Patient safety incidents associated with airway devices in critical care: a review of reports to the UK National Patient Safety Agency

Improving detection by pediatric residents of endotracheal tube dislodgement with capnography: a randomized controlled trial

OBJECTIVE

The authors sought to determine if capnography could improve time to correction of a simulated endotracheal tube (ETT) dislodgement by pediatric residents.

STUDY DESIGN

Pediatric residents attended a didactic session that included interpretation of capnography. A randomized controlled study was then performed using patient simulators. Residents were randomized to standard monitoring (control group) or standard monitoring plus capnography (intervention group). The primary outcome was time to correction of ETT dislodgement. Correction of dislodgement prior to decline in pulse oximetry was our secondary outcome.

RESULTS

Twenty-seven subjects completed the simulation. Subjects in the intervention group corrected the ETT dislodgement faster than those in the control group (2.38 minutes vs 3.92 minutes, P = .02). There were no differences in time to correction based on postgraduate year, clinical experiences, or comfort with capnography. Two subjects corrected the dislodgement prior to changes in pulse oximetry, both from the intervention group. Fifty-nine percent of subjects had seen capnography used in the past and 82% felt very or somewhat comfortable with capnography.

CONCLUSION

Capnography decreased time to correction of ETT dislodgement by pediatric residents. Capnography should be considered as an essential monitoring device for intubated patients to enhance patient safety.

Emergency capnography monitoring: comparing ergonomic design of intensive care unit ventilator interfaces and specific training of staff in reducing time to activation

Modern ventilators provide capnography monitoring in patients with tracheal tubes, in compliance with national and international recommendations. This technology is often not used when patients' lungs are non-invasively ventilated; however, it should be accessed immediately following tracheal intubation to confirm tube placement. This study assessed the effect of ventilation interface design on the speed with which capnography can be activated by comparing the Dräger Evita 4 and Dräger V500 before and after a specific training episode. We configured the V500 to have a capnography activation button on the front screen in contrast to the Evita 4 which requires a sequence of actions to access capnography monitoring. We used a randomised crossover design, measuring time to monitoring activation, and repeated the study after 3 months. Survival analysis showed significantly quicker activation associated with ventilator choice (V500, p < 0.0001) and training (p = 0.0058). The training improved activation speed with both machines, though this was only significant for the Evita 4 (p = 0.0097).

Review of patient safety incidents reported from critical care units in North-West England in 2009 and 2010

We categorised and established the rates of patient safety incidents reported during 2009 and 2010 from critical care units in 12 hospital trusts in North-West England. We identified a total of 4219 incidents reported during 127, 467 calendar days of critical care with a median (IQR [range]) of 31 (26-45 [20-57]) incidents per 1000 days per trust. A median (IQR [range]) of 10 (7-13 [3.5-27]) incidents per 1000 days were associated with harm. Pressure sores were the most common cause of harm, with a median (IQR [range]) of 3.9 (1.0-6.6 [0-20.4]) incidents per 1000 days. Only 89 (2.1%) incidents described more than temporary harm, of which 12 were airway related incidents. Five incidents described the use of inappropriate arterial flush solutions. It is possible to compare rates of incident reporting in different trusts over time to determine if different methods of care are associated with different reporting rates. The wide range of reported pressure sore rates suggests that their incidence could be reduced.

Strategies to prevent airway complications: a survey of adult intensive care units in Australia and New Zealand

BACKGROUND

There is growing evidence that airway complications are relatively common in critical care. Strategies have been suggested to decrease their incidence.

METHODS

We conducted a telephone survey of all adult intensive care units (ICUs) in Australia and New Zealand to establish the current practice regarding strategies used to reduce airway complications in five key areas: (i) use of capnography; (ii) care of oral tracheal tubes; (iii) care of tracheostomy tubes; (iv) difficult and failed intubation; and (v) training and medical staffing.

RESULTS

Of 176 ICU meeting inclusion criteria, 171 agreed to participate. Capnography is used during tracheal intubation in 88% of ICUs and for continuous monitoring in 64%. Protocols for advancing or partially withdrawing malpositioned tracheal tubes are used by 54% of units, with most allowing repositioning by unaccredited nurses. A small minority of ICUs use bed head signs to identify patients with 'critical airways' or laryngectomy, while only 8% have specific protocols for the care of these high-risk patients. Tracheostomy emergency algorithms are available in 13% of ICUs. At night, a doctor is exclusively assigned to 73% of units, although in 72%, the night doctor is not required to have prior anaesthetic/airway training. In 97% of the institutions surveyed, the senior doctor relied upon for airway emergencies at night is either non-resident or working elsewhere in the hospital.

CONCLUSIONS

Our data suggest that several possible strategies for avoiding airway complications in ICU patients dependent on an artificial airway are poorly implemented. This may expose these patients to avoidable risk.

Tracheal intubation in the critically ill: a multi-centre national study of practice and complications

BACKGROUND

Complications associated with tracheal intubation may occur in up to 40% of critically ill patients. Since practice in emergency airway management varies between intensive care units (ICUs) and countries, complication rates may also differ. We undertook a prospective, observational study of tracheal intubation performed by critical care doctors in Scotland to identify practice, complications, and training.

METHODS

For 4 months, we collected data on any intubation performed by doctors working in critical care throughout Scotland except those in patients having elective surgery and those carried out before admission to hospital. We used a standardized data form to collect information on pre-induction physical state and organ support, the doctor carrying out the intubation, the techniques and drugs used, and complications noted.

RESULTS

Data from 794 intubations were analysed. Seventy per cent occurred in ICU and 18% occurred in emergency departments. The first-time intubation success rate was 91%, no patient required more than three attempts at intubation, and one patient required surgical tracheostomy. Severe hypoxaemia ( <80%) occurred in 22%, severe hypotension (systolic arterial pressure <80 mm Hg) in 20%, and oesophageal intubation in 2%. Three-quarters of intubations were performed by doctors with more than 24 months formal anaesthetic training and all but one doctor with <6 months training had senior supervision.

CONCLUSIONS

Tracheal intubation by critical care doctors in Scotland has a higher first-time success rate than described in previous reports of critical care intubation, and technical complications are few. Doctors carrying out intubation had undergone longer formal training in anaesthesia than described previously, and junior trainees are routinely supervised. Despite these good results, further work is necessary to reduce physiological complications and patient morbidity.

Airway challenges in critical care

Airway management in the intensive care unit is more problematic than during anaesthesia. In general, critically ill patients have less physiological reserve and complications are more common, both during the initial airway intervention (which includes risks associated with induction of anaesthesia), and later once the airway has been secured. Despite these known risks, those managing the airway of a critically ill patient, particularly out of hours, may be relatively inexperienced. Solutions to these challenging airway problems include: recognition of those patients with a potential airway problem; implementation of a plan to deal with their airway; immediate availability of a difficult airway trolley; use of capnography for every airway intervention and continuously in all ventilator-dependent patients; and appropriate training of all intensive care unit staff including use of simulation.

Critical incident reports concerning anaesthetic equipment: analysis of the UK National Reporting and Learning System (NRLS) data from 2006-2008*

Anaesthetic equipment plays a central role in anaesthetic practice but brings the potential for malfunction or misuse. We aimed to explore the national picture by reviewing patient safety incidents relating to anaesthetic equipment from the National Reporting and Learning System for England and Wales between 2006 and 2008. We searched the database using the system's own classification and by scrutinising the free text of relevant incidents. There were 1029 relevant incidents. Of these, 410 (39.8%) concerned patient monitoring, most commonly screen failure during anaesthesia, failure of one modality or failure to transfer data automatically from anaesthetic room to operating theatre. Problems relating to ventilators made up 185 (17.9%) of the reports. Sudden failures during anaesthesia accounted for 142 (13.8%) of these, with a further 10 cases (0.9%) where malfunction caused a sustained or increasing positive pressure in the patient's airway. Leaks made up 99 (9.6%) of incidents and 53 (5.2%) of incidents arose from the use of infusion pumps. Most (89%) of the incidents caused no patient harm; only 30 (2.9%) were judged to have led to moderate or severe harm. Although equipment was often faulty, user error or unfamiliarity also played a part. A large variety of causes led to a relatively small number of clinical scenarios, that anaesthetists should be ready, both individually and organisationally, to manage even when the cause is not apparent. We make recommendations for enhancing patient safety with respect to equipment. You can respond to this article at http://www.anaesthesiacorrespondence.com.

Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 2: intensive care and emergency departments

BACKGROUND

The Fourth National Audit Project of the Royal College of Anaesthetists and Difficult Airway Society (NAP4) was designed to identify and study serious airway complications occurring during anaesthesia, in intensive care unit (ICU) and the emergency department (ED).

METHODS

Reports of major complications of airway management (death, brain damage, emergency surgical airway, unanticipated ICU admission, prolonged ICU stay) were collected from all National Health Service hospitals over a period of 1 yr. An expert panel reviewed inclusion criteria, outcome, and airway management.

RESULTS

A total of 184 events met inclusion criteria: 36 in ICU and 15 in the ED. In ICU, 61% of events led to death or persistent neurological injury, and 31% in the ED. Airway events in ICU and the ED were more likely than those during anaesthesia to occur out-of-hours, be managed by doctors with less anaesthetic experience and lead to permanent harm. Failure to use capnography contributed to 74% of cases of death or persistent neurological injury.

CONCLUSIONS

At least one in four major airway events in a hospital are likely to occur in ICU or the ED. The outcome of these events is particularly adverse. Analysis of the cases has identified repeated gaps in care that include: poor identification of at-risk patients, poor or incomplete planning, inadequate provision of skilled staff and equipment to manage these events successfully, delayed recognition of events, and failed rescue due to lack of or failure of interpretation of capnography. The project findings suggest avoidable deaths due to airway complications occur in ICU and the ED.

Tracheostomy care and management in general wards and community settings: literature review

AIMS AND OBJECTIVES

To identify current perspectives and areas for research regarding care and management of tracheostomized adult patients discharged to general wards and the community.

BACKGROUND

The increased number of tracheostomies being performed has led to more tracheostomized patients being discharged to non-specialized areas. Staff within these diverse areas may care for this patient group on an infrequent basis, and may lack the skills, knowledge and confidence to provide safe tracheostomy care. Although several guidelines and quality improvement initiatives have been developed to guide and improve tracheostomy care, concerns continue to be raised regarding this aspect of care. These factors inadvertently create significant risks for example, tube displacement in addition to the risks associated with procedures such as tracheal suctioning.

SEARCH STRATEGY

Database searches of MEDLINE, BRITISH NURSING INDEX and CINAHL (1998-2009). Inclusion criteria was literature regarding tracheostomized adult patients discharged to non-specialized areas. Exclusion criteria was paediatric literature.

CONCLUSIONS

Although best practice is applied to the care of tracheostomized adult patients in some areas, including support for ward staff from specialist nurses or teams, this is not always formalized or consistent. Furthermore studies indicate a lack of medical follow-up once the patient is discharged from specialized areas with a tracheostomy. Research is very limited in relation to the care and management of tracheostomized adult patients outside specialized areas, yet there is morbidity and mortality associated with this patient group. Staff education is widely recommended, but further development is needed to determine the best methods of delivering education, especially for health care professionals who care for tracheostomized patients on an infrequent basis.

RELEVANCE TO CLINICAL PRACTICE

More tracheostomized patients are being discharged to non-specialized areas, and issues have been raised regarding risks to patients. Research is required to determine the best methods of promoting best practice to improve tracheostomy care.

The use of capnography and the availability of airway equipment on Intensive Care Units in the UK and the Republic of Ireland

At least 20% of reported major adverse airway events occur on the intensive care unit. This study surveyed 315 (96%) of all general, satellite, hepatobiliary, cardiac and neuro-intensive care units in the UK and the Republic of Ireland, finding that only 100 (32%) units always use capnography for tracheal intubation while only 80 (25%) always use capnography for continuous monitoring of patients requiring controlled ventilation. Three hundred and ten (98%) units utilise a checklist of airway equipment, 311 (99%) check its functionality on a daily basis and 296 (94%) units have access to a bronchoscope. Whilst 297 (94%) ICUs have an airway trolley, sufficient equipment for unanticipated difficult intubation was only seen on 33 (10%) of units. Guidelines addressing minimum standards for monitoring and airway safety on ICU are not being met and remain below the standard expected.

Survey of the Use of Capnography in UK Intensive Care Units

Capnography is not currently part of standard monitoring in intensive care practice in the UK. In order to investigate how widely capnography is used and reasons for lack of use, we sent a survey to lead clinicians of adult intensive care units. The response rate was 61%; 45% of responding units did not have the facility to monitor carbon dioxide at all funded bedspaces. Approximately 30% of units were covered at least part of the time by doctors who did not have advanced airway skills. Reasons for not using capnography included its lack of correlation with arterial blood gases and the fact that capnography is not 100% sensitive or specific for the diagnosis of airway misplacement. Capnography should be used during intubation to confirm airway placement in the intensive care unit.

Review of patient safety incidents submitted from Critical Care Units in England & Wales to the UK National Patient Safety Agency

We reviewed and classified all patient safety incidents submitted from critical care units in England and Wales to the National Patient Safety Agency for the first quarter of 2008. A total of 6649 incidents were submitted from 141 organisations (median (range) 23 (1-268 incidents)); 786 were unrelated to the critical care episode and 248 were repeat entries. Of the remaining 5615 incidents, 1726 occurred in neonates or babies, 1298 were associated with temporary harm, 15 with permanent harm and 59 required interventions to maintain life or may have contributed to the patient's death. The most common main incident groups were medication (1450 incidents), infrastructure and staffing (1289 incidents) and implementation of care (1047 incidents). There were 2789 incidents classified to more than one main group. The incident analysis highlights ways to improve patient safety and to improve the classification of incidents.