An Airway Quality Improvement Project Improves First Pass Success Rate and. Decreased Adverse Events Associated with ED Airway Management.
An Airway Quality Improvement Project Improves First Pass Success Rate and Decreased Adverse Events Associated with ED Airway Management A NZ EMN-ANZEDAR Quality Improvement Initiative Andrew Brainard, MD, MPH, FACEP, FACEM 1, 2, 3, 4 Paul Sellens, MBChB1 Vanessa Thornton, MBChB, FACEM1 G Luke Larkin, MD, MSPH, FACEP1, 3, 4
Figure 1: ED Airway Algorithm and Final Checklist
42%
Figure 4: Adverse Events
1 Counties
Manukau Health Emergency Department, Middlemore Hospital 2 Australian and New Zealand Emergency Department Airway Registry 3 New Zealand Emergency Medicine Network (NZ EMN) 4 University of Auckland School of Medicine
33% 30%
Background
22%
At a large (100,000 presentations per year) ED in Auckland New Zealand, ED airway care has been most frequently performed by anesthetic trainee physicians based out of the Intensive Care Unit. Anecdotal observations and initial audit indicated a low first pass success rate, low utilization of “best practice” ED airway techniques, and a high adverse event rate. An airway quality improvement project on airway care.
14%
Any Adverse Event
Difficult airway course for some consultants Increased bedside skills teaching in department Essentials of Emergency Airway Care Course every 6 months Focus on teamwork, decision making, practical skills, and core knowledge ED consultants, trainees, and nurses Online Pre-Study and Pre-Test (www.thesharpend.org/EEACC) 8-hours of skills labs and simulation workshops 4:1 faculty:trainee ratio
Desaturation Hypotension SBP Oesophageal 3min
Nasal Apnoeic Oxygen
Optimal Pt Positioning
Formal Airway Briefing and Final Bougie or Stylet Assessment Checklist on 1st Attempt
54% 51%
49% 49% 46%
73.4%
78.9%
43%
40%
20%
20.0% July 2012 - June 2013 (12 months) N = 123
July - Dec 2013 (6 months) N = 79
Conclusions A focused program to increase the proficiency of ED airway care can increase airway “best practice” procedures, increase the first pass success rate, and decrease adverse event rates. Many aspects of this project can be emulated and expanded at other institutions.
40.0%
0.0%
62%
62%
60%
100.0%
June 2012 80.0% Start of Registry
70%
68%
67%
Using the registry data, 123 intubations performed in the 12-month period before the first EEACC workshop were compared to the most-recent 6-month period following the intervention. The first pass success rate increased (Fig. 2). ED based providers performed more of the intubations but “difficult airway” calls involving theatre have increased (Fig. 3). Hypoxia and hypotension rates decreased (Fig. 4). Adherence to “best practice” techniques have also increased (Fig. 5). Adherence to “best practice” techniques was associated with increased first pass success and decreased adverse events. In addition to improved patient outcomes, ED staff have reported that ED airways have appeared to become more controlled and less stressful.
Joint training with anaesthetics
Regional/National ED Airway Cooperation
2%
95%
Equipment
Education
5% 5%
Figure 5: "Best Practice" Rate
Maintain formal ED airway registry Debrief and feedback after ED airways Trainee airway passport
Standard ED airway algorithm Standard ED airway checklist
7%
7%
0% 0%
Measurement and Feedback
Process
11%
7%
Table 1: ED Airway Quality Improvement Project
Simple upgraded ED airway equipment Cognitive aids
13%
Jan - June 2014 (6 months) N = 90
6%
Acknowledgements:
2% 0%
0%
Theatre Based
ICU Based
ED Based
Toby Fogg for the ANZEDAR project. Debbie Hailstone for data collection. Sumintra Grounder for data entry. Irene Zeng for preliminary data analysis.
