Out of OR Airway Management Program Hines VA Medical Center 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 Notification of Intubating Team “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 Actual specific Problems 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?