2017-18 HSC Section 3 Green Book

Journal of Intensive Care Medicine

clinical context, preexisting patient characteristics, operator experience, equipment availability, urgency, and human fac- tors. 24,25 Most of the available knowledge pertinent to ESA is derived from studies of patients in prehospital and emergency department (ED) contexts, with only limited data in hospita- lized critically ill patients in ICUs or other inpatient units. Our focused case reviews and observations of patients undergoing ESA performed by our difficult airway manage- ment team (DAMT) prompted us to review our institutional experience with ESA. The primary goal of this investigation was to examine the frequency, clinical circumstances, methods, complications, and outcomes of patients undergoing ESA and so inform us of potential opportunities to enhance patient safety and improve outcomes of critically ill patients with difficult or challenging airways. This study was approved by the Quality Improvement (QI) Review Committee at the University of Pittsburgh Medical Center (UPMC) Presbyterian Hospital and was exempt from institutional review board review and approval. The UPMC Presbyterian Hospital is a major academic adult medical–sur- gical referral and level 1 trauma center. Pediatric, obstetrical, and gynecological patients are cared for at other UPMC hospitals. Difficult Airway Management Team Organization and Equipment In September 2005, a DAMT was established in our institution as an adjunctive component to our rapid response system (RRS). Our RRS was established as an intensivist-led model that includes a critical care medicine (CCM) attending and CCM fellow responding to all rapid response team (RRT) acti- vations throughout the institution. All emergency airway man- agement events occurring in the context of RRT activation and in our ICUs are supervised or performed by attending ICU physicians. The DAMT was conceived and designed to provide additional airway expertise and equipment for situations in which airway managers encountered or anticipated encounter- ing difficult or challenging airways in the ICUs or other hos- pital locations. From September 2005 through July of 2008, the DAMT was loosely configured and was activated at the discre- tion of the attending physician. In July 2008, concerted efforts to improve organization, equipment, communication, and out- comes were initiated as a continuous QI project emerging out of focused DAMT case reviews. Quality improvement inter- ventions were sequentially introduced including the addition of an electronic health record alert for patients identified as a DA (2008), addition of a portable video laryngoscope (GlideScope Ranger; 2009), the development and dissemination of specific DAMT activation criteria (2010), DA wristband alerts (2011), DA safe extubation protocol (2011), preformatted DAMT note Methods Quality Improvement Project Approval

(2011), and endotracheal tube sticker alerts (2012). Several ICUs subsequently purchased GlideScope AVL devices (2012) independent of dedicated DAMT equipment, making video laryngoscopes readily available to all ICUs. The DAMT activation criteria were subsequently revised following an in- depth review of team experience (2014). The DAMT is constituted as a multidisciplinary group of attending physicians in CCM, anesthesiology, and trauma/ acute care surgery and are available in hospital 24/7. As an academic institution, physicians in training from each speci- alty participated in or observed airway events as circum- stances permitted. During the time frame of the study cohort, surgical residents and CCM fellows received no for- malized training in ESA. For every DAMT alert, specialized airway equipment housed in designated ICUs is transported to the site of the event by ICU nursing personnel in a backpack that currently includes a GlideScope Ranger, sterile surgical airway kit, disposable Fastrach laryngeal mask airways (LMAs), AirTraq optical laryngoscope, lighted stylette, Cook ENK oxygen flow modulator set with 6.0F needle, multiple endotracheal tubes (ETTs) including inner diameter (ID) sizes 5.0 and 6.0, and several extra-long tracheostomy (TRACH) tubes. In addi- tion to scalpel blades, the surgical airway kit includes iris scissors (1), Trousseau dilator (1), Weitlaner retractor (1), Senn retractors (2), and curved mosquito clamps (2). Standard intubation kits are available in all ICUs and are routinely brought to all RRT calls. Fiber-optic bronchoscopes are immediately available in all ICUs. Written DAMT activation criteria were established by consensus agreement among DAMT leadership and were widely distributed and in effect by July 2010. Once activated through our hospital emergency operator, DAMT physicians immediately respond to the location of the airway event where the CCM attending physician serves as the team leader, the anesthesiologist as the rescue airway manager, with the trauma/acute care surgeon standing by to perform an ESA when necessary. Control of the airway is relinquished to the anesthesiologist upon arrival. The final decision to perform an ESA is that of the attending surgeon in collaboration with other team members. In our institution, the preferred ESA method is an open CRIC performed as a skin incision followed by inci- sion and dilation of the cricothyroid membrane with subse- quent advancement of a small cuffed ETT (typically 6 mm ID) into the trachea. Patient Population Using our hospital operator database to identify cases, we retro- spectively reviewed the medical records of all consecutive patients in whom the DAMT was activated from January 2008 through December 2012. From this cohort, we sought to identify patients who underwent ESA defined as any surgical airway event in patients with respiratory distress who were judged to require immediate control of the airway and culmi- nated in the performance of an ESA (CRIC or TRACH).

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