PURPOSE: Endotracheal intubation (ETI) performed in the ICU may be significantly different from that in a controlled environment like the operating room. Frequently, the ICU patient population is sicker and has higher risks of complications. Furthermore, ETI-related complications are often not reported as part of ETI failure. This study examined an ETI protocol used in the Medical ICU of a tertiary teaching hospital and performed a safety system analysis on its application. The analysis identified and quantified critical parameters that contributed most substantively to the ETI failure in the ICU setting.
METHODS: A standard event-tree and fault-tree safety analysis was applied to our ETI protocol that was based on the universal airway algorithm1,2. A distinction was made between failure to insert the tube properly, i.e., insertion failure, and overall intubation failure, defined as insertion failure with or without hypoxemia and/or hypotension occurring during intubation. Fault-tree analysis was employed to evaluate contributions from inadequate procedure preparation, procedural errors by supervising attendings or fellows, house staff, nursing and respiratory therapists, and failure to monitor hemodynamic status. The performance of the intubator under stressful conditions was also examined.
RESULTS: These analyses showed that if severe hypoxia and/or hypotension were considered, the overall intubation success rate fell from 93% to 80%. Hypotension and hypoxia were the most common complications. The results further suggested that inadequate staff support during the ETI procedure contributed proportionally to the overall rate of intubation failure. Given the occurrence of a staffing failure, there was a 23% probability that it would lead to a complicated intubation.
CONCLUSION: Our assessment of an ETI sequence protocol in the ICU reveals the need to include intubation complications as a part of the definition of an intubation failure. Staff support failure contributes proportionally to the overall ETI failure rate.
CLINICAL IMPLICATIONS: ETI failure is system specific. Each ICU should collect site-specific data for monitoring and quality improvement. We also propose the use of an ETI performance vector to communicate the status of ETI.
DISCLOSURE: Kelvin Shiu, None.