Advancing emergency airway management by reducing intubation time at a high-volume academic emergency department

Abstract

Background: Airway management is a life-saving procedure in the emergency department (ED). Hypoxia during rapid sequence intubation (RSI) is associated with high morbidity and mortality.

Aim: To decrease the median time of intubation (time from administration of paralytic agent to the successful passage of endotracheal tube) by 40% from baseline 300 s in patients undergoing RSI in the ED.

Methods: A multidisciplinary quality improvement team worked to improve the airway management. The bottle necks identified using process mapping and fish bone analysis were lack of formal training of residents and nursing officers, and communication gap between residents and nursing officers. Change ideas focused on training residents in laryngoscopy and intubation and nursing officers in facilitating airway management by preparation of drugs and equipment; on-site awareness of logistical issues to the residents and nursing officers, introducing airway drug checklist and ensuring availability of difficult airway equipment.

Results: After implementation of change ideas there was a significant reduction in intubation time. At the end of first Plan-Do-Study-Act (PDSA) cycle median intubation time was 165 s (IQR 125 s). By the end of last PDSA cycle, median intubation time reduced to 157 s (IQR 66 s). A shift was obtained on the run chart with a new median time of 141.5 s from mid-PDSA 1. The 8-week data after the end of PDSA 3 showed sustainability with median time of 126 s (IQR 42 s).

Conclusion: A well organised team effort, simple change ideas such as structured training of residents and nursing officers, introduction of airway drug checklist and improved communication can decrease the intubation time in a chaotic ED.

Keywords: airway management; emergency department; quality improvement.

Conflict of interest statement

Competing interests: None declared.

© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Figures

Figure 1

Process flow diagram with bottlenecks highlighted in vertical red lines. T1 as denoted was the start time of measuring and T2 the end time in successful first pass intubation. In case of reattempt, the end point considered was T3. Change ideas were planned as per the problems highlighted in the flow diagram. ET tube, endotracheal tube; RSI, rapid sequence intubation.

Figure 2

Run chart depicting the time of placement of endotracheal (ET) tube after the administration of the paralytic agent. Each data point on X-axis represents the date on which rapid sequence intubation (RSI) was performed. Each data point on the Y-axis represents the time required for successful placement of ET tube into the trachea after the administration of paralytic agent. The baseline median intubation time was 300 s (red line) and the new median was 141.5 s (pink line).