The introduction of an airway registry in a Scottish Intensive Care Unit (ICU) can it improve standards? Edmunds CT, Robinson O, Scott I Aberdeen Royal Infirmary, Scotland

INTRODUCTION & OBJECTIVES Background.. INTRODUCTION & OBJECTIVES Airway Management in Intensive Care: Difficulty – Results of National Audit Project 4 in 2011. 1 in 4 airways in ICU and ED had complications. Failure to use capnography was related to 70% of ICU deaths, with displaced tracheostomy a leading cause of increased complications. Documentation – Do we know what we do with each airway, current practice is to use a sticker in the notes. An airway registry in our Emergency Department and other services have shown benefits and improvements to airway management. Staffing – ICU is staffed with clinicians of mixed background, introduction of standalone training for ICM in the UK has encouraged the non-anaesthetist to take on critical care roles. Emergency – all ICU patients are critically unwell, therefore limited ability to compensate physiologically.

INTRODUCTION & OBJECTIVES Aim - can we get better.. INTRODUCTION & OBJECTIVES Our current ICM airway practice: Airway specific equipment - including specific trolleys and airway boxes. Kit dump – designed to improve setup for interventions and standisation of practice. Documentation – use of an airway sticker that is placed in the notes, often hidden in notes in days after intervention. Emergency Department team practice: Documentation - Successful use of specific reproducible documentation for every airway intervention, goes into the patients notes and instantly recognisable as an airway document. Airway Registry - Data for every airway stored and reviewed, allowed improvement of practice. Our vision: Improve each patient’s documentation for airway interventions. Create documentation that was easily accessibly for clinicians later in a patients care. Ability to review current practice and identify how to improve it via creation of an airway registry.

INTRODUCTION & OBJECTIVES Change implemented.. INTRODUCTION & OBJECTIVES Specific airway intervention form – created to replace current stickers. Accessibility - Once complete kept in patient records at the front off the notes. Electronic records – scanned into electronic format so appears and is accessible to non-ICM clinicians. ICM Airway Registry – all data from forms entered into a database documenting practice trends. Review and critique – data in registry regularly reviewed and complex case or those with complications discussed.

INTRODUCTION & OBJECTIVES Results – what do we actually do.. INTRODUCTION & OBJECTIVES Data collected from August 2015 to May 2016. Total 40 airway interventions entered into the database. 15/40 (37.5%) out of hours (20:00 to 08:00). Difficulty predicted in 17/40 (42.5%). Complications recorded in 16/40 (40%) these were low SpO2 <90% (56.2%) and low BP <100mmHg (37.5%). 1st pass success in 90% of cases, 4 (10%) requiring more than one attempt. Adjuncts (e.g. bougie/stylet) were used in 17/40 (42.5%) but only in 3/4 (75%) of intubations that required further attempts. Supervision for intervention was by a Consultant In 17/40 (42.5%) and ST4-8 ICU or Anaesthetics in 11/40 (27.5%). Induction Number Propofol 38 (95%) Ketamine 2 (5%) Paralytic Number Rocuronium 31 (77.5%) Atracurium 6 (15%) Suxamethonium 3 (7.5%) Opioid Number Alfentanil 23 (57.5%) Fentanyl 3 (7.5%) None 14 (35%) Vasoactive Number Metaraminol 18 (45%) None 22 (55%)

INTRODUCTION & OBJECTIVES Conclusions – going forward.. INTRODUCTION & OBJECTIVES We have good success with our airway interventions – first pass rate 90%. We have considered the following in our practice: High complications rate could be improved – do we need to look at using more cardiovascularly stable induction agents or have concurrent vasoactive support on a pumped infusion? Despite difficulty in patients receiving more than one laryngoscopy attempt an adjunct e.g. bougie was not always used - could standard use of a bougie improve time to intubation and our first pass rate? Large proportion of our airway interventions are out of hours, this has real affect on the skill mix required to staff an ICU. Feedback demonstrated that the documentation was positively received and in a number of cases aided better airway plans due to a better understanding what had been done previously. We are planning on creating a hospital wide airway database for all patients outside of theatre, this has been undertaken with colleagues in the Emergency Department.