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Abstract
Aims and Objectives Current evidence suggests advanced airway management in the Emergency Department (ED) incurs an adverse event rate approaching 20%. Initiatives to improve safety have been studied over the last decade and several are now recommended in national specialty guidance. There has been little study on the implementation or impact of these measures within routine NHS settings. We sought to evaluate these issues within a large major trauma and neurosciences centre in North West England.
Method and Design A prospective 5-year service evaluation and quality improvement programme, between 2017 and 2022. PDSA cycles included revised local guidelines, airway trolley redesign, video laryngoscopes, prefilled medications in room temperature airway drug boxes and regular multidisciplinary simulation training. Our aims were to evaluate first pass success, complication rates and temporal changes in practice. Intubation data was collected in real time by clinicians via novel ‘endotracheal intubation’ digital record forms, with validation and additional case screening by the study team. The project was approved by local R&I.
Results and Conclusion We collated data on 2034 intubation episodes, of which 949 were in the ED. First pass success rate rose from a baseline of 81.5% to a consistent level at >90%. We saw a corresponding drop in the periprocedural complication rate of more than 50%, from an average of 15.6% over the first 21 months to 5.9% during the latter equivalent study period. Use of VL increased during the study period compared to direct laryngoscopy and primary induction agent also changed over time, with decreasing use of thiopentone and rising use of ketamine (figure 1). Documentation of consultant presence at the bedside increased, rising to consistently >60%.
Showing the primary induction agent used (as percentage of all inductions) in each yearly quarter for intubations in the emergency department
Our real-world study links quality improvement in advanced airway management to improvements in both first pass success and safety. We confirm sustained changes in departmental practice over time and highlight improvement cycles which could be replicated.