Airway Safety Webinar PresentationL - Patient Safety Movement · • 10 Minutes: Introduction to...
Transcript of Airway Safety Webinar PresentationL - Patient Safety Movement · • 10 Minutes: Introduction to...
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
(VTE)
In order to reach ZERO our goal for 2017:
8
Dr.ArthurKanowitz,MD,FACEP
• MedicalDirector(Retired),StateofColorado,EmergencyMedicalandTraumaServices
• Founder,Chairman,CMO,Securisyn Medical• Member,PatientSafetyMovementFoundation,Airway
SafetyWorkgroup
9
WhyisAirwaySafetysoImportant?
10
Andrew“Drew”Hughes
1999-2013
11
DrewDiedFromthePerfectStorm
of
AirwaySafetyEvents
UnplannedExtubation
FailuretoIntubate
FailuretoRecognizeaMalpositioned Tube
12
DrewDiedA
PreventableDeath
ComplicationsofAirwayManagement
13
TubeMalposition
PressureIschemia
SafetyEvents
Aspiration
FailedIntubation
UnplannedExtubation
SoreThroat
VocalCordParalysis
Pneumonia
CollapsedLung
SevereBrainInjury
DEATH
Complications
ComplicationsofAirwayManagement
14
TubeMalposition
PressureIschemia
SafetyEvents
Aspiration
FailedIntubation SoreThroat
VocalCordParalysis
Pneumonia
CollapsedLung
SevereBrainInjury
DEATH
Complications
UnplannedExtubation
UnplannedExtubationACommonandCostlySafetyEvent
ComplicationsofAirwayManagement
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
Death
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.
CostlyTotalIncreasedCostofHospitalStay
AverageCostofICUStay(VentilatedPatientswithUE)=$116,070
AverageCostofICUStay(VentilatedPatientswithoutUE)=$59,206________________________________________________________________________
AverageCostofComplicationsfromUnplannedExtubation=$56,864/pt
$4,151,072,000
Needham,etal.Theimportanceofunderstandingthecostsofcriticalcareandmechanicalventilation.Crit CareMed2005Jun33(6)1266-71.
UnplannedExtubation
Dasta,etal.DailyCostofanICUDay.Crit CareMed2005June33(6)1266-71
253USHospitals.51,000pts.
CostlyTotalIncreasedCostofHospitalStay
AverageCostofICUStay(VentilatedPatientswithUE)=$116,070
AverageCostofICUStay(VentilatedPatientswithoutUE)=$59,206________________________________________________________________________
AverageCostofComplicationsfromUnplannedExtubation=$56,864/pt
AveHospital(4500MVpts/yr)
Every1%ImprovementinUERate=$2.5M
Needham,etal.Theimportanceofunderstandingthecostsofcriticalcareandmechanicalventilation.Crit CareMed2005Jun33(6)1266-71.
UnplannedExtubation
Dasta,etal.DailyCostofanICUDay.Crit CareMed2005June33(6)1266-71
253USHospitals.51,000pts.
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
Rate
Is likelyjust the
tip of the Iceberg
HowDoWeGetTo
ZEROPREVENTABLEDEATHS
FromUnplannedExtubation?
GETTINGTOZERO
7.3%Unplanned Extubation
Rate
Is likelyjust the
tip of the Iceberg
Unplanned Extubation
WhatwillittaketogettoZEROPREVENTABLEDEATHS?
• UniversalTracking
• ApplicationofAPSS
• SharingBestPractices
• New“Disruptive”Technology
7.3%Unplanned Extubation
Rate
Is likelyjust the
tip of the Iceberg
“IfYouCan’tMeasureIt,YouCan’tImproveIt”.
-PeterDrucker
GETTINGTOZERO
7.3%Unplanned Extubation
Rate
Is likelyjust the
tip of the Iceberg
UnplannedExtubationisasignificant
PatientSafetyIssue.
Yet,mosthospitalsdon’ttrack
unplannedextubation…
UnplannedExtubation
…partiallybecausemostofthemajorEMRs
donotincludeUEasadatafield.
7.3%Unplanned Extubation
Rate
Is likelyjust the
tip of the Iceberg
UnplannedExtubation
QualityMetrics
CurrentlyConsideringAdding
UnplannedExtubation
7.3%Unplanned Extubation
Rate
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)
7.3%Unplanned Extubation
Rate
Is likelyjust the
tip of the Iceberg
Actionable Patient Safety Solutions (APSS)
AirwaySafetyAPSS#8ExecutiveSummaryChecklist
• Assembleacoremultidisciplinaryteam
• EstablishNeedforImprovement
• RequireTracking;UseDatatoImproveCare
• PoliciesandProcedures;StandardizeBestPractices,
• DevelopComprehensiveAirwayToolkit
• CollectData;Review;FindSolutions;Educate;Implement;Verify
7.3%Unplanned Extubation
Rate
Is likelyjust the
tip of the Iceberg
Actionable Patient Safety Solutions (APSS)
AirwaySafetyAPSS#8
• PerformanceGap• LeadershipPlan• PracticePlan• TechnologyPlan• Metrics
• SaferAirwayEssentialComponents• FailedAirwayProtocol• AirwayEquipment• CriticalPractices• TeamTraining
7.3%Unplanned Extubation
Rate
Is likelyjust the
tip of the Iceberg
Unplanned Extubation
Whatwillittake
togetto
ZEROPREVENTABLEDEATHS?
7.3%Unplanned Extubation
Rate
Is likelyjust the
tip of the Iceberg
Unplanned Extubation
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
7.3%Unplanned Extubation
Rate
Is likelyjust the
tip of the Iceberg
UnplannedExtubation
FindOut:
Whatisyourhospital’srateofUE?
Doesyourhospital’sEMRhaveUESpecificDataFields?
Implement:
ActionablePatientSafetySolutionsAPSS#8– AirwaySafety
Q & A
Thank you!