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Impact of a targeted bundle of audit with tailored education and an intubation checklist to improve airway management in the emergency department: an integrated time series analysis
  1. Christopher Groombridge1,2,3,4,
  2. Amit Maini1,2,3,
  3. Alexander Olaussen3,
  4. Yen Kim1,3,
  5. Mark Fitzgerald1,3,4,
  6. Biswadev Mitra1,2,3,
  7. De Villiers Smit1,2,3
  1. 1 National Trauma Research Institute, Melbourne, Victoria, Australia
  2. 2 Emergency & Trauma Centre, Alfred Health, Melbourne, Victoria, Australia
  3. 3 Monash University, Melbourne, Victoria, Australia
  4. 4 Trauma Service, Alfred Hospital, Melbourne, Victoria, Australia
  1. Correspondence to Dr Christopher Groombridge, National Trauma Research Institute, Melbourne, VIC 3004, Australia; Christopher.Groombridge{at}


Background Endotracheal intubation (ETI) is a commonly performed but potentially high-risk procedure in the emergency department (ED). Requiring more than one attempt at intubation has been shown to increase adverse events and interventions improving first-attempt success rate should be identified to make ETI in the ED safer. We introduced and examined the effect of a targeted bundle of airway initiatives on first-attempt success and adverse events associated with ETI.

Methods This prospective, interventional cohort study was conducted over a 2-year period at an Australian Major Trauma Centre. An online airway registry was established at the inception of the study to collect information related to all intubations. After 6 months, we introduced a bundle of initiatives including monthly audit, monthly airway management education and an airway management checklist. A time series analysis model was used to compare standard practice (ie, first 6 months) to the postintervention period.

Results There were 526 patients, 369 in the intervention group and 157 in the preintervention comparator group. A total of 573 intubation attempts were performed. There was a significant improvement in first-attempt success rates between preintervention and postintervention groups (88.5% vs 94.6%, relative risk 1.07; 95% CI 1.00 to 1.14, p=0.014). After the introduction of the intervention the first-attempt success rate increased significantly, by 13.4% (p=0.006) in the first month, followed by a significant increase in the monthly trend (relative to the preintervention trend) of 1.71% (p<0.001). The rate of adverse events were similar preintervention and postintervention (hypoxia 8.3% vs 8.9% (p=0.81); hypotension 8.3% vs 7.0% (p=0.62); any complication 27.4% vs 23.6% (p=0.35)).

Conclusions This bundle of airway management initiatives was associated with significant improvement in the first-attempt success rate of ETI. The introduction of a regular education programme based on the audit of a dedicated airway registry, combined with a periprocedure checklist is a worthwhile ED quality improvement initiative.

  • airway
  • rsi
  • emergency department management

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  • Handling editor Ellen Weber

  • Contributors Contributor Statement: CG, AM, MF and DVS designed the study. CG, AM and AO extracted data. CG, AO, YK, MF and BM analysed the data. All authors were involved in drafting of the manuscript and critical review.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Patient consent for publication Not required.

  • Ethics approval Necessary ethics committee approval was secured for the study reported. Approval for conducting this study was received from Alfred Health research and ethics committee (Approval number 640/18).

  • Provenance and peer review Not commissioned; externally peer reviewed.