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Airway and rapid sequence intubation quality assurance and improvement: Should airway management training be more intensive?
2005 AMTC Scientific Assembly Tuesday, October 25, 2005 Editor’s note: The following pages feature the 11 oral and 22 poster presentations scheduled for the Air Medical Transport Conference in Austin, Texas. Contact the Association of Air Medical Services at (703) 836-8732 for more information.
❖ ORAL PRESENTATIONS
■ Airway and Rapid Sequence Intubation Quality Assurance and Improvement: Should Airway Management Training Be More Intensive? R. Brozen, S. Nordaby Dartmouth-Hitchcock Medical Center Introduction: Many organizations have guidelines or position papers for rapid sequence intubation (RSI) in the prehospital setting. Air medical transport programs routinely utilize RSI and assess their performance through quality assurance and improvement programs. We attempted to assess our airway management to determine the need to increase intensiveness of training and maintenance protocols. Methods: Using AeroMed Software, we retrospectively reviewed 5 months of completed transports that had prospectively collected data. Results: During the time period 542 transports were completed (293 air and 249 ground). Thirty-five transports had intubations performed: 91% air transports, 43% female, average age 35.8 years old (17% below age 10), average weight 66.12 kg (3% not recorded), and average Glasgow Coma Score 9.94 (9% not recorded). Standard documentation was not completed 3% of the time. Protocols were followed 94% of the time. Twenty-four percent utilized additional airway techniques prior to intubation. RSI was utilized in 100% of intubation attempts. Three percent had inappropriate sedation medication dosage, and 37% had inappropriate paralytic medication dosage. Ninety-seven percent of the time the intubation was achieved. Sixty-four percent were achieved on first attempt, 33% were not, and 3% were unknown. Average number of attempts was 1.88 (range 1-6). Endotracheal tube (ETT) placement confirmation was not documented 6% of the time, 3% had no confirmation done, 91% were appropriate, 50% did not have cricoid pressure documented, 3% unknown, and 47% documented cricoid pressure during intubations. Twenty percent had complications during intubation. Eighteen percent did not have the tube secured. Of those with documentation on tube securing only 53% stated the method. After patient movement, ETT reassessment was documented 47% of the time. 200
Air Medical Journal 24:5
Conclusion: The study is weakened by small total numbers. We were surprised to find that contrary to the literature examples our program accurately doses sedatives in the vast majority of cases but in a significant minority (37%) the paralytic is inappropriately dosed. Also surprising was the average number of attempts needed to achieve intubation was 1.88. We plan on continuing to address problems that occur in a minority of the cases withthe individuals involved. With errors found in larger numbers, we plan to address identified problems through ongoing education. The specific percentage at which to change from a quality assurance to a quality improvement approach remains to be determined. We plan to reassess airway management to see if the instituted education produces improvement.
September-October 2005
201
❖ ORAL PRESENTATIONS
■ Airway and Rapid Sequence Intubation Quality Assurance and Improvement: Should Airway Management Training Be More Intensive? R. Brozen, S. Nordaby Dartmouth-Hitchcock Medical Center Introduction: Many organizations have guidelines or position papers for rapid sequence intubation (RSI) in the prehospital setting. Air medical transport programs routinely utilize RSI and assess their performance through quality assurance and improvement programs. We attempted to assess our airway management to determine the need to increase intensiveness of training and maintenance protocols. Methods: Using AeroMed Software, we retrospectively reviewed 5 months of completed transports that had prospectively collected data. Results: During the time period 542 transports were completed (293 air and 249 ground). Thirty-five transports had intubations performed: 91% air transports, 43% female, average age 35.8 years old (17% below age 10), average weight 66.12 kg (3% not recorded), and average Glasgow Coma Score 9.94 (9% not recorded). Standard documentation was not completed 3% of the time. Protocols were followed 94% of the time. Twenty-four percent utilized additional airway techniques prior to intubation. RSI was utilized in 100% of intubation attempts. Three percent had inappropriate sedation medication dosage, and 37% had inappropriate paralytic medication dosage. Ninety-seven percent of the time the intubation was achieved. Sixty-four percent were achieved on first attempt, 33% were not, and 3% were unknown. Average number of attempts was 1.88 (range 1-6). Endotracheal tube (ETT) placement confirmation was not documented 6% of the time, 3% had no confirmation done, 91% were appropriate, 50% did not have cricoid pressure documented, 3% unknown, and 47% documented cricoid pressure during intubations. Twenty percent had complications during intubation. Eighteen percent did not have the tube secured. Of those with documentation on tube securing only 53% stated the method. After patient movement, ETT reassessment was documented 47% of the time. 200
Air Medical Journal 24:5
Conclusion: The study is weakened by small total numbers. We were surprised to find that contrary to the literature examples our program accurately doses sedatives in the vast majority of cases but in a significant minority (37%) the paralytic is inappropriately dosed. Also surprising was the average number of attempts needed to achieve intubation was 1.88. We plan on continuing to address problems that occur in a minority of the cases withthe individuals involved. With errors found in larger numbers, we plan to address identified problems through ongoing education. The specific percentage at which to change from a quality assurance to a quality improvement approach remains to be determined. We plan to reassess airway management to see if the instituted education produces improvement.
September-October 2005
201