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A Novel Rescue Technique for Difficult Intubation and Difficult Ventilation
Published on: January 17, 2011
Implementation of NAP4 emergency airway management recommendations in a quaternary-level pediatric hospital
Elliot Long1,2,3, Domenic Cincotta1,2,3, Joanne Grindlay1,2,3
1Department of Emergency Medicine, The Royal Children's Hospital, Parkville, Vic, Australia.
Insights
Implementing hospital-wide systems changes, including a new intubation algorithm and standardized equipment, can improve the safety of emergency airway management outside the operating room. Continuous monitoring and multidisciplinary training are key components for success.
Area of Science:
- Anesthesiology
- Critical Care Medicine
- Patient Safety
Background:
- Emergency airway management outside the operating room carries a high risk of adverse events.
- The 4th National Audit Project highlighted the need for improved safety protocols.
Purpose of the Study:
- To develop and implement hospital-wide systems changes to enhance the safety of emergency airway management.
- Establish a governance framework through a hospital airway special interest group.
Main Methods:
- Developed a modified intubation algorithm (Difficult Airway Society's A-B-C-D approach) with clear escalation pathways.
- Standardized airway equipment in identical carts across critical care areas.
- Implemented a preintubation checklist, continuous waveform capnography, and multidisciplinary team training.
Main Results:
- A comprehensive framework for governance and systems changes was established.
- Key interventions included a modified intubation algorithm, standardized equipment, checklists, capnography, and team training.
- Methodology for ongoing performance monitoring via a quality assurance framework was described.
Conclusions:
- Hospital-level process changes for emergency airway management are achievable through collaborative efforts.
- Further research is needed to evaluate the impact of these changes on patient outcomes.
Abstract:
Emergency airway management, particularly outside of the operating room, is associated with a high incidence of life-threatening adverse events. Based on the recommendations of the 4th National Audit Project, we aimed to develop hospital-wide systems changes to improve the safety of emergency airway management. We describe a framework for governance in the form of a hospital airway special interest group. We describe the development and implementation of the following systems changes: 1. A local intubation algorithm modified from the Difficult Airway Society's plan A-B-C-D approach, including clear pathways for airway escalation, and emphasizing the concepts of resuscitation prior to intubation, planning for failure, and avoidance of fixation error. 2. Simplified and standardized airway equipment located in identical airway carts in all critical care areas. 3. A preintubation checklist and equipment template to standardize preparation for airway management. 4. Availability of continuous waveform endtidal capnography in all critical care areas for confirmation of correct endotracheal tube placement. 5. Multidisciplinary team training to address the technical and nontechnical aspects of nonoperating room intubation. In addition, we describe methodology for ongoing monitoring of performance through a quality assurance framework. In conclusion, changes in the process of emergency airway management at a hospital level are feasible through collaboration. Their impact on patient-based outcomes requires further study.
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