Canadian paramedic experience with intramuscular ketamine for extreme agitation: A quality improvement initiative

BackgroundThere are no published reports in Canada examining paramedic use of ketamine for highly agitated patients or excited delirium syndrome. We employed a Plan, Do, Study, Act (PDSA) quality improvement approach to evaluate the safety and effectiveness of advanced care paramedic administered intramuscular (IM) ketamine for patients with extreme agitation in the out-of-hospital setting.MethodsData were prospectively collected from July 2018 to January 2019 when advanced care paramedics with specific training administered IM ketamine as an alternative to midazolam. Paramedics used a clinical audit form to document the ketamine dose, patient response on the Richmond Agitation Sedation Scale (RASS) at time intervals, adverse effects, and any airway management interventions they performed. ResultsThirty-three patients received either 4 mg/kg or 5 mg/kg of ketamine. Combining data for both doses, the median change in RASS score at 5 minutes post-ketamine was 3 (range 0 to 8) and statistically significant for each dose. There were seven cases (21%) with reported adverse effects including SpO2 <90% (3/7), hypersalivation (3/7), trismus or teeth grinding (2/7), muscular rigidity (1/7) and laryngospasm (1/7). Statistical analysis confirmed that the incidence of adverse events was not dose dependent. Basic airway management was performed in one-third of all cases.ConclusionWe piloted the implementation of ketamine for sedation in our paramedic system by employing a PDSA cycle. Ketamine 5 mg/kg IM provided effective control of acutely agitated patients with adequate sedation at 5 minutes post-delivery. Any adverse events that occurred as a result of IM ketamine were readily managed with basic airway management interventions.

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Adverse events in radiation oncology: A case series from wake up safe, the pediatric anesthesia quality improvement initiative

Pediatric Anesthesia ◽

10.1111/pan.13567 ◽

2019 ◽

Vol 29 (3) ◽

pp. 265-270 ◽

Cited By ~ 6

Author(s):

Robert E. Christensen ◽

Rebecca C. Nause-Osthoff ◽

Jeffrey C. Waldman ◽

Daniel E. Spratt ◽

Jason W. D. Hearn

Keyword(s):

Quality Improvement ◽

Adverse Events ◽

Radiation Oncology ◽

Pediatric Anesthesia ◽

Case Series ◽

Quality Improvement Initiative

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Procedural Sedation for Infants, Children, and Adolescents

10.1542/9781581109344 ◽

2015 ◽

Author(s):

Keyword(s):

Quality Improvement ◽

Adverse Effects ◽

Adverse Events ◽

Children And Adolescents ◽

Health Professionals ◽

Procedural Sedation ◽

Design And Implementation ◽

Anesthetic Agents ◽

Clinical Scenarios ◽

Sedation Program

New! Invasive and noninvasive procedures are a common and necessary component in the management of infants and children with acute and chronic diseases. As technology continues to expand, there are an increasing number of techniques that require procedural sedation outside of the operating room. Authored by experts in a variety of specialties, Procedural Sedation for Infants, Children, and Adolescents is a comprehensive guide for the initial design and implementation of a procedural sedation program and a tool to educate pediatric health professionals on medications used for sedation, associated adverse events, and the treatment of these adverse effects. Contents include: Pre-sedation evaluation Documentation and parental instructions Monitoring for procedural sedation Medications Specific clinical scenarios Non-pharmacologic interventions Topical and local anesthetic agents Quality improvement and assurance and more

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A quality improvement initiative to increase the safety of pediatric emergency airway management

Pediatric Anesthesia ◽

10.1111/pan.13275 ◽

2017 ◽

Vol 27 (12) ◽

pp. 1271-1277 ◽

Cited By ~ 4

Author(s):

Elliot Long ◽

Domenic R. Cincotta ◽

Joanne Grindlay ◽

Stefano Sabato ◽

Emmanuelle Fauteux-Lamarre ◽

...

Keyword(s):

Quality Improvement ◽

Airway Management ◽

Pediatric Emergency ◽

Quality Improvement Initiative ◽

Emergency Airway Management ◽

Emergency Airway

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Faculty Opinions recommendation of A quality improvement initiative to increase the safety of pediatric emergency airway management.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.732029546.793538584 ◽

2017 ◽

Author(s):

Narasimhan Jagannathan

Keyword(s):

Quality Improvement ◽

Airway Management ◽

Pediatric Emergency ◽

Quality Improvement Initiative ◽

Emergency Airway Management ◽

Emergency Airway

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Decline in ICU adverse events, nosocomial infections and cost through a quality improvement initiative focusing on teamwork and culture change

BMJ Quality & Safety ◽

10.1136/qshc.2005.016576 ◽

2006 ◽

Vol 15 (4) ◽

pp. 235-239 ◽

Cited By ~ 181

Author(s):

M Jain

Keyword(s):

Quality Improvement ◽

Adverse Events ◽

Nosocomial Infections ◽

Culture Change ◽

Quality Improvement Initiative

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Improving first-pass success rates during emergency intubation at an academic emergency department: a quality improvement initiative

International Journal for Quality in Health Care ◽

10.1093/intqhc/mzab132 ◽

2021 ◽

Vol 33 (3) ◽

Author(s):

Abdullah Bakhsh ◽

Ahd Alharbi ◽

Raghad Almehmadi ◽

Sara Kamfar ◽

Arwa Aldhahri ◽

...

Keyword(s):

Emergency Department ◽

Quality Improvement ◽

Airway Management ◽

Performance Monitoring ◽

Video Laryngoscopy ◽

Rapid Sequence Intubation ◽

Quality Improvement Initiative ◽

Success Rates ◽

Improvement Program ◽

First Pass

Abstract Background Airway management is a high-stakes procedure in emergency medicine. Continuously monitoring this procedure allows performance improvement while revealing safety issues. We instituted a quality improvement initiative in the emergency department to improve first-pass success rates in the emergency department. Methods This was a quality improvement initiative at an academic emergency department from 2018 to 2020. We developed a rapid sequence intubation guideline for procedure standardization and introduced an intubation procedure note for performance monitoring. Data were entered directly by the primary physician and nurse during intubation. The quality improvement team thereafter collected the data retrospectively and entered into a local airway database. More importantly, we introduced a culture of quality improvement and safety in airway management via regular education and feedback. Results We included a total of 146 intubations. The first-pass success rate started at 57.1% and increased to 80.0% during the study period (P < 0.01). Fifty-six percent were male, and the mean age (±SD) was 55.56 (±17.64). Video laryngoscopy was used in 101 (69.2%) patients, while direct laryngoscopy was used in only 44 (30.8%) patients. A logistic regression analysis was conducted to determine the independent factors associated with first-pass success. These factors included the use of video laryngoscopy (odds ratio (OR) 2.47 95% confidence interval (95% CI) [1.62–3.76]) (adjusted OR 3.87 [1.13–13.23]) and good Cormack–Lehane views (grades 1–2) (OR 2.71 95% CI [1.74–4.20]) (adjusted OR 7.88 [2.43–25.53]). Conclusion Our study shows that implementing and maintaining an airway quality improvement program improves first-pass intubation success. Moreover, the use of video laryngoscopy and obtaining good Cormack–Lehane views (grades 1–2) are independently associated with improved first-pass success.

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Impact of a targeted bundle of audit with tailored education and an intubation checklist to improve airway management in the emergency department: an integrated time series analysis

Emergency Medicine Journal ◽

10.1136/emermed-2019-208935 ◽

2020 ◽

Vol 37 (9) ◽

pp. 576-580

Author(s):

Christopher Groombridge ◽

Amit Maini ◽

Alexander Olaussen ◽

Yen Kim ◽

Mark Fitzgerald ◽

...

Keyword(s):

Emergency Department ◽

Time Series ◽

Adverse Events ◽

Time Series Analysis ◽

Airway Management ◽

Success Rate ◽

Intervention Group ◽

Quality Improvement Initiative ◽

Series Analysis ◽

Major Trauma Centre

BackgroundEndotracheal intubation (ETI) is a commonly performed but potentially high-risk procedure in the emergency department (ED). Requiring more than one attempt at intubation has been shown to increase adverse events and interventions improving first-attempt success rate should be identified to make ETI in the ED safer. We introduced and examined the effect of a targeted bundle of airway initiatives on first-attempt success and adverse events associated with ETI.MethodsThis prospective, interventional cohort study was conducted over a 2-year period at an Australian Major Trauma Centre. An online airway registry was established at the inception of the study to collect information related to all intubations. After 6 months, we introduced a bundle of initiatives including monthly audit, monthly airway management education and an airway management checklist. A time series analysis model was used to compare standard practice (ie, first 6 months) to the postintervention period.ResultsThere were 526 patients, 369 in the intervention group and 157 in the preintervention comparator group. A total of 573 intubation attempts were performed. There was a significant improvement in first-attempt success rates between preintervention and postintervention groups (88.5% vs 94.6%, relative risk 1.07; 95% CI 1.00 to 1.14, p=0.014). After the introduction of the intervention the first-attempt success rate increased significantly, by 13.4% (p=0.006) in the first month, followed by a significant increase in the monthly trend (relative to the preintervention trend) of 1.71% (p<0.001). The rate of adverse events were similar preintervention and postintervention (hypoxia 8.3% vs 8.9% (p=0.81); hypotension 8.3% vs 7.0% (p=0.62); any complication 27.4% vs 23.6% (p=0.35)).ConclusionsThis bundle of airway management initiatives was associated with significant improvement in the first-attempt success rate of ETI. The introduction of a regular education programme based on the audit of a dedicated airway registry, combined with a periprocedure checklist is a worthwhile ED quality improvement initiative.

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