RSI Guidelines and audit process

[Melbourne MICA]

Hi troops

I appreciate the RSI topic is a common one but could I ask for your assistance on particular issue.

I am working in our education department and the audit process for RSI cases is being streamlined. Our department is trying to design an audit template that is based upon a objective analysis of RSI's performed by staff. At the moment, particularly on the issue of "was the RSI necessary" the conclusion is still way too subjective. I have suggested to our department head a useful first step would be to look at overseas RSI guidelines or better still, if you have already formulated an audit template.

IF anyone could help with perhaps a link to your published RSI guidelines or audit process this would be much appreciated. If material is confidential by all means send me a personal message.

Thanks all

MM

 

[MrBrown]

RSI is still "newish" here in that while we have had it since 2006 it's been exclusive to Auckland because it has the largest population and greatest clinical infrastructure so its easiest to keep an eye on people using it and get opportunities to use it. Almost like Metro vs County in Victoria, well, AV now lol.

We have now rolled out RSI nationwide to select Intensive Care Paramedics who must pass a threefold selection, training and exam package. Brown has not seen said package but given that RSI here is the doing of Tony Smith (our Medical Director) and that he both a Consultant Anaesthetist and Consultant Intensivest it's fair to say it's probably a rather rigorous and best practice package. Let Brown see if Brown can get a looksee.

Anyway, our actual RSI guideline is below.

6.3 RAPID SEQUENCE INTUBATION (RSI)
• Indicated for patients with a GCS <10 with airway or ventilatory
compromise.

• Absolute contraindications:
a. Known history or family history of malignant hyperthermia or
b. Paraplegics/quadriplegics or
c. Any muscle disorder with long term weakness or
d. Hyperkalemia strongly suspected or
e. Electronic capnography unavailable or
f. No dedicated suitable assistant (2nd AP preferred).

• Relative contraindications:
a. Age < 5 or > 75 yrs or
b. Age > 75 years with stroke or COAD as underlying cause or
c. Predicted difficult airway or
d. Less than 15 minutes to hospital or
e. Underlying cause is likely to rapidly improve e.g. GHB
poisoning or post seizure.

• Preparation:
a. Assess the patient for signs of difficult intubation.
b. Prepare all equipment and brief assistant.
c. Draw up and label drugs, ensure running IV line.
d. Ensure monitoring in place: SpO2, ETCO2, ECG and NIBP.
e. Pre-oxygenate for 3 minutes with 100% oxygen via manual
ventilation bag. If unable to pre-oxygenate administer 6 large
breaths immediately after apnoea occurs.
Miscellaneous 87

• Medicines:
a. Give IV fentanyl over 1 minute, 2-3 minutes before induction.
b. Regimen 1. For all patients with neurological cause for coma
(e.g. TBI, stroke, post cardiac arrest) that do not have significant
shock - give IV midazolam and IV suxamethonium.
c. Regimen 2. For all other patients and particularly for those with
shock – give IV ketamine and IV suxamethonium.

• Intubate and confirm ETT position with capnography.
• If unable to intubate implement failed intubation drill.
• Give IV vecuronium once ETT confirmed in trachea.
• Ventilate to ETCO2 30-35 mmHg (exception – life threatening
asthma, ventilate at 6 breaths/min and ignore ETCO2).
• Give additional sedation (midazolam 1-3 mg and morphine 1-3
mg) and vecuronium as required.

Now each potential or actual RSI must be debriefed with Tony Smith

 

[boingo]

We maintain an airway registry of all intubations including RSI, similar to the National Emergency Airway Registry. www.near.edu

 

[Melbourne MICA]

Auditing RSI

Thanks guys. Sorry I haven't responded sooner.

I'm more interested in the auditing process rather than the guidelines. As I said our department is trying to come up with an objective auditing template for RSI - at the moment final conclusions are often subjective especially for the decision/rationale to RSI - that being the most important one after all.

There is no problem with the skill itself amongst our staff. I'm currently in the process of doing our quarterly RSI reviews and our boys and girls are nailing the procedure almost without fault. I have done our January and half of Feb results - about 80- or 90 cases so far and the strike rate is about 99%+. (read it and weap says the aussie!). SO the issue is not procedure or skill just whether the RSI was warranted.

Cheers

MM

 

[Melbourne MICA]

Thanks

We maintain an airway registry of all intubations including RSI, similar to the National Emergency Airway Registry. www.near.edu

Hey Boingo I just had a look at your link - exactly the kind of thing I am after -thanks heaps.

MM

 

[Smash]

I have a bit of trouble imagining how an objective set of criteria can be applied to an intervention that is, and needs to be, very much subjective. Sure, you can have a list of "things that need RSI" and "things that don't need RSI", but for every item on every list there will be an equally long, or longer, list of exceptions and caveats.
Is the need for a simple set of criteria driven by a view that RSI is being done inappropriately, or is it just because the audit process is too onerous for those doing it? It seems to me that implementing a set of "you must/must not" criteria is the antithesis of what Australian paramedicine claims to be: non-protocol bound, evidence based best practice, where highly trained clinicians make appropriate decisions based on the situation and their gestalt.
My personal view is that medics carrying out RSI should be expected to make decisions based on knowledge and experience. If they need set criteria written down, they probably shouldn't be given the scary drugs to play with.

 

[Melbourne MICA]

RSI audit

Sorry SMASH I didn't explain very well what we are trying to do and I concur with everything you said.

Our staff already have a well established guideline and audit process at the team level. RSI and other major interventions also get bumped up a level to our CSO's - clinical support officers as well as getting audited by our team managers. This process therefore assesses each and every application of the RSI guideline at an individual level.

Now when the cases come through to headquarters however, they are looked at more strategically if you like to see if trends are emerging such as more and more OD RSI's or occasions where staff are close to hospital but electively RSI anyway. The Guidelines cover a lot of contingencies and set the clinical framework for our practice and our staff have shown they are consistently meeting high standards of practice.

However RSI as a pre-hospital practice also comes under the scrutiny of the medical community in general especially from the ED drs at the coalface. Our department has to look at feedback from here and also address concerns. So in order to be able to go back to them with meaningful general and more specific data my bosses wanted to look at a template type approach where we can scrutinise all the nuances of cases, spot trends (as mentioned) as they develop or conversely be able to demonstrate that our staff are doing a great job in every respect from decision making rationales, compliance with guidelines, clinical troubleshooting, procedural success, good clinical judgements etc.

So the the audit is with a bigger brush as it were. At the moment the practicalities are such that myself or someone else sits at a desk and goes through each case and every case month by month one by one so it is very much operator dependant. Some guys doing the job are sharp and pick things up, others not so. (I hope I am the former!!!).

Its not about being prescriptive or formularised but rather having redundancy built into the system so no matter who does the audit we make sure we cover the right areas.

I hope that makes a bit more sense.

As you said, our troops have a world's best practice standard in the EMS RSI area our recently successful RSI for head trauma trial being an example.

We want to keep it that way hence I'm looking to my comrades here on the forum to give some feedback.

Thanks as always for your contributions and those of others.

MM

 

[boingo]

Hey Boingo I just had a look at your link - exactly the kind of thing I am after -thanks heaps.

MM

Glad I could help.

 

[Melbourne MICA]

Hey there Brown

RSI is still "newish" here in that while we have had it since 2006 it's been exclusive to Auckland because it has the largest population and greatest clinical infrastructure so its easiest to keep an eye on people using it and get opportunities to use it. Almost like Metro vs County in Victoria, well, AV now lol.

We have now rolled out RSI nationwide to select Intensive Care Paramedics who must pass a threefold selection, training and exam package. Brown has not seen said package but given that RSI here is the doing of Tony Smith (our Medical Director) and that he both a Consultant Anaesthetist and Consultant Intensivest it's fair to say it's probably a rather rigorous and best practice package. Let Brown see if Brown can get a looksee.

Anyway, our actual RSI guideline is below.

6.3 RAPID SEQUENCE INTUBATION (RSI)
• Indicated for patients with a GCS <10 with airway or ventilatory
compromise.

• Absolute contraindications:
a. Known history or family history of malignant hyperthermia or
b. Paraplegics/quadriplegics or
c. Any muscle disorder with long term weakness or
d. Hyperkalemia strongly suspected or
e. Electronic capnography unavailable or
f. No dedicated suitable assistant (2nd AP preferred).

• Relative contraindications:
a. Age < 5 or > 75 yrs or
b. Age > 75 years with stroke or COAD as underlying cause or
c. Predicted difficult airway or
d. Less than 15 minutes to hospital or
e. Underlying cause is likely to rapidly improve e.g. GHB
poisoning or post seizure.

• Preparation:
a. Assess the patient for signs of difficult intubation.
b. Prepare all equipment and brief assistant.
c. Draw up and label drugs, ensure running IV line.
d. Ensure monitoring in place: SpO2, ETCO2, ECG and NIBP.
e. Pre-oxygenate for 3 minutes with 100% oxygen via manual
ventilation bag. If unable to pre-oxygenate administer 6 large
breaths immediately after apnoea occurs.
Miscellaneous 87

• Medicines:
a. Give IV fentanyl over 1 minute, 2-3 minutes before induction.
b. Regimen 1. For all patients with neurological cause for coma
(e.g. TBI, stroke, post cardiac arrest) that do not have significant
shock - give IV midazolam and IV suxamethonium.
c. Regimen 2. For all other patients and particularly for those with
shock – give IV ketamine and IV suxamethonium.

• Intubate and confirm ETT position with capnography.
• If unable to intubate implement failed intubation drill.
• Give IV vecuronium once ETT confirmed in trachea.
• Ventilate to ETCO2 30-35 mmHg (exception – life threatening
asthma, ventilate at 6 breaths/min and ignore ETCO2).
• Give additional sedation (midazolam 1-3 mg and morphine 1-3
mg) and vecuronium as required.

Now each potential or actual RSI must be debriefed with Tony Smith

Herr Brown

Hope you didn't have to type all that in. If you did thanks for the info -if you didn't thanks for the info. You guys across the Tassie Sea had a centre involved in our RSI trial didn't you? By the way - on a serious note; we all felt the pain over here about Christchurch. Sincerely hope you had no rellies or friends involved. We aussies like you Kiwis after all - well a bit anyway - well except for the All Blacks and Jonah Lomu - I rmember seeing Tim Horan a while back (who used to play fullback for the Wallabies as you would recall and stood all of about 5 foot 7 tall) crash tackle Jonah head on up the wing whilst the big fella was in full sprint. We could see it about to happen - we all figured someone should order a burial casket for Tim ahead of time. I couldn't watch.

Anyway - very similar guideline to ours. On my question above we are looking at maybe an algorhythm or similar type template.

Thanks as always for the willing contributions.

MM

 

[MrBrown]

Brown thinks we had something to do with the Victorian study

Ah, Clinical Procedures in PDF format make copying easier lol

 

[Melbourne MICA]

All blacks and then some

What?!!%&$ - Brown prefers talking about PDf over talking about Rugby?

MM