Out of OR Airway OOORAM
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Transcript Out of OR Airway OOORAM
Patrick McElhone
Chief Nurse Anesthetist
Hines VA Hospital
Hines, IL
Hines, IL
Just outside of Chicago
Our own city
Zip Code 60141
Director is the mayor
It is 1 VA and if you been
to 1 VA….
Objectives
Provide an overview of our multidisciplinary approach
Ensures institutional buy-in of entire process
Describe the partnership between Anesthesia, Respiratory
Therapy and Emergency Department
Importance of investing in equipment
Role of CRNAs in this process
2012 Hines VA OOORAM
161 Intubations Outside the OR
109 (67%) Intubations by Anesthesia
Overall Success Rate 99%
43 (27%) Intubations by Respiratory Therapy
Overall Success Rate 96%
9 (6%) Intubations by Emergency Physicians
100% Success Rate
OOORAM by Anesthesia
In house, M-F, 0700-1700, 60min call back after hours
109 Intubations- 67% of all intubations OORAM
Equipment
Glidescope: 91 (83%)
Laryngoscopy: 15 (14%)
Fiberoptic: 3 (3%)
>99% Success Rate
1 required tracheotomy
OOORAM by Respiratory
Therapy
In house, 24/7, 365
RT competent in airway management always in-house
43 Intubations-27% of total Intubations
96% Success Rate
2 failed* attempts (4%) Note: both successfully intubated by
Anesthesia
OOORAM by Respiratory
Therapy
Difficulty in Intubating
1 attempt: 28 (65%)
2 attempts: 11 (25%)
>2 attempts: 3 (6%)
2 attempts 1 RT, 2 RT successful intubation
2 attempts DL, 1 successful intubation with GS
3 attempts-full arrest, success on 3rd attempt
Intubation Equipment used by RTs
Glidescope (GS): 70% (30)
Laryngoscopy: 30% (13)
OOORAM by ED Physicians
Intubations 9 (6%)
All performed in Emergency Department
Difficulty
1st Attempt: 9
Equipment:
Glidescope: 5 (55%)
Larygoscopy: 3 (45%)
OOORAM at Hines Overview
2012 Successful Management of OORAM
Reasons
Oversight of Process by Hines VA Out of OR Airway
Management Committee
Partnership between Anesthesia, Respiratory Therapy and
Emergency Department
Investing in Equipment
Embracing videolaryngoscopy and capnography
Airway Carts for all intubating personnel
Hines VA Out of OR Airway
Management Committee
Multidisciplinary Subcommittee of the Hines Acute and
Critical Care Committee
Meets monthly to review every intubation
Intubations are tracked through CPRS
Provides oversight of the entire process of intubating
outside the OR process
Works to correct systems problems
Works to anticipate future problems
Hines VA OOORAM Committee
Members
Chief of Anesthesia-Chairman
Chief CRNA
Chief of SICU
Chief of MICU
Chief of CCU
Chief Emergency Department
Chief Respiratory Therapy
Head Nurse MICU/CCU
Head Nurse SICU
ENT Physician Representation
Process of OOORAM
Decision to intubate
“Patients don’t suddenly go bad….”
“Is anesthesia in house?”
“If you are considering intubation….”
Chiefs of MICU, SICU, CCU, Head Nurses, RT
Notification of Intubating Team
“Anesthesia did not respond….”
Head Nurses
Process of OOORAM
Performance of Intubation
Track every intubation at Hines
Discuss every intubation
Entire group process
Actual specific Problems
Individual or Systems Issues
Future Problems
Role of Chief CRNA
Reviews and tracks all out of OR intubations
Requires all intubations to have an “Out of OR Intubation”
template note completed in CPRS
Accomplished through “view alerts” in CPRS
Copies of Hines OOORAM note, e-mail me!
Meets regularly with Chief Respiratory Therapy
Constant improvement in the process
Serves as subject matter expert at Hines VA
Constant feedback to non-anesthesia intubators
Available to advise committees, education, Chief of Staff,
etc.
Chief of Respiratory Therapy
Completes an initial review of all OOORAM Intubations
performed by Respiratory Therapy
Arranges Respiratory Therapy Staff education based on
Airway committee feedback will
Ensures that at least 1 RT competent in intubations is
always on duty at Hines VA
Provides oversight of anesthesia personnel intubation
attempts
Hines VA OOORAM Committee
Members
Case Studies
RT failed intubation in ED, RT insists ETT correctly placed,
residents disagree
Residents not stopping chest compressions for intubation
attempts
“One additional thing I think you should mention with the
multidisciplinary approach is that there is monthly
intensive review with the ability to give direct feedback to
individual providers when issues arise, as well as
constantly addressing the success of the program or
obstacles with the respiratory therapists at their monthly
staff meetings. ”
-Sandra Reynertson, MD, Medical Director, CCU, Assistant
Chief, Medical Service Line
Partnership of Services
Each service is committed to the success of this program
Anesthesia offers continued support of ED and
Respiratory Therapy
Personal relationships between all “intubators”
Education
Supplies
Assist in acquiring airway supplies
Informs of potential new products
Emergency restocking
Anesthesia Intubation Educator
Anesthesia is committed to training non anesthesia
clinicians to perform intubations
Specific CRNA has this additional duty
Works closely with committee to address education needs
Dexterity and Cognitive
Program includes:
Didactic Instruction-Cognitive
Simulation- Dexterity and Cognitive
Operating Room Instruction-Dexterity
Training of Non-Anesthesia
Personnel
Didactic Instruction
Anatomic structures of the airway
Use of equipment
Hines VA OOORAM Algorithm
Knowledge of medications used at facilitate intubation
Switching over to the new TMS course
Training of Non-Anesthesia
Personnel
Simulation
Introduction to the
procedural skills of
intubation
Goal to have individual
safely perform task
without instruction
Training of Non-Anesthesia
Personnel
Instruction in OR-exceeds
new National OOORAM
Policy
5 successful intubations,
at least 2 with Glidescope
5 successful mask
ventilations
3 successful LMA
placements
Equipment in OOORAM
Service Specific Airway Carts
Videolaryngoscopy
Glidescope
Continuous Capnography
Technology can increase objective confirmation of
endotracheal tube placement
Service Specific Airway Carts
Allows each service to
have access to airway
supplies they need
Brought to intubation by
the intubator
Stocked and maintained
by each service
Anesthesia assists as
needed
Videolaryngoscopy
Integral to our success
79% of OOORAM cases
done with Glidescope
Allows entire room to
view the ETT passing
through the glottis
Time to skill acquisition
faster with Glidescope vs
DL
Nouruzi, et al, 2009 93%
Continuous Capnography
Address limitation of Easy
Cap
Hypercapnia
Low perfusion states
Provides objective
feedback on placement of
tube placement
Current Directions
Improving
Communication
How to contact anesthesia
for back-up
Webpage links
Poster
Call Schedule
Airway Poster
Future Direction
Hines OOORAM Cognitive Aid
Cognitive Aids are critical
in emergency situation
Cognitive Aids have a role
in OOORAM
“When you have the
answers you do better on
the test”
Conclusion
Multidisciplinary approach
Entire Process of OOORAM at Hines
Track every intubation through CPRS note and view alerts
Partnership between Anesthesia, Respiratory Therapy and
Emergency Department
Investing in equipment
Institutional buy-in
Questions?