Out of OR Airway OOORAM

Patrick McElhone
Chief Nurse Anesthetist
Hines VA Hospital
Hines, IL
Hines, IL
 Just outside of Chicago
 Our own city
 Zip Code 60141
 Director is the mayor
 It is 1 VA and if you been
to 1 VA….
 Provide an overview of our multidisciplinary approach
Ensures institutional buy-in of entire process
 Describe the partnership between Anesthesia, Respiratory
Therapy and Emergency Department
 Importance of investing in equipment
 Role of CRNAs in this process
2012 Hines VA OOORAM
 161 Intubations Outside the OR
 109 (67%) Intubations by Anesthesia
Overall Success Rate 99%
 43 (27%) Intubations by Respiratory Therapy
Overall Success Rate 96%
 9 (6%) Intubations by Emergency Physicians
100% Success Rate
OOORAM by Anesthesia
 In house, M-F, 0700-1700, 60min call back after hours
 109 Intubations- 67% of all intubations OORAM
 Equipment
 Glidescope: 91 (83%)
 Laryngoscopy: 15 (14%)
 Fiberoptic: 3 (3%)
 >99% Success Rate
 1 required tracheotomy
OOORAM by Respiratory
 In house, 24/7, 365
 RT competent in airway management always in-house
 43 Intubations-27% of total Intubations
 96% Success Rate
 2 failed* attempts (4%) Note: both successfully intubated by
OOORAM by Respiratory
 Difficulty in Intubating
 1 attempt: 28 (65%)
 2 attempts: 11 (25%)
 >2 attempts: 3 (6%)
2 attempts 1 RT, 2 RT successful intubation
2 attempts DL, 1 successful intubation with GS
3 attempts-full arrest, success on 3rd attempt
 Intubation Equipment used by RTs
 Glidescope (GS): 70% (30)
 Laryngoscopy: 30% (13)
OOORAM by ED Physicians
 Intubations 9 (6%)
 All performed in Emergency Department
 Difficulty
 1st Attempt: 9
 Equipment:
 Glidescope: 5 (55%)
 Larygoscopy: 3 (45%)
OOORAM at Hines Overview
 2012 Successful Management of OORAM
 Reasons
 Oversight of Process by Hines VA Out of OR Airway
Management Committee
 Partnership between Anesthesia, Respiratory Therapy and
Emergency Department
 Investing in Equipment
Embracing videolaryngoscopy and capnography
Airway Carts for all intubating personnel
Hines VA Out of OR Airway
Management Committee
 Multidisciplinary Subcommittee of the Hines Acute and
Critical Care Committee
 Meets monthly to review every intubation
 Intubations are tracked through CPRS
 Provides oversight of the entire process of intubating
outside the OR process
 Works to correct systems problems
 Works to anticipate future problems
Hines VA OOORAM Committee
Chief of Anesthesia-Chairman
Chief CRNA
Chief of SICU
Chief of MICU
Chief of CCU
Chief Emergency Department
Chief Respiratory Therapy
Head Nurse MICU/CCU
Head Nurse SICU
ENT Physician Representation
Process of OOORAM
 Decision to intubate
 “Patients don’t suddenly go bad….”
 “Is anesthesia in house?”
 “If you are considering intubation….”
 Chiefs of MICU, SICU, CCU, Head Nurses, RT
 Notification of Intubating Team
 “Anesthesia did not respond….”
 Head Nurses
Process of OOORAM
 Performance of Intubation
 Track every intubation at Hines
 Discuss every intubation
 Entire group process
 Actual specific Problems
 Individual or Systems Issues
 Future Problems
Role of Chief CRNA
 Reviews and tracks all out of OR intubations
 Requires all intubations to have an “Out of OR Intubation”
template note completed in CPRS
 Accomplished through “view alerts” in CPRS
Copies of Hines OOORAM note, e-mail me!
 Meets regularly with Chief Respiratory Therapy
 Constant improvement in the process
 Serves as subject matter expert at Hines VA
 Constant feedback to non-anesthesia intubators
 Available to advise committees, education, Chief of Staff,
Chief of Respiratory Therapy
 Completes an initial review of all OOORAM Intubations
performed by Respiratory Therapy
 Arranges Respiratory Therapy Staff education based on
Airway committee feedback will
 Ensures that at least 1 RT competent in intubations is
always on duty at Hines VA
 Provides oversight of anesthesia personnel intubation
Hines VA OOORAM Committee
 Case Studies
 RT failed intubation in ED, RT insists ETT correctly placed,
residents disagree
 Residents not stopping chest compressions for intubation
“One additional thing I think you should mention with the
multidisciplinary approach is that there is monthly
intensive review with the ability to give direct feedback to
individual providers when issues arise, as well as
constantly addressing the success of the program or
obstacles with the respiratory therapists at their monthly
staff meetings. ”
-Sandra Reynertson, MD, Medical Director, CCU, Assistant
Chief, Medical Service Line
Partnership of Services
 Each service is committed to the success of this program
 Anesthesia offers continued support of ED and
Respiratory Therapy
 Personal relationships between all “intubators”
 Education
 Supplies
Assist in acquiring airway supplies
Informs of potential new products
Emergency restocking
Anesthesia Intubation Educator
 Anesthesia is committed to training non anesthesia
clinicians to perform intubations
 Specific CRNA has this additional duty
 Works closely with committee to address education needs
 Dexterity and Cognitive
 Program includes:
 Didactic Instruction-Cognitive
 Simulation- Dexterity and Cognitive
 Operating Room Instruction-Dexterity
Training of Non-Anesthesia
 Didactic Instruction
 Anatomic structures of the airway
 Use of equipment
 Hines VA OOORAM Algorithm
 Knowledge of medications used at facilitate intubation
 Switching over to the new TMS course
Training of Non-Anesthesia
 Simulation
 Introduction to the
procedural skills of
 Goal to have individual
safely perform task
without instruction
Training of Non-Anesthesia
 Instruction in OR-exceeds
new National OOORAM
 5 successful intubations,
at least 2 with Glidescope
 5 successful mask
 3 successful LMA
Equipment in OOORAM
 Service Specific Airway Carts
 Videolaryngoscopy
 Glidescope
 Continuous Capnography
 Technology can increase objective confirmation of
endotracheal tube placement
Service Specific Airway Carts
 Allows each service to
have access to airway
supplies they need
 Brought to intubation by
the intubator
 Stocked and maintained
by each service
 Anesthesia assists as
 Integral to our success
 79% of OOORAM cases
done with Glidescope
 Allows entire room to
view the ETT passing
through the glottis
 Time to skill acquisition
faster with Glidescope vs
 Nouruzi, et al, 2009 93%
Continuous Capnography
 Address limitation of Easy
 Hypercapnia
 Low perfusion states
 Provides objective
feedback on placement of
tube placement
Current Directions
 Improving
 How to contact anesthesia
for back-up
 Webpage links
 Poster
 Call Schedule
Airway Poster
Future Direction
Hines OOORAM Cognitive Aid
 Cognitive Aids are critical
in emergency situation
 Cognitive Aids have a role
 “When you have the
answers you do better on
the test”
 Multidisciplinary approach
Entire Process of OOORAM at Hines
Track every intubation through CPRS note and view alerts
 Partnership between Anesthesia, Respiratory Therapy and
Emergency Department
 Investing in equipment
Institutional buy-in

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