Effect of a medical checklist on performance in a tricyclic antidepressant poisoning scenario: a simulation-based randomized controlled trial

Successful and rapid management of critically ill patients in the emergency department (ED) is complex. While checklists improve crisis management in surgical and anesthesiologic settings, their effectiveness in emergency medicine remains understudied. This study aimed to assess the impact of checklists on the simulated scenario duration and adherence to critical interventions in a simulated tricyclic antidepressant (TCA) poisoning scenario. A simulation-based randomized controlled trial was conducted involving 56 emergency physicians, randomly assigned (1:1) to manage a high-fidelity simulation of life-threatening TCA poisoning with or without access to an evidence-based paper checklist. The primary outcome was total scenario duration. Secondary outcomes included time to first administration of key intervention (sodium bicarbonate), protocol adherence (percentage of critical interventions performed), and physician satisfaction with the checklist. Between-group differences were analyzed using independent-samples t-tests or Mann-Whitney U tests based on distribution. Multivariable linear regression was used to adjust for potential confounders. Checklist access significantly reduced mean scenario duration from 665.8 seconds (95% CI: 619.1–712.5) in the control group to 520.7 seconds (95% CI: 471.1–570.3) in the checklist group ( p < 0.001). Median time to sodium bicarbonate was 125.0 seconds (IQR 100.5–164.5) with the checklist versus 163.5 seconds (IQR 100.8–325.8) without ( p = 0.08). Adherence to critical interventions was significantly higher in the checklist group (median 87.5%, IQR 87.5–100) than the control group (median 62.5%, IQR 62.5–75; p < 0.001). Most participants (27/28; 96.4%) would use the checklist again in similar real-time situations. Checklist access significantly reduced simulated scenario duration and improved adherence to critical interventions in a simulated TCA scenario. Emergency physicians expressed high satisfaction with the tool. These findings demonstrate that cognitive checklists can enhance task performance in high-fidelity emergency simulations, highlighting the need for further research to evaluate their clinical impact in real-world resuscitation. ClinicalTrials.gov (protocol ID W22_163, NCT number NCT05496114, registration date August 9, 2022).