERIC strategies and incorporated them into an implementation blueprint, detailing how each could be applied across different phases to guide future airway teams.

An implementation blueprint for a PED pre-intubation checklist was collaboratively developed with interprofessional AC team members and implementation scientists. This blueprint includes a manageable set of prioritized barriers and detailed strategies to navigate the implementation process. Future steps involve implementation of the checklist with concurrent evaluation of implementation and patient outcomes.