Australasian ED Airway Registry

April 10, 2012 by  
Filed under All Updates, Resus

Managing the emergency airway is one of the most important and risky things we do. We have a responsibility to record, monitor, report and improve our performance.

In the US, the National Emergency Airway Registry has been running for over a decade and has significantly contributed to our airway knowledge base.

In the UK, the NAP4 audit provided fascinating and scary insight into complications of emergency airway management.

Pre-hospital registries have been developed, like Minh Le Cong’s Flying Doctor Emergency Airway Registry; and many of us are now contributing to the Airway Management Study in Physician Manned Helicopter Emergency Medical Services (AIRPORT) study.

Now there is an opportunity for Australasian emergency departments to contribute to a national audit.

Dr Toby Fogg FACEM, emergency physician at Royal North Shore Hospital in Sydney, who began the registry, explained in a recent Life in The Fast Lane response:


I have been running an airway registry in the ED at The Royal North Shore Hospital in Sydney for the last 2 years.

I presented the first 18 months of data at the ASM in Sydney last year and I must admit, they showed room for improvement!.

One of the many things we have subsequently done is introduced a Pre Intubation Checklist which I have published, along with our preliminary findings, at www.airwayregistry.org.au.

I am happy for people to download the file and use it as is, or with appropriate modifications.

Furthermore I would love to hear from anyone keen to undertake an Airway Registry in their own ED — a PDF of the data collection form we use is also on the website.

As the authors of the NAP4 study conclude, it is essential we all audit our practice of this potentially high risk procedure.


Dr Toby Fogg uses his C-MAC video laryngoscope to demonstrate the audit form


Background: Successful airway management is one of the cornerstones of care for critically ill or injured patients in the Emergency Department (ED). The risks of intubation are known to be higher in this environment than in the operating theatre (OT) yet there are no published data on airway management in an Australian ED.

Objectives: To describe the practice of intubation in the ED of a tertiary hospital in Australia, with particular emphasis on the number of attempts, adjuncts used, the seniority of staff involved and the rate of complications.

Methods: A prospective, observational study.

Results: Over the 18-month study period, 295 episodes of intubation occurred with a total of 345 attempts. Consultant supervision occurred in 69.8% of cases, registrars made the first attempt at intubation in 57.5% and SRMOs in 31.0% of the patients. 83.7% of the patients were intubated at the first pass with a further 13.0% intubated one the second attempt. This leaves 10 patients (3.4%) that required ≥3 attempts, 4 (1.4%) ≥4 attempts and 1 (0.4%) required a 5th attempt. Difficult laryngoscopy, as defined by Cormack and Lehane grade III or IV, occurred in 24% of the first attempts. Bougies were used in 36% of attempts, whilst a stylet in 35%. Video laryngoscopy was used in 47.5% of attempts. Complications occurred in 28%.

Discussion: The success rate within two attempts is comparable to the anaesthetic literature, and although high, the rate of complications is comparable to data from EDs overseas. The rate of difficult laryngoscopy, however, is surprisingly high. The study has prompted a significant review of airway training and management within the ED at Royal North Shore Hospital and the results of the interventions will be monitored.

The Royal North Shore Hospital Emergency Department Airway Registry. A Prospective Observational Study of Airway Management in a Tertiary Hospital Emergency Department in Sydney, Australia
Annesley N,Vassiliadis J, Kerry Hitos K, Fogg T
Emerg. Med. Australas. 24 (Suppl. 1):27-28

Study authors Toby Fogg and Nick Annesley demonstrate the 'Happiness Triad'

Comments

6 Responses to “Australasian ED Airway Registry”

  1. Tim Leeuwenburg on April 10th, 2012 17:41

    Brilliant. I reckon there are several ‘prongs’ to an airway audit in Oz

    - elective intubation in OT by mostly anaesthetists (FANZCAs and trainees); sub categorised into public and private

    Perhaps more important is the ‘occasional intubator’ cohort which is where one may anticipate problems and look for improvement

    - tertiary EDs (FACEMs and trainees; public and private)

    - ICUs

    - prehospital inc. paramedic/HEMS

    - country hospitals (rural doctors, a ragbag of GP-anaesthetists, CMOs and FACRRMs)

    Might be really interesting to run some comparisons…especially to look at whether increasing no. of airway problems in the less frequent centres.

    It’s do-able, but needs a cross-sectional analysis breaking free of the traditional FANZCA-FACEM-FACRRM (or anaes-ED-Country) divides and instead trying to capture ALL intubations, whether public/private, tertiary/prehospital etc

    Also got to figure in the absolutely nuts bureacracies between States….

    Still, maybe worth a look – how to drive this though? A simple audit form from the Colleges for use in OT/ED/ICU/rural/prehospital? Might work…

  2. Robert Simpson on April 11th, 2012 04:08

    A worthy cause, and some spectacular porntaches!

    Many (?most) ambulance services in Australia use electronic reporting that should make extraction of most of the data from the audit sheet a reasonably simple affair (dependant upon how amicable to such questions being asked individual services are – hopefully very, given how important this area is)
    That said, the audit data is pretty straight forward and would not add any appreciable time spent on paperwork as far as I can see.

    If Tim, or anyone else, wants a collaborator within the Victorian service to get such an undertaking off the ground, I would be more than happy to volunteer my time!

    Robbie,
    MICA Paramedic, Melbourne

  3. Toby Fogg on April 12th, 2012 03:51

    Robbie,

    It would be wonderful if you could get data from the Victorian Paramedics. I’d be keen to chat to you….

    Toby
    toby@airwayregistry.org.au

  4. Alex Tzannes on April 12th, 2012 17:59

    Nice effort by Toby getting the ball rolling in Australia. Since January we have been on board at St George Hospital. An early analysis is showing similar trends to RNSH. A positive byproduct has been the promulgation of good technique with regards to preoxygenation, apnoeic oxygenation, and assessment for predicted difficulty.
    The largest challenge has been “buy in” from staff who suffer from “form fatigue”. A strategy to capture all the ED intubations that may not have been reported on a form at the time of the procedure is paramount; for eg scanning the disposition data to ICU/OT/mortuary.

  5. Minh Le Cong on April 12th, 2012 18:53

    Alex is profoundly correct! Culture change is challenging to manage. Checklists are a great idea but suffer from the problem that no use if your staff see no need to change the traditional practice . THAT IS WHY TOBY’s WORK IS SO VITAL!! The only way we will know if what we are doing is good enough, is to share our data and experiences. It took my own service , after doing our own airway registry to wake up to the fact, that despite availability, one in five prehospital intubations were not utilising end tidal capnography for tube confirmation and monitoring of ventilation. ANZCA have argued that a national registry of airway related deaths should be established rather than separate state based coronial reporting.

  6. Tim Leeuwenburg on April 13th, 2012 03:37

    Exactly Alex – promulgate the concepts as above…such audit can only lead to improved outcomes.

    Interesting to see ideas such as apnoeic oxygenation rubbished by some of the anaesthetists on doctors.net…. whereas such concepts keenly taken up by the ED/ICU/prehospital/rural crowd.

    Form fatigue is a real danger…may be better to get a few key sites going initially

    Would be really interesting to focus on the emergent airway in both tertiary ED and ICUs, as well as prehospital retriveal services and also small rural centres…

    I’m in…