Contributing Factors and Time Delays in Management of Difficult Airways in the Emergency Department
CCCF ePoster library. Fernando S. Nov 2, 2016; 151011; 129
Dr. Shannon Fernando
Dr. Shannon Fernando
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Topic: Quality Assurance & Improvement

Contributing Factors and Time Delays in Management of Difficult Airways in the Emergency Department


Fernando, Shannon M; White, Shannon; Kwok, Edmund SH
Quality Improvement Unit, Department of Emergency Medicine, University of Ottawa, Ottawa, ON



Abstract:

Background: Airway management in the Emergency Department (ED) is an important first step in the stabilization of a critically ill patient. While this task is often performed by ED physicians, the presence of a difficult airway (DA) may necessitate expert consultation from Anesthesiology, Otolaryngology or Critical Care Medicine. Several institutions have implemented multidisciplinary rapid response teams for management of these cases. However, from a Quality and Patient Safety perspective, little is known regarding existing rate of response in the absence of such teams, as well as the factors that contribute to DA in the ED.
Objectives: We performed a retrospective analysis of DA cases at The Ottawa Hospital between 2010-2014. 'Difficult airway' was defined as any case requiring expert consultation from Anesthesiology for the purpose of airway management. We sought to determine: 1) The latency to definitive airway in these cases; 2) The patient factors that contribute to DA in the ED; 3) The incidence of complications in DA management; and 4) The association between the incidence of complications, latency to definitive airway, and ICU length of stay (LOS).
Methods: We first identified cases of STAT page to Anesthesiology from the ED between 2010-2014. These pages were then matched to patient records, which were analyzed. Primary outcomes were time between: 1) Decision to intubate by the ED physician and STAT page to Anesthesiology; 2) STAT page and Anesthesiology arrival; and 3) Anesthesiology arrival and establishment of definitive airway. Secondary analyses focused on identifying patient factors associated with DA, the incidence of complications, and association between the presence of complications, the latency to definitive airway, and ICU LOS.    
Results: We identified 33 cases of DA in the ED over this time period. Average age of included patients was 56.2 ± 3.1 years. Approximately 69.7% survived to hospital discharge. Mean time between decision to intubate by the ED physician and STAT page to Anesthesiology was 15.2 ± 2.4 min. Mean time for arrival of Anesthesiology was 7.4 ± 1.0 min. Finally, mean time between Anesthesiology arrival and establishment of definitive airway was 11.3 ± 2.3 min. Overall, mean latency from decision to intubate and definitive airway was 34.8 ± 3.2 min. Factors associated with DA included airway secretions/emesis, airway edema, and obesity. Of the patients who survived to discharge, 47.8% had a complication attributed to intubation. The patients that had complications had a significantly longer time to airway security than the group that did not have complications (50.0 ± 4.6 mins vs. 26.1 ± 3.9 mins, P < 0.01). The group with complications also had a significantly longer ICU LOS than the group that did not have complications (14.6 ± 2.4 days vs. 7.2 ± 1.4 days; P < 0.05).     
Conclusions: Our analysis identifies significant areas of latency in the management of DA, as well as patient factors associated with DA in the ED. We also demonstrate an association between the presence of peri- and post-intubation complications and increased latency to definitive airway, as well as longer ICU LOS. Taken together, these findings suggest potential benefit of multidisciplinary rapid response teams for these cases. 


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