Difficult Airways: All Airways are NOT Created Equal July 23, 2018 ACS Quality and Safety Conference Lisa Failace, MSN, RN, CCRN-K Donna Swartz, MAS, RN, CPHQ, CPPS Hackensack University Medical Center Hackensack, New Jersey
775 bed tertiary care, teaching non-profit hospital. Level 2 Trauma center with greater than 2,000 encounters and 1,051 trauma admissions. Our pilot took place in the Surgical Intensive Care Unit a 14 bed trauma, surgical, neuro ICU. Disclosure: We have no financial disclosures to report. Non-Financial Disclosure: Dr Richard Levitan and Airway Cam Technologies provided education to our participants in 2017 and 2018. We did not receive financial compensation.
How our Journey Began 82 year old fall from ladder SICU Progress Cardiac Arrest Outcome Facial fractures, subdural hematoma, subarachnoid hemorrhage Failed attempts at weaning Goals of care being discussed Occluded ETT Surgical airway required Anoxic brain injury Comfort measures leading to expiration Project Aim: To develop a standardized approach to airway management in our Surgical Intensive Care Unit (SICU). To improve team confidence in caring for patients with difficult airways.
Actions taken: Recognition of gaps in resources/ knowledge Creation of algorithm and difficult airway cart Education Education Jan 2016 Apr 2016 Jul 2016 Sept 2016 Sept 2017 Mar 2017 Nov 2017 Apr 2018 Difficult airway response team formed Cycles of change for cart and algorithm SICU Pilot
Education March, 2017 and April, 2018 Difficult Airway program. August 2017 education for RN Staff in SICU.
ICU Airway Algorithm 1. Oxygenation/Ventilation Prep for tracheal intubation (Ventilation is KEY, Intubation is elective) Responsible persons- RN, RT, APP, MD CALL ANESTHESIA- Spectra # 72152 Provide anesthesia with pt s history and Mallampati score if known HOB elevated- OPTIMIZE POSITION Mandible forward if difficulty oxygenating O s Up the NOSE¹ Nasal Cannula- High flow External Laryngeal Manipulation (ELM) Prep room with Video Laryngoscopy- GLIDESCOPE/CART/medication box 2. Responsible Parties: Anesthesiologist Critical Care Provider Anesthesiology Attending #71665 Provider will determine needs based upon- ASA algorithm (reverse side) 3. Cricothyroidotomy Surgical Airway Responsible parties: Surgeon Prep for Surgical Airway Melker Blue Rhino Shiley Trach Percutaneous Trach as directed by surgeon 1.Levitan, R. M., MD. (2015). 2015 EMRA/AirwayCam Fundamentals of Airway Managment (3rd ed.). Irving, TX: EMRA
2018 Pre and Post Education Assessment 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% All comparisons p<0.0001 Pre Post Pre Post Pre Post Pre Post Pre Post Pre Post 1 Level of Confidence 2. Appropriate method of management 3. Able to Identify difficult airway 4. Able to skillfully manage 5. Skillful with adjunct airways 6. Confident in ability to Optimize laryngeal exposure Somewhat Confident or Very Confident
Investment of all Stakeholders - CRUCIAL Champions- Nursing, Physician, Patient Safety Resources Human and Financial Need for ongoing PDSA-Rapid Cycles Education, Simulation and Didactic
Challenges Protected time for all team members Financial restrictions Inconsistent team members Exchange cart process Scheduling education
Conclusions Our overall goal to standardize airway management care in the SICU was achieved with the implementation of education, an algorithm and the difficult airway cart. Staff report more confidence in caring for patients in respiratory distress. Ongoing airway event review yields no further safety events.
References Health Research & Education Trust (2017,February). Airway Safety Change Package:2017 Update. Chicago,Il:Health Research & Education Trust. Accessed at http://hret-hiin.org Kane, B. G., Bond, W. F., Worrilow, C. C., & Richardson, D. M. (2006). Airway Carts. Journal of Patient Safety, 2(3), 154-161. doi:10.1097/01.jps.0000242995.09037.07 Weingart, S. D., & Levitan, R. M. (2012). Preoxygenation and Prevention of Desaturation During Emergency Airway Management. Annals of Emergency Medicine, 59(3). doi:10.1016/j.annemergmed.2011.10.002