University of Arizona College of Medicine, Department of Emergency Medicine, Tucson, Arizona.
Virginia Commonwealth University School of Medicine, Richmond, Virginia.
West J Emerg Med. 2019 Jul;20(4):610-618. doi: 10.5811/westjem.2019.4.42343. Epub 2019 Jun 3.
Airway management in the critically ill is associated with a high prevalence of failed first attempts and adverse events which negatively impacts patient care. The purpose of this investigation is to describe an airway continuous quality improvement (CQI) program and its effect on the safety of rapid sequence intubation (RSI) in the emergency department (ED) over a 10-year period.
An airway CQI program with an ongoing airway registry was initiated in our ED on July 1, 2007 (Academic Year 1) and continued through June 30, 2017 (Academic Year 10). Data were prospectively collected on all patients intubated in the ED during this period using a structured airway data collection form. Key data points included method of intubation, drugs and devices used for intubation, operator specialty and level of training, number of intubation attempts, and adverse events. Adult patients who underwent RSI in the ED with an initial intubation attempt by emergency medicine (EM) resident were included in the analysis. The primary outcome was first pass success which was defined as successful tracheal intubation with a single laryngoscope insertion. The secondary outcome was the prevalence of adverse events associated with intubation. Educational and clinical interventions were introduced throughout the study period with the goal of optimizing these outcomes. Data were analyzed by academic year and are reported descriptively with 95% confidence intervals (CI) of the difference of means.
EM residents performed RSI on 342 adult patients during Academic Year 1 and on 445 adult patients during Academic Year 10. Over the 10-year study period, first pass success increased from 73.1% to 92.4% (difference = 19.3%, 95% CI 14.0% to 24.6%). The percentage of patients who experienced an adverse event associated with intubation decreased from 22.5% to 14.4% (difference = -7.9%, 95% CI -13.4% to -2.4%). The percentage of patients with first pass success without an adverse event increased from 64.0% to 80.9% (difference = 16.9%, 95% CI 10.6% to 23.1%).
The use of an airway CQI program with an ongoing airway registry resulted in a substantial improvement in the overall safety of RSI in the ED as evidenced by an increase in first pass success and a decrease in adverse events.
危重病患者的气道管理与首次尝试失败和不良事件的高发生率有关，这对患者的治疗产生负面影响。本研究的目的是描述一个气道持续质量改进（CQI）计划，以及它在过去 10 年中对急诊科（ED）快速序贯插管（RSI）安全性的影响。
我们的 ED 于 2007 年 7 月 1 日（学术年度 1）开始实施气道 CQI 计划，并持续到 2017 年 6 月 30 日（学术年度 10）。在此期间，使用结构化气道数据收集表，前瞻性地收集所有在 ED 插管的患者的数据。关键数据点包括插管方法、插管使用的药物和设备、操作者的专业和培训水平、插管尝试次数和不良事件。本分析纳入在 ED 接受 RSI 且首次插管尝试由急诊医学（EM）住院医师完成的成年患者。主要结局是首次通过成功率，定义为单次喉镜插入成功进行气管插管。次要结局是与插管相关的不良事件的发生率。在整个研究期间引入了教育和临床干预措施，以优化这些结果。根据学术年度进行数据分析，并以均值差异的 95%置信区间（CI）报告描述性结果。
EM 住院医师在学术年度 1 期间对 342 名成年患者进行了 RSI，在学术年度 10 期间对 445 名成年患者进行了 RSI。在 10 年的研究期间，首次通过成功率从 73.1%增加到 92.4%（差异=19.3%，95%CI 14.0%至 24.6%）。与插管相关的不良事件发生率从 22.5%下降至 14.4%（差异=-7.9%，95%CI -13.4%至 -2.4%）。首次通过且无不良事件的患者比例从 64.0%增加到 80.9%（差异=16.9%，95%CI 10.6%至 23.1%）。
使用带持续气道登记的气道 CQI 计划显著提高了 ED 中 RSI 的整体安全性，表现在首次通过成功率提高和不良事件减少。
