Create a Goal
Safe First Pass Success (sFPS)
An Airway Quality Assurance Program Improves First Pass Success without Desaturation
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- What is good FPS
- Emerg Med Australas 2017;29:40
- Research published in the last 16 years shows a mean ED FPS rate of 84.1%. This represents the best available published data that can be used to benchmark emergency airway performance.
- 60% of ED Intubations deemed difficult Acad Emerg Med 2013;20:71
- Emerg Med Australas 2017;29:40
- What is good FPS
Creation of an Airway Lead
One attending was assigned to oversee airway management quality and empowered to enact changes to maximize success. (2020 DOI: 10.1016/j.bja.2020.04.053)
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- Watches every intubation
- Conducts CQI / Reviews every Intubation that went Awry
- Training
- Lit Watch
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Development of a Debrief Form
This form allowed a review and quality improvement process for every intubation.
Development of an Airway Database
If you are not measuring, I promise you, you are not doing well
Checklist
A call-and-response checklist was used for all non-crashing intubations. The nurse-leader of the resuscitation would read through each item of the checklist (see on-line materials) and a member of the intubating team would affirm or stop to remedy the missed item.
Use of a Validated Failed Airway Algorithm
A three pass maximum airway algorithm was adopted as standard practice (2009 DOI: 10.1213/ane.0b013e3181ad87b0; 2011 DOI: 10.1097/ALN.0b013e318201c42e)
Development of an Airway Note
Key aspects of management: CL, story behind the airway
Standard Operating Procedure
No everyone cannot have their own way of doing things
Perfect Preox and Preintubation Optimization
We changed the allowable preoxygenation techniques to allow full denitrogenations. ETO2 monitoring was added to allow monitoring of success. Positioning of the patient for intubation was standardized
Midline Approach
Some attendings were teaching a right-sided mouth entry with aggressive tongue sweep. Video review demonstrated that often with this approach, key structures were missed and the esophagus was entered. A switch to mandatory midline approach with progressive visualization of uvula and epiglottis avoided this issue.
VL for all First Passes
At the beginning of the intervention, there was wide variance on techniques and choice of intubating equipment between the attending staff of our department. This was viewed as a primary source of poor first-pass performance and decreased the teaching potential for residents. Video laryngoscopy allows for real-time teaching during airway management and allows salvage of poor performance during the first pass.
- Maximize FPS
- Maximize Learning
- Maximize Teamwork
- Maximize Reflection
Standard Geometry Video Laryngoscopy as Standard
Unless intubating a patient with cervical spinal precautions, a CMAC macintosh standard geometry blade was made the standard for all first-pass intubation attempts. Based on the impediments noted on the first laryngoscopy, in some cases a switch to a hyper-angulated blade was indicated for subsequent passes.
Recordings and Videographic Review of All Intubations
Once the switch was made to video laryngoscopy for all intubations, mandatory recording of the intubations was required. This allowed a video review by the Airway Lead of all intubations.
Bougie for all First Pass Except Hyperangulated Blade Intubations
After the publication of two studies documenting high FPS, we switched to bougie on first pass for every standard geometry blade intubation (2018 DOI: https://doi.org/10.1111/anae.14182; 2018 DOI: 10.1001/jama.2018.6496)
Change in Bougie Allowed use in All Intubations
A switch to a steerable tip, prebent bougie [Sharn Anesthesia Flexible Tip Bougie] allowed the use of this airway adjunct even with hyperangulated blades. It also allowed placement in the glottis in patients with an anterior glottic opening.
Airway Corner Session in Resident Conference
Key intubation recordings demonstrating errors or difficult conditions were shown in a monthly, 20-minute session. This allowed the entire program to benefit from rarely seen airway conditions and consistently noted errors in technique.
Teaching and Encouragement to Use Awake Intubation Techniques
Frees you from the dangers of 2nd pass decompensation
Tell me what you are doing with your airway CQI
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Simply amazing! Working in Scandinavia, EM is slowly taking over or sharing the airway, whatever you name it. Your tips will serve as the back bones to build our Airway QI program!
BTW, I have been filming every intubations I have done or our residents have done. It is great to rewatch them with them, always full of learning points. Great way to learn and see how people trouble shoot certain problems!
Thanks for the inspiration!
Dr.Weingart I appreciate your podcast so much and all the knowledge you share. Some of the information is definitely way further down the line in the emergency case and things I can not apply fully to the field, but it is nice to hear what it is like further on into emergency cases. I would really appreciate your help with this question please. How do you record your intubations in your department? Is it the glidescope that allows you to have an sd card in it for storage? Is there a list somewhere I can find some VL devices that… Read more »
most of the new generation VL devices have recording capacity, including glidescope, cmac, and others.
I’ve run into the problem at my facility that IT won’t let us use an unencrypted flash drive, while the Glidescope won’t record to an encrypted drive. The Glidescope records date & time, which is considered PHI
set the year to 2099 and the time off by 6 hours
Any thoughts on incorporating high flow nasal oxygen into first pass intubation protocols…essentially extending the time prior to desaturation while apneic
not sure if there is bang for the buck unless the pt is already on it (in which case leave it on). If they are not on it, it will impede BVM and won’t provide sig. benefit compared to just cranking up the standard NC
Dr. Weingart, I have become very interested in data collection to improve outcomes and steer education. I find the level of debrief we currently exercise paltry and am fighting for improvement. Would you be willing to share your airway debrief tool? Your discussion of its importance led me to a “DUH!” moment and I wish to try and adopt something in my small world… Or if you have any further readings/research on this topic you would be willing to share?
Hi Scott. Long time listener, first time poster! I’m chair of our department and got super interested in this after listening to this. Just set out on trying to replicate some of your work here. I was wondering if you’d be willing to share your airway form. Or at least a list of the contents. I very much understand the balance between getting the right info and not making it onerous. Trying to get it right-ish from the getgo.
Thanks,
Tom K.
Hi Scott!
You talked about putting up the airway corner videos on your site or on youtube like the airway videos from Sydney HEMS. Is this coming soon?
Best regards
Ola
This is so amazing, i really liked reading this article.
Am so impressed by this.keep sharing more such articles.
Source: https://www.tharwaniinfrastructures.com/millenia/