ED Quality Improvement Project. A NZ EMN-ANZEDAR Quality Improvement Initiative. Andrew Brainard ... Figure 5: All Trauma Indications (n=97). 27. 134. 97.
An ED Airway Registry is a Feasible and Useful Portion of an ED Quality Improvement Project A NZ EMN-ANZEDAR Quality Improvement Initiative Andrew Brainard, MD, MPH, FACEP, FACEM1, 2, 3, 4 Paul Sellens, MBChB1 Vanessa Thornton, MBChB, FACEM1 G Luke Larkin, MD, MSPH, FACEP1, 3, 4
Figure 3: Indications for ED Intubation
Figure 2: NZ EMN-ANZEDAR Data Collection Form
134 97
1 Counties
Manukau, Emergency Department, Middlemore Hospital 2 Australia and New Zealand Emergency Department Airway Registry 3 New Zealand Emergency Medicine Network (NZ EMN) 4 University of Auckland School of Medicine 27
Background Airway management is a core skill for emergency medicine consultants in New Zealand. Although several other emergency department (ED) airway registries report data on ED intubations throughout the world, there is only a single study describing ED intubations in Australasia. There has been no published data on how ED intubations are practiced in New Zealand. At a single large (100,000 presentations per year) ED in Auckland, New Zealand, anecdotal observations and a small airway audit indicated that there was room for improved ED airway care. An ED airway registry was developed in cooperation with the Australia and New Zealand Emergency Department Airway Registry (ANZEDAR) to collect data on all ED intubations in order to evaluate perforance.
89%
88%
90%
91%
100%
97%
92%
91% 87% 83% 78%
77% 75%
70% 62%
60% 51% 46% 45%
40%
30% 13%
15%
0%
Figure 1b: First Pass Success Rate
95% 90%
90%
87%
90%
83% 76% 75%
74%
88%
87% 83%
81%
79%
79%
73%
75%
75%
71% 65%
60%
45%
30%
15%
0%
16.0%
All Medical
All Trauma
Figure 4: All Medical Indications (n=134)
14.0%
12.4% 12.0%
11.4%
10.0%
11.0% 9.0%
8.0%
6.6% 6.0% 4.0%
2.8% 2.0%
2.1%
1.4% 0.3%
0.3%
0.0%
Methods
Figure 1a: Proportion of ED airways by ED Providers 97%
Cardiac Arrest
Following a thorough literature search of other airway registries (Fig. 1), a standardized form was modified from the ANZEDAR data collection form (Fig. 2). This included patient demographics, intubator qualifications, situational, technical, and procedural data, the number of intubation attempts, adverse events, and patient disposition. Completion of the form occurred immediately after each intubation performed in the ED. In addition to collecting data, it also provided an outline for a structured debrief, a reminder of ED airway “best practices”, and an opportunity to provide focused feedback to the resuscitation team. Data was then entered into a spreadsheet. Missing cases were identified by reviewing radiology reports, ICU admissions, ED transfers, and deaths in the department. Counts, proportions, and rates were calculated for selected variables and fed back to the ED providers as part of an ongoing quality improvement process.
Results The team leader, primary airway operator, airway assistant, and/or nursing leader were able to complete the data entry form. Completing the airway form immediately after each intubation required approximately 2minutes. Although initially cumbersome to complete, with increasing experience, the form has become a useful tool in guiding the airway debriefing and providing immediate resuscitation team feedback. There has been a steady decrease in “missed cases” from an initial rate of approximately 30% to the current rate of
