A Continuous Quality Improvement Airway Program Results in Sustained Increases in Intubation Success

Olvera, David; Stuhlmiller, David F.E.; Wolfe, Allen; Swearingen, Charles; Pennington, Troy; Davis, Daniel P.

doi:10.1080/10903127.2018.1433734

Cited by 15 publications

(7 citation statements)

References 29 publications

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“…Of note, their standard approach for emergency intubation was not RSI, but rather sedative only intubation. In the prehospital setting, Olvera and colleagues reported on their experience with the introduction of a CQI program in a large aeromedical transport service 26. They implemented an elaborate CQI program across 160 helicopter bases and over a three-year period found an improvement in first pass success from 85% to 95%.…”

Section: Discussionmentioning

confidence: 99%

Improvement in the Safety of Rapid Sequence Intubation in the Emergency Department with the Use of an Airway Continuous Quality Improvement Program

Sakles

Augustinovich

Patanwala

et al. 2019

WestJEM

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Introduction: Airway management in the critically ill is associated with a high prevalence of failed first attempts and adverse events which negatively impacts patient care. The purpose of this investigation is to describe an airway continuous quality improvement (CQI) program and its effect on the safety of rapid sequence intubation (RSI) in the emergency department (ED) over a 10-year period. Methods: An airway CQI program with an ongoing airway registry was initiated in our ED on July 1, 2007 (Academic Year 1) and continued through June 30, 2017 (Academic Year 10). Data were prospectively collected on all patients intubated in the ED during this period using a structured airway data collection form. Key data points included method of intubation, drugs and devices used for intubation, operator specialty and level of training, number of intubation attempts, and adverse events. Adult patients who underwent RSI in the ED with an initial intubation attempt by emergency medicine (EM) resident were included in the analysis. The primary outcome was first pass success which was defined as successful tracheal intubation with a single laryngoscope insertion. The secondary outcome was the prevalence of adverse events associated with intubation. Educational and clinical interventions were introduced throughout the study period with the goal of optimizing these outcomes. Data were analyzed by academic year and are reported descriptively with 95% confidence intervals (CI) of the difference of means. Results: EM residents performed RSI on 342 adult patients during Academic Year 1 and on 445 adult patients during Academic Year 10. Over the 10-year study period, first pass success increased from 73.1% to 92.4% (difference = 19.3%, 95% CI 14.0% to 24.6%). The percentage of patients who experienced an adverse event associated with intubation decreased from 22.5% to 14.4% (difference =-7.9%, 95% CI-13.4% to-2.4%). The percentage of patients with first pass success without an adverse event increased from 64.0% to 80.9% (difference = 16.9%, 95% CI 10.6% to 23.1%). Conclusion: The use of an airway CQI program with an ongoing airway registry resulted in a substantial improvement in the overall safety of RSI in the ED as evidenced by an increase in first pass success and a decrease in adverse events. [

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Section: Discussionmentioning

confidence: 99%

Improvement in the Safety of Rapid Sequence Intubation in the Emergency Department with the Use of an Airway Continuous Quality Improvement Program

Sakles

Augustinovich

Patanwala

et al. 2019

WestJEM

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“…Strengths of this study include the large sample size, uniform approach to airway management training and protocols, and systematic collection of data in a comprehensive airway registry. While the generalizability of emergency medical service-based studies to other settings and practitioner types may be challenged, the high intubation success rates – which have since exceeded 99% overall intubation success – underscore the relevance of these data to other advanced airway practitioners working in less extreme conditions [2, 9, 21, 22]. In addition, the HEAVEN criteria can be assessed prospectively in any setting without requirement for additional tools, devices, or patient cooperation.…”

Section: Discussionmentioning

confidence: 99%

“…The uniformity of protocols and training and the strong association between HEAVEN criteria and laryngoscope view helps to offset the influence of these factors. Ultimately, the true value of the HEAVEN criteria may best be evidenced by the improvements in intubation success over time with their use as the foundation of our advanced airway management program, with overall intubation success rates exceeding 99% [9].…”

Section: Discussionmentioning

confidence: 99%

“…Air medical crews utilized RSI for all non-arrest patients requiring endotracheal intubation. Preoxygenation was performed using passive oxygenation with a non-rebreather oxygen mask and either assisted or post-paralysis ventilation using bag-valve-mask (BVM) [9]. Oxygen saturation values above 93% were targeted prior to laryngoscopy based on our previous study defining desaturation patterns [10].…”

Section: Methodsmentioning

confidence: 99%

“…Confirmation of tracheal positioning was performed using waveform capnography. This airway program has resulted in intubation success rates that exceed 99% [9].…”

Section: Methodsmentioning

confidence: 99%

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The HEAVEN criteria predict laryngoscopic view and intubation success for both direct and video laryngoscopy: a cohort analysis

Nausheen

Niknafs

MacLean

et al. 2019

Scand J Trauma Resusc Emerg Med

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Background Existing difficult airway prediction tools are not practical for emergency intubation and do not incorporate physiological data. The HEAVEN criteria (Hypoxaemia, Extremes of size, Anatomic challenges, Vomit/blood/fluid, Exsanguination, Neck mobility) may be more relevant for emergency rapid sequence intubation (RSI). Methods A retrospective analysis included air medical RSI patients. A checklist was used to assess HEAVEN criteria prior to RSI, and Cormack-Lehane (CL) laryngoscopic view was recorded for the first intubation attempt. The incidence of a difficult (CL III/IV) laryngoscopic view as well as failure to intubate on first attempt with and without oxygen desaturation were determined for each of the HEAVEN criteria and total number of HEAVEN criteria. In addition, the association between HEAVEN criteria and both laryngoscopic view and intubation performance were quantified using multivariate logistic regression for direct laryngoscopy (DL) and video laryngoscopy (VL) configured with a Macintosh #4 non-hyperangulated blade. Results A total of 5137 RSI patients over 24 months were included. Overall intubation success was 97%. A CL III/IV laryngoscopic view was reported in 25% of DL attempts and 15% of VL attempts. Each of the HEAVEN criteria and total number of HEAVEN criteria were associated with both CL III/IV laryngoscopic view and failure to intubate on the first attempt with and without oxygen desaturation for both DL and VL. These associations persisted after adjustment for multiple co-variables including the other HEAVEN criteria. Conclusion The HEAVEN criteria may be useful to predict laryngoscopic view and intubation performance for DL and VL during emergency RSI. Electronic supplementary material The online version of this article (10.1186/s13049-019-0614-6) contains supplementary material, which is available to authorized users.

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The evolution of quality concepts and methods

Crowe¹

2021

Emergency Medical Services

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A Continuous Quality Improvement Airway Program Results in Sustained Increases in Intubation Success

Abstract: An integrated advanced airway management program was successful in improving RSI intubation performance in a large air medical company.

Cited by 15 publications

References 29 publications

Improvement in the Safety of Rapid Sequence Intubation in the Emergency Department with the Use of an Airway Continuous Quality Improvement Program

Improvement in the Safety of Rapid Sequence Intubation in the Emergency Department with the Use of an Airway Continuous Quality Improvement Program

The HEAVEN criteria predict laryngoscopic view and intubation success for both direct and video laryngoscopy: a cohort analysis

The evolution of quality concepts and methods

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