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Airway and Procedural Sedation Quality Improvement at Northwestern: A Model for Resident-Led Change

Samia Farooqi, MD

Airway and sedation management are some of the most crucial skills in the emergency physician’s repertoire. Borne from a critical evaluation of our institution’s airway and procedural sedation practices, the Northwestern Airway and Procedural Sedation Quality Committee is a resident-led group developed to achieve the following mission: to create and enact a comprehensive and sustainable quality improvement framework for airway and procedural sedation management. Our committee’s resident members are dedicated to overseeing activity in one of three main realms: 1) Documentation/Research, 2) Equipment/Operations, and 3) Education – and are responsible for formally reporting quarterly quality metrics to the Northwestern Emergency Department’s QM Committee.

Previously, important quality metrics such as informed consent, time-out, airway assessment, desaturations, and number of intubation attempts were difficult to track given incomplete, inaccurate and non-standardized documentation. Moreover, poor documentation resulted in lost potential revenues of $18,900 for procedural sedations alone over the course of one year.

Our first task was to create an efficient, standardized documentation system that would allow us to track and better understand our outcomes over time. We created novel procedure notes in the electronic medical record for intubation and procedural sedation. These notes were designed with IT and ED Operations leadership with an eye towards easily harvesting the data for quarterly analysis of quality metrics and patient outcomes. Now, outcomes analysis before and after educational and institutional interventions is easier, and we have created a basis for institutional learning.

Equipment and Operations Management:
Underlying this quality improvement initiative is a motivation to promote culture change in our department. Our cultural change is simple – approach and prepare for every airway as a difficult airway. Gone are the days of a rarely used “difficult airway cart” that gathers dust in the trauma bay. We designed, implemented, and manage a well-organized airway cart that contains all critical airway equipment, including a number of adjuncts that are easily brought to the bedside for every intubation in the department. We continually review our airway equipment inventory, trial various novel airway rescue devices and end-tidal CO2 monitors, evaluate them for department leadership, and formally present our recommendations.

Our educational initiatives are multifaceted, and involve teaching RNs, residents, and bringing department-wide awareness to critical airway successes and challenges. We collaborated with nursing leadership to educate nurses on the use of end-tidal CO2 monitoring during procedural sedation. We also created a procedural sedation checklist to facilitate on-shift education of junior learners tasked with preparing for and managing sedations. We play a critical role in teaching our peers how to use novel airway equipment introduced to the department. Perhaps most importantly, to foster institutional learning, our new documentation system allows for regular review of intubations flagged as difficult, such that we are able to formally present challenging airways during our monthly department-wide M&M.

At Northwestern’s Emergency Department, airway and procedural sedation quality improvement is a truly collaborative effort, involving resident physicians, operations leadership, nurses, and ED technicians. The Airway and Procedural Sedation Quality Committee comprised of residents with a keen interest in quality improvement and patient safety is committed to developing impactful and sustainable interventions that promote an institutional culture of quality and safety, aimed ultimately at improving patient outcomes.

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