Long Elliot, Cincotta Domenic R, Grindlay Joanne, Sabato Stefano, Fauteux-Lamarre Emmanuelle, Beckerman David, Carroll Terry, Quinn Nuala
Department of Emergency Medicine, The Royal Children's Hospital, Parkville, Vic., Australia.
Murdoch Children's Research Institute, Parkville, Vic., Australia.
Paediatr Anaesth. 2017 Dec;27(12):1271-1277. doi: 10.1111/pan.13275. Epub 2017 Oct 24.
Emergency airway management is commonly associated with life-threatening hypoxia and hypotension which may be preventable.
The aim of this quality improvement study was to reduce the frequency of intubation-related hypoxia and hypotension.
This prospective quality improvement study was conducted over 4 years in the Emergency Department of The Royal Children's Hospital, Melbourne, Australia. A preintervention cohort highlighted safety gaps and was used to design study interventions, including an emergency airway algorithm, standardized airway equipment, a preintubation checklist and equipment template, endtidal carbon dioxide monitoring, postintubation team debriefing, and multidisciplinary team training. Following implementation, a postintervention cohort was used to monitor the impact of study interventions on clinical process and patient outcome. Process measures were as follows: use of a preintubation checklist, verbalization of an airway plan, adequate resuscitation prior to intubation, induction agent dose titration, use of apneic oxygenation, and use of endtidal carbon dioxide to confirm endotracheal tube position. The primary outcome measure was first pass success rate without hypoxia or hypotension. Potential harms from study interventions were monitored.
Forty-six intubations were included over one calendar year in the postintervention cohort (compared to 71 in the preintervention cohort). Overall clinical uptake of the 6 processes measures was 85%. First pass success rate without hypoxia or hypotension was 78% in the postintervention cohort compared with 49% in the preintervention cohort (absolute risk reduction: 29.0%; 95% confidence interval 12.3%-45.6%, number needed to treat: 3.5). No significant harms from study interventions were identified.
Quality improvement initiatives targeting emergency airway management may be successfully implemented in the emergency department and are associated with a reduction in adverse intubation-related events.
紧急气道管理通常与可能可预防的危及生命的缺氧和低血压相关。
这项质量改进研究的目的是降低插管相关缺氧和低血压的发生率。
这项前瞻性质量改进研究在澳大利亚墨尔本皇家儿童医院急诊科进行了4年。干预前队列突出了安全差距，并用于设计研究干预措施，包括紧急气道算法、标准化气道设备、插管前检查表和设备模板、呼气末二氧化碳监测、插管后团队汇报以及多学科团队培训。实施后，干预后队列用于监测研究干预措施对临床过程和患者结局的影响。过程指标如下：使用插管前检查表、阐述气道计划、插管前充分复苏、诱导剂剂量滴定、使用无氧通气以及使用呼气末二氧化碳确认气管导管位置。主要结局指标是首次插管成功率且无缺氧或低血压。监测研究干预措施的潜在危害。
干预后队列在一个日历年中有46例插管（干预前队列为71例）。6项过程指标的总体临床采用率为85%。干预后队列中首次插管成功率且无缺氧或低血压的比例为78%，而干预前队列为49%（绝对风险降低：29.0%；95%置信区间12.3%-45.6%，需治疗人数：3.5）。未发现研究干预措施有显著危害。
针对紧急气道管理的质量改进措施可能在急诊科成功实施，并与插管相关不良事件的减少相关。
