Patrick McElhone Chief Nurse Anesthetist Hines VA Hospital
Hines, IL Slide 2 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.
Slide 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 Slide 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 Slide 5 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
Slide 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 Slide 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 3 rd attempt Intubation
Equipment used by RTs Glidescope (GS): 70% (30) Laryngoscopy: 30%
(13) Slide 8 OOORAM by ED Physicians Intubations 9 (6%) All
performed in Emergency Department Difficulty 1 st Attempt: 9
Equipment: Glidescope: 5 (55%) Larygoscopy: 3 (45%) Slide 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 Slide 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 Slide 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 Slide 12 Process of OOORAM Decision to
intubate Patients dont 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 Slide 13 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 Slide 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, 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.
Slide 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 Slide 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 Slide 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 Slide 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 Slide 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 Slide 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 Slide
21 Training of Non-Anesthesia Personnel Simulation Introduction to
the procedural skills of intubation Goal to have individual safely
perform task without instruction Slide 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 Slide 23
Equipment in OOORAM Service Specific Airway Carts Videolaryngoscopy
Glidescope Continuous Capnography Technology can increase objective
confirmation of endotracheal tube placement Slide 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 Slide
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, 2009 93% Slide 26 Continuous
Capnography Address limitation of Easy Cap Hypercapnia Low
perfusion states Provides objective feedback on placement of tube
placement Slide 27 Current Directions Improving Communication How
to contact anesthesia for back-up Webpage links Poster Call
Schedule Slide 28 Airway Poster Slide 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 Slide 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 Slide 31 Questions?
