Improving Critical Care Intubation at a Community Hospital: A Prospective Quality Improvement Study

Improving Critical Care Intubation at a Community Hospital:

A Prospective Quality Improvement Project

Dr. Samuel Kohen

Comox, BC

BC Quality Forum March 2, 2017 – 14:30 to 15:30

Breakout Session – C4

St Joseph’s General Hospital

Disclosure: Emergent Intubation Experience

• Overall risk of complications is high (39%)

– 19% Severe hypoxemia (SaO2 < 80%)

– 10% Severe hypotension (sBP < 70 mmHg)

– 7% Esophageal intubation

– 6% Frank aspiration

• Associated with high mortality

– ICU 15%, Hosp 29%

Critical Care Intubation 2014 Audit

• Documentation

– Data spread between MD, RN, RT notes

– 25% did not have a MD note at all

• Procedural Efficiency

– Time from meds to CXR = 43 min

• Procedural Safety

– Life threatening complication rate = 35%

Procedural Documentation

Documentation Requirement Points

Was there a signed physician intubation note? 1

Was the indication for intubation documented? 1

Were the drugs used in the intubation listed? 1

Were the airway tools used listed? 1

Was the airway difficulty documented? 1

Was ETT placement clinically confirmed with ETCO2? 1

Were complications listed? 1

Total /7

Objective 1: Improve CCI documentation

Procedural Efficiency

Objective 2: Reduce procedural time

Life Threatening Complications

Complication Definition

Severe Hypoxemia New SpO2 < 80%

Severe Hypotension New sBP < 70 mmHg

Esophageal Intubation ETT mistakenly placed in the esophagus

Frank aspiration New vomitus in airway that requires suctioning

Cardiac Arrest Procedural cardiac arrest

Objective 3: Reduce life threatening complications

Documentation Time Objective 4: No increase in documentation time.

Study Methodology

2014 2015

Exclusion criteria:

Inclusion criteria:

INTUBATION CHALLENGES

EQUIPMENT

PROVIDERS POLICY

No Assessment of Performance

No CME

RT

RN

MD

Ward

ICU: Small with Awkward Layout

PROCESSES LOCATION

No review or evaluation protocol

“Intubation Kit”

No GL in ICU No workflow algorithm

Medication cabinet

Insufficient Bedside Tables

Root Cause Analysis and Proposed Solutions

No ICU Intubation Policy

Open ICU

Protocolization

RSI Kit

RN/MD Education and Simulation

Airway Kit

Encourage adherence to standard protocol Continuous CCIs review

Intervention 1: Standard Protocol and Worksheet

Intervention 2: Airway and Medication Boxes

Standard Adult RSI Kit

Standard RSI Kit Standard Adult Airway Kit

Intervention 3: Multidisciplinary Simulation Course

Results: Patient Demographics

CL 5.3

6.5

2

3

4

5

6

7

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26

Do

cum

en

tati

on

sco

re (

/7)

CCI #

17% improvement in documentation (Significant)

CL 5.3

6.5

2

3

4

5

6

7

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26

Do

cum

en

tati

on

sco

re (

/7)

CCI #

Critical Care Intubation Documentation (C-chart)

Results: Documentation

1

3

UCL 116.5

54.9

CL 43.1

26.8

0.0

20.0

40.0

60.0

80.0

100.0

120.0

140.0

1 2 3 4 5 6 7 8 10 11 12 13 17 18 20 3 4 5 6 8 9 10 13 14 15 18 19 20 21 22 23 24 26

Tim

e f

rom

Me

dic

atio

n A

dm

inis

tati

on

to

CX

R (

min

)

CCI #

38% improvement in process efficiency (Significant)

Results: Procedural Efficiency

57% relative reduction in life threatening CCI complications (Not significant)

35%

15%

0%

5%

10%

15%

20%

25%

30%

35%

40%

2014 2015

Results: Complications

Documentation Time

Successes and Challenges

Future Directions:

Thank you

Contact Information: [email protected]

Questions

Contact Information: [email protected]