1. Out of OR Airway Management Program Hines VA Medical Center
Patrick McElhone
Chief Nurse Anesthetist
Hines VA Hospital
Hines, IL

2. 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….

3. 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

4. 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

5. OOORAM by Anesthesia
In house, M-F, , 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

6. 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

7. 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)

8. OOORAM by ED Physicians
Intubations 9 (6%)
All performed in Emergency Department
Difficulty
1st Attempt: 9
Equipment:
Glidescope: 5 (55%)
Larygoscopy: 3 (45%)

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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, 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.

15. 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

16. 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

17. “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

18. 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

19. 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

20. 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

21. Training of Non-Anesthesia Personnel
Simulation
Introduction to the procedural skills of intubation
Goal to have individual safely perform task without instruction

22. 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

23. Equipment in OOORAM Service Specific Airway Carts Videolaryngoscopy
Glidescope
Continuous Capnography
Technology can increase objective confirmation of endotracheal tube placement

24. 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

25. 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, %

26. Continuous Capnography
Address limitation of Easy Cap
Hypercapnia
Low perfusion states
Provides objective feedback on placement of tube placement

27. Current Directions Improving Communication
How to contact anesthesia for back-up
Webpage links
Poster
Call Schedule

28. Airway Poster

29. 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”

30. 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

31. Questions?