Department of Veterans Affairs Amended on VHA Directive 1157(1) Veterans Health Administration September 19, 2018 Transmittal Sheet Washington, DC 20420 June 14, 2018 OUT OF OPERATING ROOM AIRWAY MANAGEMENT 1. REASON FOR ISSUE: This Veterans Health Administration (VHA) directive addresses the requirements to provide Out of Operating Room Airway Management (OOORAM) care for Veterans. 2. SUMMARY OF MAJOR CHANGES: a. Amendment dated September 19, 2018, updates The Difficult Airway Algorithm and Rescue Cricothyrotomy (DAARC) training web sites in paragraph 5.f.(2)(b). b. This update clarifies the appropriate competencies for providers who perform urgent and emergent airway management including intubation outside of VA facility operating rooms, establishes criteria for privileging clinicians, and ensures a training program for those seeking intubation privileges at a VA facility by creating three levels of airway management competency (Level 1, Level 2, and Level 3) and directing that an adjunctive device be used to confirm tube placement. This update also establishes a documentation requirement when a Level 3 OOORAM provider determines the patient has a difficult-to-intubate airway. Documentation must be done using the National Difficult Airway Template in Computerized Patient Record System (CPRS). 3. RELATED ISSUES: None. 4. RESPONSIBLE OFFICE: The Office of Specialty Care Services (10P11) is responsible for the contents of this directive. Questions may be addressed to the Office of Specialty Care Services, National Director of Anesthesia at 202-461-7120. 5. RESCISSIONS: VHA Directive 2012-032, Out of Operating Room Airway Management, dated October 26, 2012, is rescinded. 6. RECERTIFICATION: This VHA directive is scheduled for recertification on or before the last working day of June 2023. This VHA directive will continue to serve as national VHA policy until it is recertified or rescinded. Carolyn M. Clancy, M.D. Executive in Charge DISTRIBUTION: Emailed to the VHA Publications Distribution List on June 15, 2018. T-1 June 14, 2018 VHA DIRECTIVE 1157(1) CONTENTS OUT OF OPERATING ROOM AIRWAY MANAGEMENT 1. PURPOSE ................................................................................................................ 1 2. BACKGROUND........................................................................................................ 1 3. DEFINITIONS .......................................................................................................... 1 4. POLICY .................................................................................................................... 3 5. RESPONSIBILITIES ................................................................................................ 3 6. AIRWAY MANAGEMENT COMPETENCY ASSESSMENT ..................................... 6 7. REFERENCES ....................................................................................................... 10 APPENDIX A DEPARTMENT OF VETERANS AFFAIRS (VA) FORM 10-0544, PRIVILEGE AND COMPETENCY VERIFICATION ...............................................................................A-1 i June 14, 2018 VHA DIRECTIVE 1157(1) OUT OF OPERATING ROOM AIRWAY MANAGEMENT 1. PURPOSE This Veterans Health Administration (VHA) directive addresses the competencies of providers who perform emergent airway management outside of Department of Veterans Affairs (VA) medical facility operating rooms; it addresses required techniques to confirm successful endotracheal tube placement and required documentation when a patient has been determined to have a difficult-to-intubate airway. AUTHORITY: Title 38 United States Code (U.S.C.) 7301(b). 2. BACKGROUND a. Emergent airway management is often required outside of an operating room. It is mandatory that individuals who respond to the airway management needs of the patient are trained and qualified to perform airway management. The ability to manage a patient’s airway must be demonstrated and cannot be assumed from the job title. As documented in this directive, specific training and procedural skills are required to meet the airway needs of the patient. b. Unrecognized esophageal intubation or other failure to appropriately ventilate the patient’s lungs will likely result in brain damage or death. The use of a device that detects carbon dioxide must be utilized in concert with auscultation to confirm ventilation in all circumstances when an endotracheal tube or alternative airway device is inserted (i.e., laryngeal mask airway (LMA), King tube™, Combitube™, etc.). c. For some patients, airway management, including insertion of an endotracheal tube, may be difficult due to prior patient experience, history, or observed anatomic and situational contexts. The use of a standardized critical path analysis tool is recommended to help determine when and how additional expertise will be consulted. An example may be found at the National Center for Patient Safety (NCPS) Web site at http://vaww.ncps.med.va.gov/ in the Guidelines and Directives section. NOTE: This is an internal VA Web site that is not available to the public. d. When a Level 3 Out of Operating Room Airway Management (OOORAM) provider encounters substantial difficulty or the inability to manage a patient airway, clear and timely documentation in the CPRS-based National Difficult Airway Template and communication of this information to the patient and other health care professionals can prevent future problems by allowing the health care team to adequately plan for future elective intubation and rapidly identify the needed airway expertise for emergent intubations. 3. DEFINITIONS a. Deep Sedation. Regardless of location in the facility, Deep Sedation is a drug- induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired requiring manipulation of 1 June 14, 2018 VHA DIRECTIVE 1157(1) the airway (for example, jaw thrust, mask ventilation, supraglottic airway insertion or intubation) in order to maintain ventilation. Patients may require assistance in maintaining a patent airway and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained. However, cardiovascular function may require the use of pharmacologic intervention to support the patient’s cardiovascular status. Patients undergoing Deep Sedation may slip into a state of General Anesthesia. b. Emergent Airway Management. Management of the airway in a patient who needs immediate support and intervention (e.g., a code situation). c. General Anesthesia. Regardless of location in the facility, General Anesthesia is a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired. d. Moderate Sedation. Moderate Sedation is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. Reflex withdrawal from a painful stimulus is not considered a purposeful response. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. e. Level 1 OOORAM Provider. An individual trained according to Section 6 to perform basic airway management which includes mask ventilation, insertion of a nasal airway, insertion of an oral airway and the insertion of a supraglottic device (such as an LMA). After establishing this level of airway assistance, the provider will assess the need to initiate activation of local processes to obtain a higher level of airway expertise (VA Level 2 or 3 provider or 911 Emergency Medical Service (EMS)). f. Level 2 OOORAM Provider. An individual trained according to Section 6 to be competent in Level 1 airway management that has received further training to perform intubation of the trachea using a video laryngoscope (VL) (indirect laryngoscopy). Direct laryngoscopy (DL) is not a required part of Level 2 airway management, however, if an individual has appropriate training and experience in use of DL, DL may be used (for example, a Respiratory Therapist). If laryngoscopy is not possible or fails, a provider with Level 3 airway management skills must be called (or 911 EMS if a Level 3 VA airway provider is not available). Medication management is not part of Level 2 airway management. g. Level 3 OOORAM Provider. This includes Level 1 and 2 airway management skills and the ability and training to manage a patient undergoing sedation deeper than the moderate level and must include expertise in DL to secure the airway. Sedation can be with or without paralytic administration. A Level 3 provider must have privileges or a 2 June 14, 2018 VHA DIRECTIVE 1157(1) scope-of-practice to use sedation/hypnotic/paralytic/reversal and resuscitation medications. h. Resident. An individual who is engaged in an accredited graduate training program for physicians, dentists, optometrists, and podiatrists, and who participates in patient care under the direction of supervising practitioners. NOTE: For the purpose of this directive, the term resident includes