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Airway Safety Webinar June 14th, 2017 Ariana Longley, MPH, Vice President, PSMF Guest Speaker: Dr. Arthur Kanowitz, MD, FACEP Patient Safety Movement Foundation Presents
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Airway Safety Webinar PresentationL - Patient Safety Movement · • 10 Minutes: Introduction to Patient Safety Movement Foundation and Actionable Patient Safety Solutions (APSS)

Jun 01, 2020

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Page 1: Airway Safety Webinar PresentationL - Patient Safety Movement · • 10 Minutes: Introduction to Patient Safety Movement Foundation and Actionable Patient Safety Solutions (APSS)

Airway Safety WebinarJune14th,2017

ArianaLongley,MPH,VicePresident,PSMFGuestSpeaker:Dr.ArthurKanowitz,MD,FACEP

PatientSafetyMovementFoundationPresents

Page 2: Airway Safety Webinar PresentationL - Patient Safety Movement · • 10 Minutes: Introduction to Patient Safety Movement Foundation and Actionable Patient Safety Solutions (APSS)

Agenda

• 10Minutes:IntroductiontoPatientSafetyMovementFoundationandActionablePatientSafetySolutions(APSS)

• 35Minutes:PatientSafetyMovementPartnerPresentation– Dr.ArthurKanowitz,MD,FACEP

• 15Minutes:Q&A

Page 3: Airway Safety Webinar PresentationL - Patient Safety Movement · • 10 Minutes: Introduction to Patient Safety Movement Foundation and Actionable Patient Safety Solutions (APSS)

OurMissionZERO PreventablePatientDeaths

by2020(0X2020)

Page 4: Airway Safety Webinar PresentationL - Patient Safety Movement · • 10 Minutes: Introduction to Patient Safety Movement Foundation and Actionable Patient Safety Solutions (APSS)

WeStrivetoFosterNewEffortsandBuildOnExistingPatientSafetyProgramsThrough

Commitmentsto

ZEROAFreshApproachtoanOldProblemWithoutReinventingtheWheel

Page 5: Airway Safety Webinar PresentationL - Patient Safety Movement · • 10 Minutes: Introduction to Patient Safety Movement Foundation and Actionable Patient Safety Solutions (APSS)

Who Can Take Action?• Hospitals&HealthcareOrganizations

– MakeaCommitment

• CommittedPartners– SigntheCommitmenttoActionletter

• HealthcareTechnologyCompanies– SigntheOpenDataPledge

• Patient&FamilyAdvocates– SharetheirPatientStory,UtilizeResources

• PolicyMakers– IncreaseawarenessandpromotepatientsafetyLegislation

Page 6: Airway Safety Webinar PresentationL - Patient Safety Movement · • 10 Minutes: Introduction to Patient Safety Movement Foundation and Actionable Patient Safety Solutions (APSS)

Actionable Patient Safety Solutions (APSS)

1.CultureofSafety

Ø Downloadatpatientsafetymovement.org

2.Healthcare-associatedInfections

(HAIs)

5.Anemia+Transfusions

8.AirwaySafety

3.MedicationErrors

9.EarlyDetection&TreatmentofSepsis

6.Hand-offCommunications

11.OptimizingObstetricSafety

10.OptimalResuscitation

7.NeonatalSafety

4.FailuretoRescue:MonitoringforOpioidInducedResp.Dep.

13.MentalHealth

12.VenousThromboembolism

(VTE)

Page 7: Airway Safety Webinar PresentationL - Patient Safety Movement · • 10 Minutes: Introduction to Patient Safety Movement Foundation and Actionable Patient Safety Solutions (APSS)

In order to reach ZERO our goal for 2017:

Page 8: Airway Safety Webinar PresentationL - Patient Safety Movement · • 10 Minutes: Introduction to Patient Safety Movement Foundation and Actionable Patient Safety Solutions (APSS)

8

Dr.ArthurKanowitz,MD,FACEP

• MedicalDirector(Retired),StateofColorado,EmergencyMedicalandTraumaServices

• Founder,Chairman,CMO,Securisyn Medical• Member,PatientSafetyMovementFoundation,Airway

SafetyWorkgroup

Page 9: Airway Safety Webinar PresentationL - Patient Safety Movement · • 10 Minutes: Introduction to Patient Safety Movement Foundation and Actionable Patient Safety Solutions (APSS)

9

WhyisAirwaySafetysoImportant?

Page 10: Airway Safety Webinar PresentationL - Patient Safety Movement · • 10 Minutes: Introduction to Patient Safety Movement Foundation and Actionable Patient Safety Solutions (APSS)

10

Andrew“Drew”Hughes

1999-2013

Page 11: Airway Safety Webinar PresentationL - Patient Safety Movement · • 10 Minutes: Introduction to Patient Safety Movement Foundation and Actionable Patient Safety Solutions (APSS)

11

DrewDiedFromthePerfectStorm

of

AirwaySafetyEvents

UnplannedExtubation

FailuretoIntubate

FailuretoRecognizeaMalpositioned Tube

Page 12: Airway Safety Webinar PresentationL - Patient Safety Movement · • 10 Minutes: Introduction to Patient Safety Movement Foundation and Actionable Patient Safety Solutions (APSS)

12

DrewDiedA

PreventableDeath

Page 13: Airway Safety Webinar PresentationL - Patient Safety Movement · • 10 Minutes: Introduction to Patient Safety Movement Foundation and Actionable Patient Safety Solutions (APSS)

ComplicationsofAirwayManagement

13

TubeMalposition

PressureIschemia

SafetyEvents

Aspiration

FailedIntubation

UnplannedExtubation

SoreThroat

VocalCordParalysis

Pneumonia

CollapsedLung

SevereBrainInjury

DEATH

Complications

Page 14: Airway Safety Webinar PresentationL - Patient Safety Movement · • 10 Minutes: Introduction to Patient Safety Movement Foundation and Actionable Patient Safety Solutions (APSS)

ComplicationsofAirwayManagement

14

TubeMalposition

PressureIschemia

SafetyEvents

Aspiration

FailedIntubation SoreThroat

VocalCordParalysis

Pneumonia

CollapsedLung

SevereBrainInjury

DEATH

Complications

UnplannedExtubation

Page 15: Airway Safety Webinar PresentationL - Patient Safety Movement · • 10 Minutes: Introduction to Patient Safety Movement Foundation and Actionable Patient Safety Solutions (APSS)

UnplannedExtubationACommonandCostlySafetyEvent

ComplicationsofAirwayManagement

Page 16: Airway Safety Webinar PresentationL - Patient Safety Movement · • 10 Minutes: Introduction to Patient Safety Movement Foundation and Actionable Patient Safety Solutions (APSS)

Yearly

70,000Incidencescausing

12,000PreventableDeathsand

$4BillioninHealthcareCosts

UnplannedExtubation

Page 17: Airway Safety Webinar PresentationL - Patient Safety Movement · • 10 Minutes: Introduction to Patient Safety Movement Foundation and Actionable Patient Safety Solutions (APSS)

UnplannedExtubation– CommonandCostly

LucasdaSilva,etal.UnplannedEndotrachealExtubations intheIntensiveCareUnit.Anesth Analg 2012;114:1003–14

Common

AnesthesiaandAnalgesia2012114:1003-1014

ReviewofWorldwideLiterature50Studies

7.3%UnplannedExtubation Rate

Last5years6.4%(2.1%-18.9%)

Page 18: Airway Safety Webinar PresentationL - Patient Safety Movement · • 10 Minutes: Introduction to Patient Safety Movement Foundation and Actionable Patient Safety Solutions (APSS)

73,000incidencesofUEyearlyintheU.S.

*Carsonetal.TheChangingEpidemiologyofMechanicalVentilation:APopulation- BasedStudy.JIntensiveCareMed.2006Feb; 21(3):173-182.

>1,000,000*MechanicallyVentilated

ICUPatients

7.3%=73,000UnplannedExtubation

UnplannedExtubation

Common

Carsonetal.TheChangingEpidemiologyofMechanicalVentilation:APopulation- BasedStudy.JIntensiveCareMed.2006Feb;21(3):173-182.

Page 19: Airway Safety Webinar PresentationL - Patient Safety Movement · • 10 Minutes: Introduction to Patient Safety Movement Foundation and Actionable Patient Safety Solutions (APSS)

CostlyPatientComplications

Pneumonia

Severe BrainInjury

Death

UnplannedExtubation

VocalCord Paralysis

Page 20: Airway Safety Webinar PresentationL - Patient Safety Movement · • 10 Minutes: Introduction to Patient Safety Movement Foundation and Actionable Patient Safety Solutions (APSS)

CostlyIncreased LOS

DeLassence A,Alberti C.Azoulay E,Miere E.ChevalC,etal.Impactofunplannedextubation andreintubationafterweaningonnosocomialpneumoniariskinintensivecareunit:aprospectivemulticenterstudy.Anesthesiology.2002Jul;97(1):148-56

UnplannedExtubation

Page 21: Airway Safety Webinar PresentationL - Patient Safety Movement · • 10 Minutes: Introduction to Patient Safety Movement Foundation and Actionable Patient Safety Solutions (APSS)

CostlyTotalIncreasedCostofHospitalStay

AverageCostofICUStay(VentilatedPatientswithUE)=$116,070

AverageCostofICUStay(VentilatedPatientswithoutUE)=$59,206________________________________________________________________________

AverageCostofComplicationsfromUnplannedExtubation=$56,864/pt

Needham,etal.Theimportanceofunderstandingthecostsofcriticalcareandmechanicalventilation.Crit CareMed2005Jun33(6)1266-71.

UnplannedExtubation

Dasta,etal.DailyCostofanICUDay.Crit CareMed2005June33(6)1266-71

253USHospitals.51,000pts.

Page 22: Airway Safety Webinar PresentationL - Patient Safety Movement · • 10 Minutes: Introduction to Patient Safety Movement Foundation and Actionable Patient Safety Solutions (APSS)

CostlyTotalIncreasedCostofHospitalStay

AverageCostofICUStay(VentilatedPatientswithUE)=$116,070

AverageCostofICUStay(VentilatedPatientswithoutUE)=$59,206________________________________________________________________________

AverageCostofComplicationsfromUnplannedExtubation=$56,864/pt

$4,151,072,000

Needham,etal.Theimportanceofunderstandingthecostsofcriticalcareandmechanicalventilation.Crit CareMed2005Jun33(6)1266-71.

UnplannedExtubation

Dasta,etal.DailyCostofanICUDay.Crit CareMed2005June33(6)1266-71

253USHospitals.51,000pts.

Page 23: Airway Safety Webinar PresentationL - Patient Safety Movement · • 10 Minutes: Introduction to Patient Safety Movement Foundation and Actionable Patient Safety Solutions (APSS)

CostlyTotalIncreasedCostofHospitalStay

AverageCostofICUStay(VentilatedPatientswithUE)=$116,070

AverageCostofICUStay(VentilatedPatientswithoutUE)=$59,206________________________________________________________________________

AverageCostofComplicationsfromUnplannedExtubation=$56,864/pt

AveHospital(4500MVpts/yr)

Every1%ImprovementinUERate=$2.5M

Needham,etal.Theimportanceofunderstandingthecostsofcriticalcareandmechanicalventilation.Crit CareMed2005Jun33(6)1266-71.

UnplannedExtubation

Dasta,etal.DailyCostofanICUDay.Crit CareMed2005June33(6)1266-71

253USHospitals.51,000pts.

Page 24: Airway Safety Webinar PresentationL - Patient Safety Movement · • 10 Minutes: Introduction to Patient Safety Movement Foundation and Actionable Patient Safety Solutions (APSS)

UnplannedExtubation

CostlyMortality

DeGroot RI,etal.Riskfactorsandoutcomesafterunplannedextubation intheICU:Acasecontrolstudy.CriticalCare,2011,15:R19

12,000DeathsYearly

intheU.S.*19%MortalityRate

Page 25: Airway Safety Webinar PresentationL - Patient Safety Movement · • 10 Minutes: Introduction to Patient Safety Movement Foundation and Actionable Patient Safety Solutions (APSS)

UnplannedExtubationis…

CommonandCostly

UnplannedExtubation

Page 26: Airway Safety Webinar PresentationL - Patient Safety Movement · • 10 Minutes: Introduction to Patient Safety Movement Foundation and Actionable Patient Safety Solutions (APSS)

forcesappliedtoremovetheairwaydevice

forcesappliedtorestraintheairwaydevice

EXCEEDS

UnplannedExtubation

TheCauseIs

SimplePhysics

Page 27: Airway Safety Webinar PresentationL - Patient Safety Movement · • 10 Minutes: Introduction to Patient Safety Movement Foundation and Actionable Patient Safety Solutions (APSS)

CurrentManagement

AdhesiveTape

HollisterAnchorFast

Laerdal ThomasTubeHolder

Page 28: Airway Safety Webinar PresentationL - Patient Safety Movement · • 10 Minutes: Introduction to Patient Safety Movement Foundation and Actionable Patient Safety Solutions (APSS)

CurrentManagement

RateofUnplannedExtubationRemains

Unacceptable

Page 29: Airway Safety Webinar PresentationL - Patient Safety Movement · • 10 Minutes: Introduction to Patient Safety Movement Foundation and Actionable Patient Safety Solutions (APSS)

7.3%Unplanned Extubation

Rate

Is likelyjust the

tip of the Iceberg

HowDoWeGetTo

ZEROPREVENTABLEDEATHS

FromUnplannedExtubation?

GETTINGTOZERO

Page 30: Airway Safety Webinar PresentationL - Patient Safety Movement · • 10 Minutes: Introduction to Patient Safety Movement Foundation and Actionable Patient Safety Solutions (APSS)

7.3%Unplanned Extubation

Rate

Is likelyjust the

tip of the Iceberg

Unplanned Extubation

WhatwillittaketogettoZEROPREVENTABLEDEATHS?

• UniversalTracking

• ApplicationofAPSS

• SharingBestPractices

• New“Disruptive”Technology

Page 31: Airway Safety Webinar PresentationL - Patient Safety Movement · • 10 Minutes: Introduction to Patient Safety Movement Foundation and Actionable Patient Safety Solutions (APSS)

7.3%Unplanned Extubation

Rate

Is likelyjust the

tip of the Iceberg

“IfYouCan’tMeasureIt,YouCan’tImproveIt”.

-PeterDrucker

GETTINGTOZERO

Page 32: Airway Safety Webinar PresentationL - Patient Safety Movement · • 10 Minutes: Introduction to Patient Safety Movement Foundation and Actionable Patient Safety Solutions (APSS)

7.3%Unplanned Extubation

Rate

Is likelyjust the

tip of the Iceberg

UnplannedExtubationisasignificant

PatientSafetyIssue.

Yet,mosthospitalsdon’ttrack

unplannedextubation…

UnplannedExtubation

Page 33: Airway Safety Webinar PresentationL - Patient Safety Movement · • 10 Minutes: Introduction to Patient Safety Movement Foundation and Actionable Patient Safety Solutions (APSS)

…partiallybecausemostofthemajorEMRs

donotincludeUEasadatafield.

7.3%Unplanned Extubation

Rate

Is likelyjust the

tip of the Iceberg

UnplannedExtubation

Page 34: Airway Safety Webinar PresentationL - Patient Safety Movement · • 10 Minutes: Introduction to Patient Safety Movement Foundation and Actionable Patient Safety Solutions (APSS)

QualityMetrics

CurrentlyConsideringAdding

UnplannedExtubation

7.3%Unplanned Extubation

Rate

Is likelyjust the

tip of the Iceberg

UnplannedExtubation

Page 35: Airway Safety Webinar PresentationL - Patient Safety Movement · • 10 Minutes: Introduction to Patient Safety Movement Foundation and Actionable Patient Safety Solutions (APSS)

DOWNLOADUnplannedExtubation

DataBrochure

www.patientsafetymovement.org/

Clickonthefollowinglinks:1. ChallengesandSolutions2. PatientSafetyNewsletter

Scrollto:WebinarArchiveAirwaySafety

AirwaySafetyIntroCard

Page 36: Airway Safety Webinar PresentationL - Patient Safety Movement · • 10 Minutes: Introduction to Patient Safety Movement Foundation and Actionable Patient Safety Solutions (APSS)
Page 37: Airway Safety Webinar PresentationL - Patient Safety Movement · • 10 Minutes: Introduction to Patient Safety Movement Foundation and Actionable Patient Safety Solutions (APSS)

NumberofUE

100patients

NumberofUE

100ventilationdays

6.4UE/100pts

6.4%(2.1%-18.9%)

0.6UE/100MVDays

0.6(0.1-3.6)

Page 38: Airway Safety Webinar PresentationL - Patient Safety Movement · • 10 Minutes: Introduction to Patient Safety Movement Foundation and Actionable Patient Safety Solutions (APSS)
Page 39: Airway Safety Webinar PresentationL - Patient Safety Movement · • 10 Minutes: Introduction to Patient Safety Movement Foundation and Actionable Patient Safety Solutions (APSS)

7.3%Unplanned Extubation

Rate

Is likelyjust the

tip of the Iceberg

Actionable Patient Safety Solutions (APSS)

AirwaySafetyAPSS#8ExecutiveSummaryChecklist

• Assembleacoremultidisciplinaryteam

• EstablishNeedforImprovement

• RequireTracking;UseDatatoImproveCare

• PoliciesandProcedures;StandardizeBestPractices,

• DevelopComprehensiveAirwayToolkit

• CollectData;Review;FindSolutions;Educate;Implement;Verify

Page 40: Airway Safety Webinar PresentationL - Patient Safety Movement · • 10 Minutes: Introduction to Patient Safety Movement Foundation and Actionable Patient Safety Solutions (APSS)

7.3%Unplanned Extubation

Rate

Is likelyjust the

tip of the Iceberg

Actionable Patient Safety Solutions (APSS)

AirwaySafetyAPSS#8

• PerformanceGap• LeadershipPlan• PracticePlan• TechnologyPlan• Metrics

• SaferAirwayEssentialComponents• FailedAirwayProtocol• AirwayEquipment• CriticalPractices• TeamTraining

Page 41: Airway Safety Webinar PresentationL - Patient Safety Movement · • 10 Minutes: Introduction to Patient Safety Movement Foundation and Actionable Patient Safety Solutions (APSS)

7.3%Unplanned Extubation

Rate

Is likelyjust the

tip of the Iceberg

Unplanned Extubation

Whatwillittake

togetto

ZEROPREVENTABLEDEATHS?

Page 42: Airway Safety Webinar PresentationL - Patient Safety Movement · • 10 Minutes: Introduction to Patient Safety Movement Foundation and Actionable Patient Safety Solutions (APSS)

7.3%Unplanned Extubation

Rate

Is likelyjust the

tip of the Iceberg

Unplanned Extubation

WhatwillittaketogettoZEROPREVENTABLEDEATHS?

• UniversalTracking

• ApplicationofAPSS

• SharingBestPractices

• New“Disruptive”Technology

Page 43: Airway Safety Webinar PresentationL - Patient Safety Movement · • 10 Minutes: Introduction to Patient Safety Movement Foundation and Actionable Patient Safety Solutions (APSS)

Disruptive Technology

UniversityofColoradoBioMed EngineeringComparativeForceStudy

FiveDevices

Page 44: Airway Safety Webinar PresentationL - Patient Safety Movement · • 10 Minutes: Introduction to Patient Safety Movement Foundation and Actionable Patient Safety Solutions (APSS)

Disruptive Technology

Restraint Force(lbs)

Tape 14- 39TwillTies 19- 30Laerdal ThomasTubeHolder 18- 31HollisterAnchorFast 19- 43SolidAIRity 46- 65

Page 45: Airway Safety Webinar PresentationL - Patient Safety Movement · • 10 Minutes: Introduction to Patient Safety Movement Foundation and Actionable Patient Safety Solutions (APSS)

7.3%Unplanned Extubation

Rate

Is likelyjust the

tip of the Iceberg

UnplannedExtubation

FindOut:

Whatisyourhospital’srateofUE?

Doesyourhospital’sEMRhaveUESpecificDataFields?

Implement:

ActionablePatientSafetySolutionsAPSS#8– AirwaySafety

Page 46: Airway Safety Webinar PresentationL - Patient Safety Movement · • 10 Minutes: Introduction to Patient Safety Movement Foundation and Actionable Patient Safety Solutions (APSS)

Q & A

Page 47: Airway Safety Webinar PresentationL - Patient Safety Movement · • 10 Minutes: Introduction to Patient Safety Movement Foundation and Actionable Patient Safety Solutions (APSS)

Thank you!


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