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Developing an Airway Management Bundle to Standardize Emergent

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Developing an Airway Management Bundle to Standardize Emergent It Takes A Village: Developing an Airway Management Bundle to Standardize Emergent Intubation Processes in the Emergency Department James Sacca, MD, Daniel Casey Kim, MD, Dimitri Papanagnou, MD, MPH, EdD(c) Department of Emergency Medicine, Thomas Jefferson University Hospital 1. Crash Airway Pre-medicate: Glycopyrrolate: 0.2 mg RSI TIME OUT If patient arrives without airway device present Ondansetron: 4 mg Pre-oxygenate and prepare for immediate intubation Nebulized or atomized Lidocaine: Patient Name__________________________________ If patient arrives with supraglottic device present 4 ml of 4% or 8 ml of 2% Needs Assessment Strategy #2 TJUH AIRWAY BUNDLE Problem Definition If able to oxygenate and ventilate, delay intubation Sedation: Code status permits intubation: Y or N or Unknown If patient arrives with ETT present Ketamine: 1 mg/kg bolus NPO since__________________ Confirm ETT placement (see 5.) Consider paralytic once successful Unconscious, Consider visualization with laryngoscopy Allergies______________________________ or NKDA Unreactive, D. Delayed sequence intubation 2. RSI Patient delirious/agitated so can’t pre-oxygenate We performed a FMEA to uncover latent threats through in situ Height___________________ Near death? Pre-medicate: Mallampati score_____________ Pretreatment: Glycopyrrolate: 0.2 mg Yes No For reactive airway disease: Lidocaine 1.5 mg/kg IV Ondansetron: 4 mg [ ] dentures removed Yes Airway management is at the core of emergent patient care. Emergent 1 For cardiovascular disease: Fentanyl 3 mcg/kg Sedation: simulation, as well as real patient intubations. A in situ simulation of Crash airway Difficult airway? For elevated ICP: both of the above meds/doses Ketamine: 1.5 mg/kg IBW bolus Personnel Pre-oxygenate No Induction: Paralyze intubations in the Emergency Department (ED) at Thomas Jefferson 1. Intubating provider (leader)_______________________ 2 Etomidate: 0.3 mg/kg TBW or 20 mg Pre-oxygenate RSI Midazolam: 0.3 mg/kg TBW or 20 mg 4. Failed Airway algorithm an emergent airway situation was performed in the ED using an airway 2. Backup intubater_______________________________ Propofol: 2 mg/kg TBW or 140 mg 3. Respiratory therapist____________________________ Ketamine: 1.5 mg/kg IBW or 100 mg Considered failed if: Failure to oxygenate or University Hospital (TJUH) have been noted by staff to be variable and 4. Medication nurse_______________________________ Attempt intubation Paralytics: Failure to bag ventilate or mannequin, with all appropriate staff at the bedside. Rocuronium: 1.0 mg/kg IBW or 70 mg >3 failed attempts at intubation Supplies Succinylcholine 1.5 mg/kg TBW or 100 mg Contraindications: Call Anesthesia at _________________ and not standardized. Staff have also described that equipment tends to be [ ] Working IV Successful? Non-acute burns Call ENT at_______________________ Yes Non-acute crush injury [ ] Fluid bolus No Non-acute stroke or SCI If unable to oxygenate: Following a qualitative analysis of FMEA and post-simulation Non-acute intra-abdominal sepsis Attempt supraglottic device (SGD) placement [ ] Medications Able to ventilate? Any neuromuscular disease difficult to locate during intubations. Induction: ________________________________ Hyperkalemia If unsuccessful SGD placement: No Call Trauma Code 1s Paralysis: ________________________________ Yes 3. Difficult Airway algorithm Prepare for surgical airway debriefing transcriptions, the following threats were identified: Sedation: ________________________________ [ ] Inject lidocaine w/ epi Consider paralytic Evaluate for difficult direct laryngoscopy Percutaneous cricothyrotomy Analgesia: _______________________________ Look externally [ ] Melker kit There is no objective data to confirm these claims. Furthermore, there Evaluate the “3-3-2” rule Open cricothyrotomy [ ] Preoxygenation Mallampati [ ] Scalpel or [ ] Nasal cannula Attempt intubation Obstruction/obesity [ ] Melker kit No consensus on when to move patients to the resuscitation bay; no [ ] Bag valve mask Neck mobility is no bundle in place to guide emergent intubations in the ED. 5. Post intubation [ ] Suction Yes Evaluate for difficult bag-mask ventilation Successful? Mask seal Confirm ETT placement: [ ] Intubation Method clear team roles; delays in securing critical equipment; lack of fully- Obstruction/obesity [ ] End-tidal CO2 color change [ ] Direct laryngoscopy: No Age [ ] Tube condensation [ ] Macintosh size_____________ No No teeth [ ] Bilateral breath sounds Able to oxygenate? Stiffness (resistance to ventilation) [ ] Absent sounds over stomach Our team sought immediate actions to improve ED airway processes. [ ] Miller size_________________ [ ] CXR stocked supply carts; no protocol for airway pre-assessment; no pre- [ ] CMAC Yes Evaluate for difficult supraglottic device placement (SGD) [ ] Tube location at teeth: ____ [ ] Glidescope Restricted mouth opening [ ] Cover >3 attempts? Obstruction/obesity Initial vent settings: [ ] Tube Distorted anatomy Mode: AC intubation EPIC order set; time-outs rarely performed; no checklist No Yes Stiffness (resistance to ventilation) Rate: 14+/-2 Size______________ TV: 6-8 ml/kg IBW 4 If concern for difficult airway: FiO2: 100% then titrate down to SpO2 goal 99% Target depth_____________cm Failed airway PEEP: 5-10 Aims For Improvement [ ] Stylet algorithm A. Call anesthesia at ___________________ and Medications for setup, medications, or equipment; no pre-identification of back- Call ENT at ___________________ if: Post intubation meds: [ ] 10 cc syringe Propofol: bolus 0.5-1 mg/kg, drip 5-80 mcg/kg/min or [ ] ETCO2 detector 5 Trauma Code 1s Midazolam: bolus 1-5 mg, drip 0.04-0.2 mg/kg/hr Post intubation Trauma or burns to face, neck, or airway Plus up providers; post-intubation management is rarely defined early. [ ] Positioned appropriately Hemorrhage from airway or upper GI Fentanyl: bolus 1-3 mcg/kg, drip 25-250 mcg/hr or management Angioedema Morphine: bolus 0.5-10 mg, drip 2-30 mg/hr Ventilator settings: Known mass or stenosis in airway Infections of neck or airway [ ] OGT placement 1. Describe staff experiences surrounding emergent intubations 3 Recent surgery of neck or airway [ ] Foley catheter placement RR: ____________ Difficult airway TV: ____________ algorithm B. RSI only if BVM or SGD and intubation predicted to succeed Debrief Was the patient difficult to intubate? in the ED at TJUH (Needs Assessment 1). FiO2: 100% then titrate down to SpO2 goal 99% C. Awake intubation What did we do well? PEEP: ____________ Pre-oxygenate What can we improve upon? Longitudinal Assessment Strategy We deployed a survey to all staff in the ED, including residents, Figure 1. Proposed ED Airway Bundle (A) and Resource Sheet (B). faculty, nurses, technicians, and mid-levels (see A, B, C, D). 1) Enrollment in the National Emergency Airway Registry (NEAR) to 2. Identify latent threats in TJUH ED processes surrounding measure measure parameters for TJUH ED intubations (i.e., emergent intubations (Needs Assessment 2). success rate, airway characteristics, hemodynamics, adverse events, Measurement Strategy and disposition). We conducted several Failure Modes and Effects Analyses using in situ simulation. Events were transcribed and qualitatively coded to 2) Following training (see below), laminated, brochure-like checklists generate specific failure points. Needs Assessment Strategy #1 will be globally stocked in the ED and on top of all airway carts. The 3. Convene a task force focused on improving ED airway A Google survey was administered to all ED staff: faculty/resident expectation is that these will be used and completed by a team processes. physicians; nurses; mid-levels; technicians. Participants rated their member. These will be included in the patient chart. A follow-up We identified airway champions from the ED, Anesthesia, Nursing, satisfaction with available airway equipment; access to equipment; survey and focus groups with staff will be conducted to capture Pharmacy, and Respiratory to inform next steps. team organization; and interest in an airway bundle that would process changes. 4. Create an airway bundle for immediate use at TJUH (i.e., streamline emergent airway processes. (Figure 2) 3) Two-months into bundle implementation, several follow-up FMEAs workflow, preparation, team roles, troubleshooting). will be conducted. We consulted evidence-based, best practices and met with local and A. B. regional airway champions to develop a checklist (see Figure 1). Implementation Plan Proposed Intervention 1) Several ED Advanced Airway CQI Task Force meetings have been A Standardized Process for ED Intubations scheduled. This group will serve as an advisory board should any issues/concerns arise during implementation. A checklist bundle was developed to improve organization and preparation surrounding intubations (Figure 1). This checklist was 2) In the next several weeks, the intervention will be presented to the inspired by a literature review, including the NEAR study database1 C. D. ED Steering Committee for stakeholder support. and the EMCrit Intubation Checklist.2 The bundle is intuitive, easy to 3) A module will be created on Articulate Rise Software. This module use, and consists of discrete sections (i.e., preparation; algorithmic will cover the basics of the bundle. All clinical staff (i.e., residents, approach; time-out; post intubation management faculty, nurses) will be asked to complete the module. E. F. 4) In-person training sessions will be conducted, with several table Standardized Equipment in
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