Title : Reducing the time of intubation from administration of induction agents to successful ET tube intubation in medical emergency Department AIIMS, India - An QI initiative
Intubation is a critical procedure performed in emergency departments (EDs). Rapid sequence intubation (RSI) is the most commonly used method of inducing anesthesia in patients who are at risk of aspiration of gastric contents into the lungs. The emergency department, AIIMS witness huge volume of patients i.e. 600-700 patients / day. Around 5-6 intubations occurs per day among red triaged patients. Baseline data showed the median time of successful intubation (from the time of administering induction agents T1 to time of successful pass of ET tube T2) was as high as 300 seconds intubation. This time was exceptionally high.
To reduce the intubation time from baseline to 2 min over next 4 months starting from January 2019 in emergency department.
Settings & Design:
Interventional research design (no control group, no randomization) was adopted to perform Quality initiative in New Medical emergency, AIIMS, New Delhi
Materials & Methods:
A quality improvement team was formed among Senior residents, nursing officers, nurse educator and consultants of emergency department. Data for intubation time (T1 from the time of administering induction agents to time of successful pass of ET tube T2) was collected by nursing officers during December 2018 to April 2019. The baseline data was collected on 15 patients showed median time of intubation as 300 seconds. The main contributory factors were space constraints to keep intubation trolley, lack of bougie for dig\fficult intubation, lack of training of doctors, equipment failure . The QI team used Plan-do-study-act cycle to test and adapt the change ideas. The key change ideas were introducing intubation checklist, training of junior doctors for intubation, sensitization of nurses and doctors, introducing Bougie for difficult intubation which were successfully induced in PDSA1 and PDSA 2.
Statistical Methods: Fish bone analysis and descriptive method of analysis was used
Within next 4 months, the intubation time reduced from 300 seconds to 165 seconds (median time of 14 intubations) in PDSA1 and further to 157 seconds (median time of 10 intubations) in PDSA 2. This improvement is sustained with introduction of Regular training program of all junior residents within first 3 days of their posting in emergency department and sensitization of nurses posted in red triaged area.
The Quality improvement initiative was successful in terms of reducing intubation time from baseline to nearly set target time of 2 minutes. Most importantly it strongly enlightened the need of regular training of health care providers and constant motivational support.