MAGIQ project proposal Title: Merseyside Anaesthetic Group for Improving Quality – Mersey Intubation Checklist MAGIQ-MIC
Project leads:
Contact Details
Joseph Hobson, Mark Dunham, Mathew Wood, Clint Jones, Tamryn Miller, Louise Schofield
Proposed Start date: 04.01.2016 Aims / objectives:
Projected duration: ten weeks
This is a multi-centre quality improvement project aiming to improve patient safety during out of theatre intubations. The 4th National Audit Project of the Royal College of Anaesthetists advocates that an intubation checklist be used for all out of theatre intubations. The aims of the project are: 1. Achieve >90% use of pre-intubation checklists for emergency out of theatre intubations within the 10 week period of the project. 2. Increase the acceptance of pre-intubation checklists for emergency out of theatre intubations
Method Pre/post project staff questionnaires It will first involve a staff questionnaire to assess current attitudes towards out of theatre intubation, with a particular focus on issues that may affect safety and other human factors. A similar questionnaire will be completed at the end of the cycle to see if attitudes have changed following any implementation of a checklist. The assigned Hospital Lead will take responsibility for the questionnaire.
Project main phase The project main phase is anticipated to last 8 weeks.
The components of this phase are: 1. Rapid audit and feedback cycles 2. Inter-site benchmarking and modification of practice through social norms 3. Using the rapid audit & feedback to enable & drive local PDSA cycles 4. Using the multi-site perspective on effective approaches (eg learning from excellence) to assist hospitals in their local PDSA Rapid audit and feedback cycles (projected to last one week each) will frame the project. Primary measures are the number of out of theatre intubations and whether or not preintubation checklists were used. This data is collected locally and collated at a regional level. They will log the use (or not) of an intubation checklist, the grade of intubator, where the intubation was performed, incidents, etc. Hospitals will receive weekly updates of their performance data as well as any qualitative ‘staff comments’. In addition to their own data, hospitals will receive a benchmarking figure in the form of a weekly aggregate statistic of checklist performance in the region plus anonymised figures of the best performing sites. This data will inform sites so they can see how their checklist and compliance matches other hospitals, suggest what they are capable of achieving and also incentivise trusts to increase their use of intubation checklists through the power of social norms. The rapid audit and feedback cycles facilitate local departments to undertake changes to increase the use of pre-intubation checklists as per the Plan-Do-Study-Act cycle. Anaesthetic departments, trainees, as well as ODPs and nurses will be encouraged to engage in developing actions in how the use of pre-intubation checklists may be improved in respect of the local context. This may include informal interviews, or process charts to identify barriers to checklist use and opportunities for local adaptation. These barriers may include impractical checklists or lack of stock in relevant locations. Through the network of project contributors there will be opportunity for the local PDSA cycles to draw upon experiences, actions, and solutions from across the region. For example there are several checklists currently in use in the region and hospitals may consider adopting a higher-performing alternative to their current checklist. At the initiation of the project, each hospital may choose to use their own checklist, or a checklist provided by MAGIQ if they don’t currently have one in practice.
Project Promotion The project will be promoted in order to raise awareness, as data collection will be driven by trainee enthusiasm. This will be done through posters in key areas and talks in departmental audit and teaching meetings.
Relationship to local / national priorities eg guidelines, national service frameworks, etc The 4th National Audit Project of the Royal College of Anaesthetists GPAS and ACSA recommend considering the use of intubation checklists for emergency out of theatre intubations.
Background / rationale for project objectives The 4th National Audit Project (NAP-4) of the Royal College of Anaesthetists highlighted the increased risks involved in intubating patients outside of a theatre environment. Death rate for failed intubations on the Intensive Care Unit was 50%. Adequate preparation is central to successful intubation. NAP-4 showed that identifying high-risk patients, preparing correct equipment and planning in case of failure were crucial in preventing complications. Consequently, NAP-4 has recommended a checklist for out of theatre intubations. Pre-intubation checklists have been shown to reduce the number or intubation related complications and increase adherence to safe practice (Smith 2015).
Smith et al (2015). A preprocedural checklist improves the safety of emergency department intubation of trauma patients. Academic Emergency Medicine; 22(80):989-92. Specialties involved:
Anaesthesia, Intensive Care, nursing staff, operating department practitioners.
Background / rationale for the QI method
1. Rapid audit and feedback Audit and feedback is an established and familiar process for cycles clinical improvement. Effective feedback is individualised, contemporaneous, and occurs on multiple occasions. 2. Inter-site benchmarking and modification of practice through social norms
Awareness of effective practice elsewhere informs clinicians as to what is possible. Social norms influence attitudes towards behaviours.
3. Using the rapid audit & feedback to enable & drive local PDSA cycles
Plan-Do Study – Act cycles and the Model For Improvement are recognised approaches to Quality Improvement and promoted by the RCoA and the Health Foundation. Locally driven PDSA cycles allow for adaptability for local context, increased ownership and investment in the change process, and develops local expertise in QI.
4. Using the multi-site Takes advantage of good practice in other sites. Facilitates perspective on effective distribution of best practice. approaches (eg learning from excellence) to assist hospitals in their local PDSA
Data to be collected, sources, method of collection Pre/post project staff questionnaires Local distribution of paper or online questionnaires by hospital project lead to anaesthetists, ODPs, and ITU nurses. See attached form for questions. Project main phase Following the initial questionnaire, the project will involve collection of data around the time of intubation. A 2 step model of data collection will be used in order to ensure data quality control, minimise trainee participation burden, and maintain trainee engagement with the project. Once an out of theatre intubation has occurred, the anaesthetist will log specific information onto a web app carried on their phone (or can be assessed on the MAGIQ website). This utilises a secure google form on www.merseymagiq.com. This may be in one of two ways: 1. Simple registering of the out of theatre intubation. The hospital project lead will subsequently follow up with the respondent and complete the dataset. 2. The trainee can also choose to complete the dataset themselves. The hospital project lead will subsequently check with the trainee that they did indeed enter the data. The Hospital Lead for the site will be alerted by the web app and project leads to any intubations in order to collect any data that was not complete. It will also be the responsibility of the Hospital Lead to collect data on any out of theatre intubations that were not registered on the MAGIQ app. Follow up contact by the hospital lead may be face to face or through other mediums eg email, SMS, etc. Data to be collected through this method includes:
1. 2. 3. 4. 5. 6. 7. 8.
Date & time of out of theatre emergency intubation Hospital site Nature of location within hospital eg ward, ITU, resus Use of intubation checklist Grade of anaesthetist completing data entry Grade of most senior anaesthetist present at time of intubation Whether the intubation was emergency or resuscitative Freetext comments regarding the use of the checklist
Will there be any personal identifiable data collected or No used? If personal identifiable data is to be collected what Information Governance measures will be taken? Not applicable
How will hospital performance data be used? Hospitals will receive weekly aggregate data feedback on their own performance consisting of total number of out of theatre intubations and frequency of intubation checklist used. Multi-hospital data will be used to form a local average, which will form a benchmark. Anonymised performance data of the best performing hospital may also be used. Qualitative / free text data will be freely released to all hospitals only if the original source cannot be identified.