Do Intubation Checklists Save Lives?

Lauren M. Westafer, MD, MPH, MS


A meta-analysis found no consistent association between use of endotracheal intubation checklists and either increased first-pass success or reduced mortality, peri-intubation arrest, or hypotension.


Intubation checklists have been widely adopted for use during endotracheal intubation in hopes of increasing the safety of this high-risk procedure, but their effect on outcomes is not clear. These researchers performed a systematic review and meta-analysis of 11 heterogenous studies (3261 patients) that assessed the effect of various intubation checklists, with or without additional interventions, on mortality and other outcomes. Only one study was randomized.


Use of a checklist was not associated with decreased mortality in the five studies that assessed this outcome (relative risk, 0.97). In the eight studies that assessed hypoxic events, checklist use was associated with reduced risk for hypoxia (RR, 0.75); however, when the authors pooled data only from the three trials with low risk of bias, this association disappeared (RR, 0.97). The authors also found no associations between checklist use and peri-intubation arrest, hypotension, esophageal intubation, or first-pass success.


Although this meta-analysis found no measurable benefit to use of intubation checklists, I don’t think we should abandon them. Intubation checklists are often a part of training and become ingrained into standard practice; thus, the “control” groups in these studies may have performed the same steps as the “intervention” groups, thereby diluting any actual effect of checklist use. Further, the effect of a checklist may be dependent on the environment in which it is used — how the team was trained and if (and how) the team is accustomed to working together.


Turner JS et al. Association of checklist use in endotracheal intubation with clinically important outcomes: A systematic review and meta-analysis. JAMA Netw Open 2020 Jul 2; 3:e209278.



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