Thank you to all who have participated in the discussion to crowd-source an awake intubation kit in both previous installments of this series (Episode 1 and Episode 2). In this final installment, we discuss the implementation of our kit and the ongoing process involved in making this an effective and sustainable quality improvement intervention.
Two years ago, we treated a critically ill patient in our trauma bay who needed an awake intubation. The supplies were scattered all over the hospital, with one nurse needing to be sent to the operating room to gather the proper atomizer. Thankfully, despite the delays, the patient had a good clinical result, but it was a near-miss. Surely, we could do better!
Since then, we have gathered the opinions of airway experts both locally and in the FOAMed community to learn the key ingredients of a successful awake intubation kit. We took this information to our local stakeholders to make a kit that was financially realistic and logistically sustainable for our department. Our kit was introduced to our trauma bays, and we hosted two separate talks to present the kit to our emergency physician and resident group.
Ultimately, we were able to accomplish the following:
- The assembly of 2 airway topicalization kits, meant to allow various strategies for topicalization, depending on physician preference (Featured Image at the top of the post, Table 1).
- Change the storage of several hard-to-find medications to our automated medication dispensing system (Pyxis).
- A sustainable plan for kit resupplying.
Initially, we had planned to include a demonstration of our kit in this post, but in the interim, several great videos emerged in the FOAMed community that would make that exercise superfluous. For those interested, here is one incredible video made by George Kovacs of airway topicalization and an awake look with a video laryngoscope.
Table 1: Final list of supplies for awake intubation.
|Airway topicalization kit||Lidocaine cream|
|MADgic Atomization device|
|5 and 10mL syringes|
|Laminated awake intubation checklist|
|Medications added to Pyxis||Lidocaine 4% solution (preservative free)|
|Medications already available through Pyxis||Haloperidol, benzodiazepines, ketamine (anti-agitation)|
Table 2: Awake intubation checklist, included in kit.
Table 3: Chronology of quality improvement process.
|November 2014||Initial patient case|
|February 2015||CanadiEM post, episode 1|
|March 2015||Meeting with local airway experts|
|April 2015||Grand rounds on awake intubation|
|July 2015||CanadiEM post, episode 2|
|August 2015||Awake intubation supplies summarized and presented to ED department head|
|October 2015||Glycopyrrolate added to Pyxis|
|December 2015||Lidocaine 4% solution ordered and added to Pyxis|
|January 2016||Meeting with respiratory therapy to review difficult airway cart and develop re-stocking plan|
|Airway topicalization kit introduced to trauma bays|
|October 2016||Department rounds on quality improvement in the ED|
The Four Stages of Change
Jared recently had the opportunity to complete a leadership and administrative elective as part of his PGY-3 year. During his elective, he completed a course called Physician Administrator Co-Leadership Training. The course included a half day seminar on change management run by Dr. Brian Golden, a professor of strategic management at the University of Toronto’s Rotman School of Management. In Dr. Golden’s seminar, he described the four stages of change 1 , which closely relates to the process that we have been through with our awake intubation kit. The four stages are:
- Determine desired end state
- Assess readiness for change
- Broaden support and organizational redesign
- Reinforce and sustain change
First, determining the desired end state began with a vision for an awake intubation kit that would improve patient care. This was highlighted by a discussion in our emergency physician group of several cases in which a kit would have been very beneficial. Dr. Golden described this process as recognizing the “performance gap” in which the leader recognizes a discrepancy between how things are functioning and how the leader would like to see them functioning.
Assessing readiness for change involved the process of meeting with and engaging key stakeholders, and acquiring buy in from top management. We had a series of key stakeholders including our ED department head, the hospital chief of staff, our ED pharmacist, the ED stock/supplies manager, emergency physicians with airway expertise, anesthesiologists, and our respiratory therapy department. One of the most important elements of success in this stage is ensuring that the need for change is agreed upon by those whose work will be impacted by the change.1
In stage three, support was broadened for the change initiative by communication and interaction between the change leaders and those who will be affected by the change.1 This was essentially the knowledge translation phase. As mentioned previously, we had a chance to present our awake intubation kit in the form of departmental grand rounds as well during quality improvement rounds.
We are currently in stage four. It is a stage of utmost importance in maintaining change through monitoring performance and showcasing successes.1 In settings where change involves sacrifice, it is also important to recognize and support sacrifices associated with the change and to reward supporters.1
Reflecting on the process after completing my leadership elective has taught us three main lessons if we were to go back and do this over again. These lessons have been echoed elsewhere in the literature as well.2
From the outset, we would come up with a comprehensive list of all key stakeholders and engage with them. Our process eventually involved all key stakeholders but they were brought on board as we discovered them in a linear fashion.
Immediately after coming up with the necessary contents of an awake intubation kit, we would come up with a cost analysis and budget so as to achieve buy in from management at an earlier stage.
We would consider a more rigorous approach to broadening support among our ED staff at an earlier stage. We delivered knowledge translation once the kit was assembled, however it would have increased earlier buy-in to communicate the need for an awake intubation kit among the whole ED group prior to deploying the kit.
A few months after our awake intubation kit was introduced to the trauma bay, another critically ill patient presented in extremis. The patient needed an urgent airway, but was morbidly obese and the emergency physician sagely decided an awake intubation would be the safest approach. This time, the supplies were right there in the trauma bay! The intubation went smoothly and safely, and the patient was transferred in stable condition to the ICU.
Leading change is something that can be initiated at any level from trainee, to allied health professional, to seasoned ED physician. Before embarking on a quality improvement project it is advantageous to have thought through your vision and completed background reading regarding other successful and similar projects. Then make sure to identify and approach all key stakeholders so as to engage them as part of the change. Lastly, celebrate successes, acknowledge challenges, and reward supporters so as to maintain your change in a sustainable fashion.
We hope this series has been useful as an example of two residents fumbling through the process of change management and quality improvement from a grassroots level. All change starts with an idea of how things can be made better. Perseverance and patience is paramount as change takes time. We welcome any questions and discussion. Please comment below or feel free to send us a tweet!
Reviewing with the staff
Healthcare is a very complex and intricate industry in which to work. We work with many individuals, especially in emergency departments, who have different perspectives, scope of expertise, and, most importantly, culture. So, what seems like a simple project to introduce an awake intubation kit into an emergency department, ends up being very complex and taking close to two years to implement.
Drs. Baylis and Ting have to be commended for their leadership – in identifying a need, engaging stakeholders, implementing change, and now sustaining change. This has made our emergency department better and, ultimately, will improve patient care.
However, what must be highlighted is this: we are all responsible for improving care for our patients. An identified gap, or need, by any of us should be the impetus for us to provide leadership in making changes toward quality. Further, any of us can do it. This is not discounting the leadership and expertise shown by Drs. Baylis and Ting, but more the fact that any one of our care team can be the champion for change. These changes do not need to be massive at the outset. In fact, small tests of change should be the starting point for large-scale quality improvement initiatives. Finally, one should not lose faith at the amount of time it takes to implement and sustain change. Depending on the environment in which you work, and the urgency to implement change, some quality improvement initiatives may take longer than others.
Had Dr. Baylis and Dr. Ting seen the need for an awake intubation kit two years ago, and done nothing, we may have negatively impacted patient care. Through this process, not only have they brought the kit to our emergency department, but they have strengthened and solidified relationships between our department and others, engaged and empowered our nursing and respiratory therapy departments, improved physician knowledge and simulator experience with difficult airways, and they have built upon a culture of continuous quality improvement. More importantly, they have, through this experience, learned how difficult and how easy it is to make changes within healthcare and shared their experiences, so that they, and you, can continue to take leadership in improving care.