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However beautiful the strategy, you should occasionally look at the results
–Winston Churchill
WE KNOW:
First-pass success is important: It’s associated with less hypoxemia and hypotension (1)
Hypoxemia and/or hypotension matter (2)
First pass success should be: at least 85% (3)
DEFINITIONS: (4)
What defines a pass (i.e. attempt at endotracheal intubation)? Instrument in, Instrument out.
E.g. DL blade in then keeping a DL blade in while being passed/grabbing a bougie= still one attempt
E.g. DL blade in then taking a DL blade out, bagging a patient while someone looks for/opens a bougie= two attempts
What defines hypoxia? O2 saturation <90% not good, <85% really not good, <80% bad
What defines hypotension? SBP <90mmHg not good, <80mmHg really not good, <70mmHg bad
HOW WELL DO YOU DO?
Record it.
The ‘Blue Card’ can be used to record your airway management over time. We have printed it on blue cardboard, front and back. Electronic version is currently being developed.
Feel free to use it, free of charge, to evaluate your own practice. Better yet, it can be used in your department or hospital-wide to give even more information.
Used at both the Royal Columbian and Vancouver General Hospitals in Vancouver, British Columbia this card has been around in various iterations for over 5 years.
This a word document. Feel free to change it/develop other questions as you see fit.
Do you want to really know how well you do?
Get someone else watching you to fill it out. Avoid your own ‘confidence bias’. Avoid multi-tasking during airway management.
How do you change your system?
Collect your data. If you are collecting patient identifiers make sure you have authorization for your Quality Improvement Initiative through your hospital’s administrative process.
Form an airway committee (we have EM, ICU, Anesth, RT, RN, Admin reps)
Look at data.
Change a system.
The Blue Card
REFERENCES:
- https://journals.lww.com/anesthesia-analgesia/fulltext/2015/11000/The_First_Shot_Is_Often_the_Best_Shot___First_Pass.39.aspx
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5173421/pdf/nihms809058.pdf
- https://onlinelibrary.wiley.com/doi/pdf/10.1111/1742-6723.12704
- While there is variation as to what defines mild, moderate or severe hypoxia or hypotension, these are how we have defined them. These are not ‘set in stone’. As more information becomes available, they should change for various conditions (e.g. traumatic brain injury may benefit from SBP>110mmHg).
If you want to compare results with others, it’s important to use the same definitions.
GOOD READS:
https://link.springer.com/article/10.1007%2Fs12630-017-0834-z
https://onlinelibrary-wiley-com.ezproxy.library.ubc.ca/doi/epdf/10.1111/acem.13271
https://onlinelibrary.wiley.com/doi/epdf/10.1111/anae.13163
https://academic.oup.com/bja/article/117/suppl_1/i60/1744126
- EMCrit – How Do You Know You Are Actually Good at Airway Management by Laura Duggan - September 22, 2018
- EMCrit – Wanted Dead or Alive, Your FONA Experiences - April 28, 2018
I think this great. As an emerge resident rotating through critical care, I often find it difficult to keep track of my intubation success, what methods I used to intubate, first past success rate, etc. This card is something that I will consider keeping with me, or at least will now be a lot more mindful of my intubations.
Thanks for sharing.