Use of a continuous quality improvement (CQI) program indicates that the safety of rapid sequence intubation in emergency departments can be improved with basic data collection and targeted interventions.
“The CQI database with ongoing data analysis allows the emergency department to see what’s working and what needs improvement,” said John C. Sakles, MD, a professor of emergency medicine at the University of Arizona College of Medicine, in Tucson. He presented the study at the 2017 annual meeting of the Society of Airway Management. “We recommend that all emergency departments institute an airway management CQI database because it’s hard to know what needs to be fixed, unless you’re measuring performance.”
Airway management in the emergency department is a high-risk procedure and is associated with a high frequency of AEs. After receiving IRB exemption, Dr. Sakles and his colleagues prospectively collected data on all patients intubated in the emergency department using a structured airway CQI data collection form. Data were obtained between July 1, 2007 and April 30, 2017, entered into a spreadsheet and analyzed for trends on an ongoing basis.
“Almost all intubations at our institution are managed by emergency medicine residents,” said Cassidy Augustinovich, an undergraduate student assisting Dr. Sakles with his airway research. “Following each intubation, the operator completed an airway CQI form that included information on patient, operator and intubation characteristics.”
As Dr. Sakles reported, over the 10-year study period, first-pass success increased from 72% to 91%, while AEs decreased from 22% to 14%. Other notable outcomes included a reduction in recognized esophageal intubations from 4.5% to zero, a 16.1% decrease in the need to switch intubation device and a 6.9% decrease in rescues by an attending physician. The investigators noted several possible reasons for these improvements, but the most likely one, Dr. Sakles said, was changes made to resident training based on the results.
“The data were analyzed periodically throughout the years, and adjustments were made to residents’ training to reflect what the data showed,” Dr. Sakles said. “For example, in 2013, we found that patients who experience first-pass success are much less likely to have adverse events. This led to a culture change throughout the academic emergency department, and a new emphasis was placed on first-pass success when training residents.”
According to Dr. Sakles, improvements in airway management also could be attributable to the increased use of video laryngoscopes by emergency medicine residents, which rose from 46% to 99% over the course of the study. “When residents are using video laryngoscopes, the supervising attending is able to see what the residents are seeing and thus better able to instruct them. The residents are less likely to make mistakes that way.”
The CQI program also demonstrated that patients who had adequate preoxygenation coupled with apneic oxygenation were much less likely to experience desaturation. After this was noticed, Dr. Sakles said, more emphasis was placed on using these techniques together, as well.
The authors pointed out several possible limitations to the study. Because it was a single-institution study, other institutions could have varying results. In addition, Dr. Sakles said, because all data were self-reported by residents, there could be bias in reporting. “It’s important to make sure you have complete data. If you’re missing 10% of your airway forms, that could be where all your complications could be hiding.”
Steven Cataldo, MD, the director of medical sciences at Revolutionary Medical Devices, a division of Vyaire Medical, noted a change in use from etomidate to ketamine over the study period, and asked whether this change was due to updates in the literature.
“Ten years ago, there was still some concern that using ketamine in head-injured patients was not a good idea,” Dr. Sakles said. “Over the last few years, however, we’ve recognized that this is not a clinically significant issue, so the ketamine increase is based on a lack of fear in using it in head-injured patients.”
“Are you aware of any other large cohort studies of rapid sequence intubations, and if so, do the results of these studies reflect your findings?” Dr. Cataldo asked.
“The biggest study I’m aware of is the National Emergency Airway Registry [NEAR], which is run out of Brigham and Women’s Hospital in Boston,” Dr. Sakles said. “They have roughly 20 hospitals around the country that submit data similar to this, and their findings have paralleled what we’ve found. I would encourage other emergency departments to collect airway CQI data or participate in a national airway registry, such as NEAR. Only in this way can the quality and safety of airway management in the emergency department be improved.”