However beautiful the strategy, you should occasionally look at the results –Winston Churchill

WE KNOW:

First-pass success is important: It’s associated with less hypoxemia and hypotension (1)

Hypoxemia and/or hypotension matter (2)

First pass success should be: at least 85% (3)

DEFINITIONS: (4)

What defines a pass (i.e. attempt at endotracheal intubation)? Instrument in, Instrument out.

E.g. DL blade in then keeping a DL blade in while being passed/grabbing a bougie= still one attempt

E.g. DL blade in then taking a DL blade out, bagging a patient while someone looks for/opens a bougie= two attempts

What defines hypoxia? O2 saturation <90% not good, <85% really not good, <80% bad

What defines hypotension? SBP <90mmHg not good, <80mmHg really not good, <70mmHg bad

HOW WELL DO YOU DO?

Record it.

The ‘Blue Card’ can be used to record your airway management over time. We have printed it on blue cardboard, front and back. Electronic version is currently being developed.

Feel free to use it, free of charge, to evaluate your own practice. Better yet, it can be used in your department or hospital-wide to give even more information.

Used at both the Royal Columbian and Vancouver General Hospitals in Vancouver, British Columbia this card has been around in various iterations for over 5 years.

This a word document. Feel free to change it/develop other questions as you see fit.

Do you want to really know how well you do?

Get someone else watching you to fill it out. Avoid your own ‘confidence bias’. Avoid multi-tasking during airway management.

How do you change your system?

Collect your data. If you are collecting patient identifiers make sure you have authorization for your Quality Improvement Initiative through your hospital’s administrative process.

Form an airway committee (we have EM, ICU, Anesth, RT, RN, Admin reps)

Look at data.

Change a system.

The Blue Card

REFERENCES:

https://journals.lww.com/anesthesia-analgesia/fulltext/2015/11000/The_First_Shot_Is_Often_the_Best_Shot___First_Pass.39.aspx https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5173421/pdf/nihms809058.pdf https://onlinelibrary.wiley.com/doi/pdf/10.1111/1742-6723.12704 While there is variation as to what defines mild, moderate or severe hypoxia or hypotension, these are how we have defined them. These are not ‘set in stone’. As more information becomes available, they should change for various conditions (e.g. traumatic brain injury may benefit from SBP>110mmHg).

If you want to compare results with others, it’s important to use the same definitions.

GOOD READS:

Click to access Preox-annals-article.pdf

https://link.springer.com/article/10.1007%2Fs12630-017-0834-z

https://onlinelibrary-wiley-com.ezproxy.library.ubc.ca/doi/epdf/10.1111/acem.13271

https://onlinelibrary.wiley.com/doi/epdf/10.1111/anae.13163

https://academic.oup.com/bja/article/117/suppl_1/i60/1744126