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October 16, 2018
10/16/2018 3:15:00 PM - 10/16/2018 4:45:00 PM
Room North, Room 22
Standardization of Emergency Airway Carts to Facilitate Difficult Airway Management
Josef Pleticha, M.D., Sarah F. Cotter, M.D., Adrien M. Wang, M.D., Katie Z. Garrett, M.D., Bharat Sharma, M.D., Charles R. Horres, M.D.
Duke University Medical Center, Durham, North Carolina, United States
Disclosures: J. Pleticha: None. S.F. Cotter: None. A.M. Wang: None. K.Z. Garrett: None. B. Sharma: None. C.R. Horres: None.
Background: Difficult airways present real-life challenges to anesthesiologists and can result in significant patient morbidity and mortality. According to ASA’s difficult airway algorithm, alternative airway techniques should be considered after 2 failed attempts at direct laryngoscopy. Many of these techniques require airway adjuncts supplied in an emergency airway cart. The ASA Task Force on Management of the Difficult Airway states that “at least one portable storage unit that contains specialized equipment for difficult airway management should be readily available.” The current airway carts at our institution were rolled out in August 2015. Subsequently, they have evolved from well-delineated units to ones frequently plagued by disorganization and inadequate replenishment or maintenance. Various factors likely contributed to these adverse changes, including inadequate user training, diverse airway management preferences, poor communication with anesthesia technicians, and prolonged time required for turnaround due to limited resources. The goal of this quality improvement project was threefold: to identify the current problems with airway carts, to improve user education and supportive staff training, and to ultimately pare down the carts to necessary, accessible and reliable entities.

Methods: Over a 1-week period, we inspected and inventoried 5 airway carts daily and recorded inconsistencies as compared to a standardized checklist. We then developed a user manual with laminated visual aids to be attached to each airway cart, which was also distributed electronically to inform users about the specifications of the newly designed carts, including pictures of the stocked items to the exact numbers, forms and locations. Following the rollout of the newly designed airway carts, we again inspected and inventoried the carts daily for 1.5 weeks to assess the rate of errors. We then compared these data to those from the pre-intervention group to determine whether the new airway cart design and user guide improved airway cart stocking and consistency.

Results: Prior to intervention, daily inspections of the airway carts demonstrated a stocking error rate of 30.7 ± 2.7% (mean ± standard deviation). The most common stocking problem prior to the intervention was missing items (55%), followed by excess items (32%), unrequested equipment (11%), unclean equipment (1%) and items in the wrong location (1%). Of note, the timely sterilization of reusable items was found to be one of the major barriers from timely restocking of the carts. Based on the identified errors, we devised an intervention consisting of (1) development of a user manual with laminated visual aid that was attached to each airway cart and also distributed electronically to the anesthesia technicians and providers; (2) removable seal attached to each cart which is broken with each use and triggers complete restocking; and (3) replacement of reusable items requiring sterilization by disposable ones. Following the intervention, the stocking error rate decreased dramatically to 3 ± 1.9%. The post-intervention stocking problems were comprised of missing items (37%), overstocking (25%), airway cart in the wrong location (25%), and unrequested equipment (13%).

Conclusion: Our quality improvement project demonstrates a dramatic decrease in stocking errors of the airway cart, resulting in almost complete standardization of the airway cart stocking and turnover at our institution. The improvement was sustained over the entire period during which airway carts were inspected. Future directions include further streamlining of the airway cart equipment and the addition of hallway signage for standardized placement of all carts. The reliable and consistent accessibility of difficult airway equipment achieved by this project will facilitate difficult airway management and improve safety of patients undergoing surgery at our institution.

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