Development of implementation strategies for the National Emergency Airway Registry for Pediatric Emergency Medicine (NEAR4PEM) pre-intubation checklist: a prospective, pre-implementation planning study

The National Emergency Airway Registry for Pediatric Emergency Medicine (NEAR4PEM) pre-intubation checklist was rigorously developed and usability-tested for pediatric emergency departments (PEDs), but effective integration into routine PED practice has not been systematically planned. We undertook a structured implementation planning process to identify site-level barriers and develop a context-responsive implementation plan to support checklist adoption. To develop strategies to support adoption, a disciplinarily-diverse team of PED clinicians performed a five-step stakeholder-informed barrier prioritization and strategy-matching process. In Step 1, focus groups and surveys were employed to identify barriers and facilitators to checklist implementation. In Step 2, barriers were ranked on feasibility to address and potential impact if addressed in order to identify which determinants to prioritize in strategy selection. In Step 3, implementation strategies were selected to address prioritized barriers via virtual facilitated sessions. In Step 4, these strategies were ranked for feasibility and impact by Advisory Board (AB) members to guide decision making around which to include in the final implementation plan. In step 5, the AB detailed the prioritized implementation strategies in an implementation plan. Sixteen unique barriers were identified, 6 of which were prioritized. 24 strategies were generated, 19 of which were prioritized and included in our implementation plan. Prioritized strategies addressed key barriers like staff turnover and competing job responsibilities, utilizing approaches like folding the checklist into provider training, and creating a network of airway champions to promote the checklist’s implementation. In addition to generating a list of strategies to support this effort, this study serves as a proof of concept that a participatory and somewhat resource-intensive process can successfully be executed in a complex emergency setting. By linking prioritized barriers to operationalized implementation strategies, it offers a practical framework for translating determinant assessment into actionable implementation plans for low-frequency, high-risk workflows. Future work will evaluate implementation and patient outcomes during checklist rollout.