2006 OPEN FORUM Abstracts
IMPROVING PATIENT SAFETY BY UPDATING INTUBATION EQUIPMENT AND PROCESSES
Kathy L. Kammeraad RRT Spectrum Health, Grand Rapids MI
DEVICE EVALUATION: Intubation Equipment
Background: The use of intubation equipment is always associated with high acuity situations. Forty-six intubation related incident reports were filed from Jan 2001-July 2004 at the Spectrum Health Campuses. A task force consisting of physicians, risk and compliance, nursing, respiratory, and central supply services was formed to address these issues; which the committee sensed, reflected only a portion of the actual incidents. Not having adequate equipment and processes in place can potentially put patients and caregivers at risk. Malfunctioning laryngoscope handles, faulty laryngoscope blades, and poor quality intubation light sources had been an ongoing concern.
Major issues identified:
- 12 separate manufacturers equipment identified
- no current system to check light source or identify shelf life once airway box sealed
- untrained staff being held responsible to judge adequacy of equipment
- inadequate light source of equipment in circulation
Method: The anesthesia department, having similar equipment concerns, had completed a multi- manufacturer trial resulting in the purchase of Heine rechargeable handles and Heine reusable metal blades, which they concluded had the best light source available on the market. Using anesthesia as our standard of excellence, the task force proposed a trial of Heine rechargeable laryngoscope handles for all crash carts throughout the system. By implementing a handle test to the crash cart checklist, the light source is checked on a regular basis. The task force continued to consider not only product but also process. Knowing the reusable metal blades used by anesthesia require some extra care to assure warranty and are quite expensive, the proposal was taken one step further. If disposable blades proved to be a reliable alternative, the need for cleaning and testing by non-clinical personnel could be eliminated. As a result, a trial of a Heine disposable plastic laryngoscope blade was developed along with the rechargeable handles. Physician champions were identified in the departments of anesthesia, pulmonary, pediatrics, and emergency medicine to conduct a 30-day trial. Company supplied equipment was distributed to six critical care units using respiratory therapy as liaison and facilitator. Evaluation forms along with discussions with physician champions assessed the acceptance of the new product. Support for disposable blades was received and the proposal for all new equipment was presented to and approved by senior leadership. Members of the committee defined processes, developed a new checklist for crash-cart, educated staff and distributed the new equipment
Results: Prior to implementation there was an average of 1.6 incidents each month. Three incident reports were generated in the first five months post implementation of the new equipment. Blades were upgraded to a disposable metal Sunmed product based on feedback from the 6-month evaluation period.
To date (May 2006) there have been no further concerns. (0 incidents)
Conclusion: Forming a multidisciplinary group helped to identify the scope of this issue and to bring its importance to the forefront for the entire Spectrum Health System. Benefits yielded by the adoption of this proposal include: improved patient safety through superior light source, elimination of connection problems, elimination of battery issues, improved turn around and cleaning process, improved infection control, standardized equipment and processes, overall improvement for risk management. The upfront cost of purchasing disposable blades ($2.95 each) for 106 crash carts was much less than that of the reusable blades ($110 each). It is estimated that over the years, the cost of replacing disposable blades will be less than the maintenance and replacement costs of the previous equipment.