Airway Safety Webinar PresentationL - Patient Safety Movement · • 10 Minutes: Introduction to...

transcript

Airway Safety WebinarJune14th,2017

ArianaLongley,MPH,VicePresident,PSMFGuestSpeaker:Dr.ArthurKanowitz,MD,FACEP

PatientSafetyMovementFoundationPresents

Agenda

• 10Minutes:IntroductiontoPatientSafetyMovementFoundationandActionablePatientSafetySolutions(APSS)

• 35Minutes:PatientSafetyMovementPartnerPresentation– Dr.ArthurKanowitz,MD,FACEP

• 15Minutes:Q&A

OurMissionZERO PreventablePatientDeaths

by2020(0X2020)

WeStrivetoFosterNewEffortsandBuildOnExistingPatientSafetyProgramsThrough

Commitmentsto

ZEROAFreshApproachtoanOldProblemWithoutReinventingtheWheel

Who Can Take Action?• Hospitals&HealthcareOrganizations

– MakeaCommitment

• CommittedPartners– SigntheCommitmenttoActionletter

• HealthcareTechnologyCompanies– SigntheOpenDataPledge

• Patient&FamilyAdvocates– SharetheirPatientStory,UtilizeResources

• PolicyMakers– IncreaseawarenessandpromotepatientsafetyLegislation

Actionable Patient Safety Solutions (APSS)

1.CultureofSafety

Ø Downloadatpatientsafetymovement.org

2.Healthcare-associatedInfections

(HAIs)

5.Anemia+Transfusions

8.AirwaySafety

3.MedicationErrors

9.EarlyDetection&TreatmentofSepsis

6.Hand-offCommunications

11.OptimizingObstetricSafety

10.OptimalResuscitation

7.NeonatalSafety

4.FailuretoRescue:MonitoringforOpioidInducedResp.Dep.

13.MentalHealth

12.VenousThromboembolism

In order to reach ZERO our goal for 2017:

Dr.ArthurKanowitz,MD,FACEP

• MedicalDirector(Retired),StateofColorado,EmergencyMedicalandTraumaServices

• Founder,Chairman,CMO,Securisyn Medical• Member,PatientSafetyMovementFoundation,Airway

SafetyWorkgroup

WhyisAirwaySafetysoImportant?

Andrew“Drew”Hughes

1999-2013

DrewDiedFromthePerfectStorm

AirwaySafetyEvents

UnplannedExtubation

FailuretoIntubate

FailuretoRecognizeaMalpositioned Tube

DrewDiedA

PreventableDeath

ComplicationsofAirwayManagement

TubeMalposition

PressureIschemia

SafetyEvents

Aspiration

FailedIntubation

UnplannedExtubation

SoreThroat

VocalCordParalysis

Pneumonia

CollapsedLung

SevereBrainInjury

Complications

TubeMalposition

PressureIschemia

SafetyEvents

Aspiration

FailedIntubation SoreThroat

VocalCordParalysis

Pneumonia

CollapsedLung

SevereBrainInjury

Complications

UnplannedExtubation

UnplannedExtubationACommonandCostlySafetyEvent

Yearly

70,000Incidencescausing

12,000PreventableDeathsand

$4BillioninHealthcareCosts

UnplannedExtubation

UnplannedExtubation– CommonandCostly

LucasdaSilva,etal.UnplannedEndotrachealExtubations intheIntensiveCareUnit.Anesth Analg 2012;114:1003–14

Common

AnesthesiaandAnalgesia2012114:1003-1014

ReviewofWorldwideLiterature50Studies

7.3%UnplannedExtubation Rate

Last5years6.4%(2.1%-18.9%)

73,000incidencesofUEyearlyintheU.S.

*Carsonetal.TheChangingEpidemiologyofMechanicalVentilation:APopulation- BasedStudy.JIntensiveCareMed.2006Feb; 21(3):173-182.

>1,000,000*MechanicallyVentilated

ICUPatients

7.3%=73,000UnplannedExtubation

UnplannedExtubation

Common

Carsonetal.TheChangingEpidemiologyofMechanicalVentilation:APopulation- BasedStudy.JIntensiveCareMed.2006Feb;21(3):173-182.

CostlyPatientComplications

Pneumonia

Severe BrainInjury

UnplannedExtubation

VocalCord Paralysis

CostlyIncreased LOS

DeLassence A,Alberti C.Azoulay E,Miere E.ChevalC,etal.Impactofunplannedextubation andreintubationafterweaningonnosocomialpneumoniariskinintensivecareunit:aprospectivemulticenterstudy.Anesthesiology.2002Jul;97(1):148-56

UnplannedExtubation

CostlyTotalIncreasedCostofHospitalStay

AverageCostofICUStay(VentilatedPatientswithUE)=$116,070

AverageCostofICUStay(VentilatedPatientswithoutUE)=$59,206________________________________________________________________________

AverageCostofComplicationsfromUnplannedExtubation=$56,864/pt

Needham,etal.Theimportanceofunderstandingthecostsofcriticalcareandmechanicalventilation.Crit CareMed2005Jun33(6)1266-71.

UnplannedExtubation

Dasta,etal.DailyCostofanICUDay.Crit CareMed2005June33(6)1266-71

253USHospitals.51,000pts.

$4,151,072,000

UnplannedExtubation

AveHospital(4500MVpts/yr)

Every1%ImprovementinUERate=$2.5M

UnplannedExtubation

CostlyMortality

DeGroot RI,etal.Riskfactorsandoutcomesafterunplannedextubation intheICU:Acasecontrolstudy.CriticalCare,2011,15:R19

12,000DeathsYearly

intheU.S.*19%MortalityRate

UnplannedExtubationis…

CommonandCostly

UnplannedExtubation

forcesappliedtoremovetheairwaydevice

forcesappliedtorestraintheairwaydevice

EXCEEDS

UnplannedExtubation

TheCauseIs

SimplePhysics

CurrentManagement

AdhesiveTape

HollisterAnchorFast

Laerdal ThomasTubeHolder

CurrentManagement

RateofUnplannedExtubationRemains

Unacceptable

7.3%Unplanned Extubation

Is likelyjust the

tip of the Iceberg

HowDoWeGetTo

ZEROPREVENTABLEDEATHS

FromUnplannedExtubation?

GETTINGTOZERO

Is likelyjust the

tip of the Iceberg

Unplanned Extubation

WhatwillittaketogettoZEROPREVENTABLEDEATHS?

• UniversalTracking

• ApplicationofAPSS

• SharingBestPractices

• New“Disruptive”Technology

Is likelyjust the

tip of the Iceberg

“IfYouCan’tMeasureIt,YouCan’tImproveIt”.

-PeterDrucker

GETTINGTOZERO

Is likelyjust the

tip of the Iceberg

UnplannedExtubationisasignificant

PatientSafetyIssue.

Yet,mosthospitalsdon’ttrack

unplannedextubation…

UnplannedExtubation

…partiallybecausemostofthemajorEMRs

donotincludeUEasadatafield.

Is likelyjust the

tip of the Iceberg

UnplannedExtubation

QualityMetrics

CurrentlyConsideringAdding

UnplannedExtubation

Is likelyjust the

tip of the Iceberg

UnplannedExtubation

DOWNLOADUnplannedExtubation

DataBrochure

www.patientsafetymovement.org/

Clickonthefollowinglinks:1. ChallengesandSolutions2. PatientSafetyNewsletter

Scrollto:WebinarArchiveAirwaySafety

AirwaySafetyIntroCard

NumberofUE

100patients

NumberofUE

100ventilationdays

6.4UE/100pts

6.4%(2.1%-18.9%)

0.6UE/100MVDays

0.6(0.1-3.6)

Is likelyjust the

tip of the Iceberg

AirwaySafetyAPSS#8ExecutiveSummaryChecklist

• Assembleacoremultidisciplinaryteam

• EstablishNeedforImprovement

• RequireTracking;UseDatatoImproveCare

• PoliciesandProcedures;StandardizeBestPractices,

• DevelopComprehensiveAirwayToolkit

• CollectData;Review;FindSolutions;Educate;Implement;Verify

Is likelyjust the

tip of the Iceberg

AirwaySafetyAPSS#8

• PerformanceGap• LeadershipPlan• PracticePlan• TechnologyPlan• Metrics

• SaferAirwayEssentialComponents• FailedAirwayProtocol• AirwayEquipment• CriticalPractices• TeamTraining

Is likelyjust the

tip of the Iceberg

Whatwillittake

togetto

ZEROPREVENTABLEDEATHS?

Is likelyjust the

tip of the Iceberg

WhatwillittaketogettoZEROPREVENTABLEDEATHS?

• UniversalTracking

• ApplicationofAPSS

• SharingBestPractices

• New“Disruptive”Technology

Disruptive Technology

UniversityofColoradoBioMed EngineeringComparativeForceStudy

FiveDevices

Disruptive Technology

Restraint Force(lbs)

Tape 14- 39TwillTies 19- 30Laerdal ThomasTubeHolder 18- 31HollisterAnchorFast 19- 43SolidAIRity 46- 65

Is likelyjust the

tip of the Iceberg

UnplannedExtubation

FindOut:

Whatisyourhospital’srateofUE?

Doesyourhospital’sEMRhaveUESpecificDataFields?

Implement:

ActionablePatientSafetySolutionsAPSS#8– AirwaySafety

Thank you!

Airway Safety Webinar PresentationL - Patient Safety Movement · • 10 Minutes: Introduction to...

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