22 min

EMCrit 300 – Airway Continuous Quality Improvement and the Resus Airway Bundle EMCrit Podcast - Critical Care and Resuscitation

    • Medicine

Create a Goal

Safe First Pass Success (sFPS)



DASH-1A



An Airway Quality Assurance Program Improves First Pass Success without Desaturation







* What is good FPS



* Emerg Med Australas 2017;29:40



* Research published in the last 16 years shows a mean ED FPS rate of 84.1%. This represents the best available published data that can be used to benchmark emergency airway performance.





* 60% of ED Intubations deemed difficult Acad Emerg Med 2013;20:71











Creation of an Airway Lead

One attending was assigned to oversee airway management quality and empowered to enact changes to maximize success. (2020 DOI: 10.1016/j.bja.2020.04.053)











* Watches every intubation

* Conducts CQI / Reviews every Intubation that went Awry

* Training

* Lit Watch











 

Development of a Debrief Form

This form allowed a review and quality improvement process for every intubation.

Development of an Airway Database

If you are not measuring, I promise you, you are not doing well

Checklist

A call-and-response checklist was used for all non-crashing intubations. The nurse-leader of the resuscitation would read through each item of the checklist (see on-line materials) and a member of the intubating team would affirm or stop to remedy the missed item.

Use of a Validated Failed Airway Algorithm

A three pass maximum airway algorithm was adopted as standard practice (2009 DOI: 10.1213/ane.0b013e3181ad87b0; 2011 DOI: 10.1097/ALN.0b013e318201c42e)

Development of an Airway Note

Key aspects of management: CL, story behind the airway

Standard Operating Procedure

No everyone cannot have their own way of doing things

Perfect Preox and Preintubation Optimization

We changed the allowable preoxygenation techniques to allow full denitrogenations. ETO2 monitoring was added to allow monitoring of success. Positioning of the patient for intubation was standardized

Midline Approach

Some attendings were teaching a right-sided mouth entry with aggressive tongue sweep. Video review demonstrated that often with this approach, key structures were missed and the esophagus was entered. A switch to mandatory midline approach with progressive visualization of uvula and epiglottis avoided this issue.

VL for all First Passes

At the beginning of the intervention, there was wide variance on techniques and choice of intubating equipment between the attending staff of our department. This was viewed as a primary source of poor first-pass performance and decreased the teaching potential for residents. Video laryngoscopy allows for real-time teaching during airway management and allows salvage of poor performance during the first pass.



* Maximize FPS

* Maximize Learning

* Maximize Teamwork

* Maximize Reflection



Standard Geometry Video Laryngoscopy as Standard

Unless intubating a patient with cervical spinal precautions, a CMAC macintosh standard geometry blade was made the standard for all first-pass intubation attempts. Based on the impediments noted on the first laryngoscopy, in some cases a switch to a hyper-angulated blade was indicated for subsequent passes.

Recordings and Videographic Review of All Intubations

Create a Goal

Safe First Pass Success (sFPS)



DASH-1A



An Airway Quality Assurance Program Improves First Pass Success without Desaturation







* What is good FPS



* Emerg Med Australas 2017;29:40



* Research published in the last 16 years shows a mean ED FPS rate of 84.1%. This represents the best available published data that can be used to benchmark emergency airway performance.





* 60% of ED Intubations deemed difficult Acad Emerg Med 2013;20:71











Creation of an Airway Lead

One attending was assigned to oversee airway management quality and empowered to enact changes to maximize success. (2020 DOI: 10.1016/j.bja.2020.04.053)











* Watches every intubation

* Conducts CQI / Reviews every Intubation that went Awry

* Training

* Lit Watch











 

Development of a Debrief Form

This form allowed a review and quality improvement process for every intubation.

Development of an Airway Database

If you are not measuring, I promise you, you are not doing well

Checklist

A call-and-response checklist was used for all non-crashing intubations. The nurse-leader of the resuscitation would read through each item of the checklist (see on-line materials) and a member of the intubating team would affirm or stop to remedy the missed item.

Use of a Validated Failed Airway Algorithm

A three pass maximum airway algorithm was adopted as standard practice (2009 DOI: 10.1213/ane.0b013e3181ad87b0; 2011 DOI: 10.1097/ALN.0b013e318201c42e)

Development of an Airway Note

Key aspects of management: CL, story behind the airway

Standard Operating Procedure

No everyone cannot have their own way of doing things

Perfect Preox and Preintubation Optimization

We changed the allowable preoxygenation techniques to allow full denitrogenations. ETO2 monitoring was added to allow monitoring of success. Positioning of the patient for intubation was standardized

Midline Approach

Some attendings were teaching a right-sided mouth entry with aggressive tongue sweep. Video review demonstrated that often with this approach, key structures were missed and the esophagus was entered. A switch to mandatory midline approach with progressive visualization of uvula and epiglottis avoided this issue.

VL for all First Passes

At the beginning of the intervention, there was wide variance on techniques and choice of intubating equipment between the attending staff of our department. This was viewed as a primary source of poor first-pass performance and decreased the teaching potential for residents. Video laryngoscopy allows for real-time teaching during airway management and allows salvage of poor performance during the first pass.



* Maximize FPS

* Maximize Learning

* Maximize Teamwork

* Maximize Reflection



Standard Geometry Video Laryngoscopy as Standard

Unless intubating a patient with cervical spinal precautions, a CMAC macintosh standard geometry blade was made the standard for all first-pass intubation attempts. Based on the impediments noted on the first laryngoscopy, in some cases a switch to a hyper-angulated blade was indicated for subsequent passes.

Recordings and Videographic Review of All Intubations

22 min