Team Based System Safety Clinical Introduction For Physicians Respiratory Therapists Nurses Your Hospitals LOGO HERE EMA Safety Leadership Group 5000 US Hospitals All have Airway Vulnerabilities ID: 525157
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Slide1
Safer AirwayTeam Based System Safety
Clinical Introduction For Physicians, Respiratory Therapists, Nurses
Your Hospital’s LOGO HERE
EMA Safety Leadership GroupSlide2
5,000 US Hospitals
All have Airway VulnerabilitiesSlide3
Airway Management - High Risk(Intubation & Unplanned Extubation)
ED/ICU Settings
5- 20% Airways “Difficult
” 1-2% Airways “Fail”
Death, brain damage 40-60x (OR)Slide4
Devastating Injuries to patients, families (and staff)Settlements
as high as $15 Million Slide5
3 Attempts or sustained
saturation below 90%
Failed Airway DefinitionSlide6
Higher associated Adverse Events for multiple passes
Aim for 1st Pass Success
# Attempts to pass ET Tube
Associated
Adverse Event Rate
1
14%
2
47%
3
64%
4
71%
Sakles
-
Acad
Emerg
Med. 2013 Jan;20(1):71-8.Slide7
Lack of protocol (Team Standard)
Lack of planning or preparation for possible intubation failure
Lack of “Plan B and C” or failure to move on to
it
Lack
of
equipment availability, use or training
Approach (“Awake”
vs
RSI
vs
other)
T
eamwork
/
communication
Areas of Airway FailureSlide8
What is Safer Airway?
Team-based
System Safety for Airway Management
Physicians, Nurses, Respiratory Therapists, TechsSlide9
Safer Airway = “Team Airway”
Everyone on same pageGreater standardization of safeguardsSystem Approach
Not relying on HOPEBeyond individual skillaSlide10
4 Key ComponentsSlide11
Failed Airway Pathway(Protocol)Slide12
Other Airway Protocols
? Operational for ED/ICU
ASA tool – Not adopted in ED/ICU
Cannot “awaken patient” if failure
Useful teaching model but maybe too complex to operationalize Slide13
Failed Airway Pathway“Operational
”
Simple ABC Approach
Universal (Any Department)
Effective
Team Based
Precedence
(Adopted/Modified from Difficult Airway Society)Slide14
A) Start with DL or VL
If that fails,
MOVE ONSlide15
B) Place a SGA
(LMA or King)
If that fails, BVM &
MOVE ONSlide16
C) Cricothyroidotomy
When needed, do early
By credentialed staff
Surgical/open is bestSlide17
Equipment(Unified Cart & Video Laryngoscope)Slide18
Unified Airway Cart & Video Laryngoscope
Essential equipment
Include VideoscopeMobile
Arrangement Reinforces the FAPWorkstation & Resource
EVERY
IntubationSlide19
Adjuncts Drawer (Top)
Items to support intubationSlide20
Plan A DrawerBasic DL or VL Supplies
Blades
Tubes
StyletsLubeBackup VL scopeSlide21
Plan “B” Drawer“B”ackup/Rescue
Intubating LMAs
King Airways
3 sizes eachSyringes for inflation
Pressure GaugeSlide22
Plan C DrawerCricothyrotomy
Disposable & OR Cric. sets
Additional clampsNeedle Jet Ventilation (Peds
- ED Cart only) Slide23
Resource Guide on Top(Under Development)
Quick Team Reference Guide
Will list:Failed Airway PathwayPositioning
SGA useETT conversionDelayed Sequence Intubation
Awake IntubationsSlide24
Supraglottic Airways (SGA)
Laryngeal Mask Airway (LMA)
King Airway
“Back up” or Rescue
Airway
Use quickly if intubation fails
Simple and blindly inserted
Work >90% time
T
wo typesSlide25
New LMA (Advantages)
Ambu AuraGain
2rd
Gen LMA – Allows h
igher
v
entilation
p
ressures
Can
Intubate
through this LMA with a regular ETT
Gastric
tube (16fr) access
Inexpensive
- $11/eachSlide26
LMA Preparation
Anticipate need
Preparation takes time (Deflation & Lubrication)
Open & Prepare if potential difficult airway or desaturationSlide27
Lubricate Back
Fully Deflate Cuff with syringe
Lubricate
back Cuff and distal end of tubeSlide28
LMA Insertion
Head elevated in “Sniffing Position”Follow the hard then soft palate
Press against POSTERIOR pharyngeal w
all in a circular motion Slide29
LMA Insertion
Continue until resistance (may need to gently rock side to side)
Inflate until seal obtained (< 60 cc/H2O)
Secure with TapeSlide30
Long acting paralytics and DEEP sedation needed (will stimulate gag reflex if awake)
Can ventilate just like ET TubePlace OG Tube through port to decompress stomachHave Anesthesia/ED convert to ET tube ASAP
Can intubate directly through the ET Tube
Flexible Videoscope guidance recommendedPost LMA InsertionSlide31
King Airway
May be easier to place Good 1st Airway for codes
Can use if LMA not fitting
Gastric Tube Access port as wellCannot intubate directly through
K
ing Airway
(must use Bougie or Aintree catheter)
Can also pass the Bougie above the King into the glottisSlide32
King Airway
2 balloons seal off the airway Small balloon in the esophagusLarger balloon behind tongue
Air enters glottis between 2 sealed balloonsSlide33
King Airway Insertion
Deflate, Lubricate tipHead elevated in “sniffing” or neutral position
Enter at corner at 90-45 degrees and rotate to midline once in post pharynxSlide34
King Airway Insertion
Once midline, advance until connector at teethInflate to < 60 cc/H20
May need to slowly pull back until ventilation achievedSlide35
Cuff Pressures
Important for ETT and SGAPressure Gauge on cart
LMA or King should be inflated to less than 60 (cm/h20)Slide36
Cricothyrotomy*
Prompt use if SGA Fails. Don’t wait for arrest
Simple open technique is best “Scalpel ,Finger, Bougie, 6.0 Tube”
Percutaneous technique. - ?40% failure ratesBest Practice – Mark the membrane prior to starting intubation if possible difficult airway
* By qualified personnel onlySlide37
Critical Practice Checklist Slide38
Airway ChecklistBeta - Helping w/ Development & Assessment
Hardwired Critical
Practices
Preparation
Performance
ProtectionSlide39
Front Page(Reinforce Critical Practices & QA)Slide40
Back Page ReferencesSlide41
Critical Team Practices Slide42
Positioning – Adults
“Ear
to sternal
notch”Elevate occiput 3-4 inchesFace
p
arallel to ceiling
Aligns airway opening increases chances of success (Both DL & VL)
3-4 inchesSlide43
Ear to Sternal NotchSlide44
Obese Positioning - RAMP
RAMP methodElevate head 30-45 degreesEAR to Sternal Notch
Face parallel to ceilingCan use blankets or Bed Technique
NO
YESSlide45
Bed Technique - RAMP(Obese Patients)
1
2
3
4
Credit: Mark Brady PA-CSlide46
Pediatric Positioning
Shoulder - Infants under 2 months
Older 2 months = neutral position
Ear to Sternal Notch Slide47
Dual PreOxygenation“
No DeSat” or “Apneic Oxygenation”
3 min or 8 breaths
KEEP NC in place at 15LPM during intubation
May add
several minutes of SAFE apnea time
Nasal Cannula at > 15 LPM
AND
NRB or BVM open O2Slide48
Long Acting Paralytics(Vecuronium or Rocuronium)
May be a better option than succinylcholine
Fewer side effectsLong term paralysis needed if becomes a failed airway and LMA/king or
cric. neededAllows more time for post intubation sedation
Note: Dose of Rocuronium is 1.2mg/kg (not 0.6) Slide49
Post - Intubation
Immediately place on continuous Waveform CO2 monitor (Standard of Care in Europe, EMS, many ICUs)
ABG soon – 15 min
OG tube -> CXRElevate Head of Bed 30-450Slide50
If Difficult Airway Discovered “BUC”
Bracelet on Patient
Update Chart
(Enter into EHR dx & Warning)Communicate on signoff & with patient/familySlide51
Preventing Unplanned Extubation (UE)
High RISK InjuryUp to & 7% ICU patientsBest Practices
Tube securing deviceAdequate Sedation
(higher RASS in ED, Transport, procedures)Restraints if neededProtocol for extubation
Tracking and reporting eventsSlide52
Team TrainingSlide53
Team Training
Standardized approach (ACLS model)Physicians, RN, RRT (Same Page)Failed Airway Pathway (Protocol)
EquipmentCritical Practices
Teamwork Slide54
Teamwork Practices
Physician shares airway assessment & strategy (Plan ABC)
Team members speak up Team members help with next steps
Team gives feedback for strengthening system (Debrief)Slide55
Example “
This patient is moderate risk, we will use a 8.0 ETT with a #4 Glidescope blade. Let’s have the Bougie and a #4 LMA ready on the cart. We will do a surgical cric if needed
” Sharing Assessment & Strategy
(Plan ABC)Slide56
Acknowledgements
EMA Safety Leadership GroupJon D’Souza, MD Marty Brown, MD
Chris Beach, MD (Northwestern)Reuben Strayer, MD
Tim Cook, MD (DAS)Haru Okuda, MD (Dir, Simulation VA)
Ken Rothfield, MD (Anesthesia)
Art Kanowitz, MD (Dir
.
EMS Colorado)
Difficult Airway
Society
Patient Safety
Movement Foundation
Emergency Medicine Patient Safety Foundation
ACEP QIPS
leadership
Heather Wright, RRT
YOUR HOSPTIAL CREDITSSlide57
Leading the Way in Safety
YOUR HOSPITAL LOGO HERE