How a hospital-wide collaborative project made off-shift intubations safer
Hospital staffing levels taper off each day as the sun goes down, and ensuring that all patients are safe during the “off-shift” hours is an ongoing challenge for administrators and providers. Recently, Brigham and Women’s Faulkner Hospital developed a solution to one such staffing quandary: performing intubations safely for inpatients hospital-wide without “borrowing” staff from other units.
According to Chief Medical Officer Margaret “Peggy” Duggan, M.D., she and others were concerned that as the emergency department staff decreased in the evening, patients there would be less safe if one of the ED’s crucial caregivers was called away for an intubation elsewhere.
This led to a nine-month patient safety improvement project. Beforehand, BWFH always had two ED providers in house. But as their staffing at night was altered to meet the lessening demands of a low evening census, they saw a potential safety risk in the lack of intubation experts.
“We consider intubations to be low frequency, high risk procedures, and they can when straightforward take very little time but occasionally can be more time consuming,” Duggan said. The procedure involves inserting a plastic tube into a patient’s trachea to maintain an open airway.
Surveying their options
After serving as the medical director of Brigham and Women’s Faulkner Breast Center since 2002, Duggan was named chief medical officer of BWFH in June 2013. The following year she and Chief Nursing Officer Judy Hayes created a task force of professionals from anesthesia, medicine, surgery, emergency medicine, special testing, and critical care nursing. They evaluated all providers typically in the hospital during off-shift hours and found that no provider type was consistently trained and experienced in the intubation procedure.
Other hospitals facing similar issues, they learned, responded by changing physician staffing in the intensive care unit or hiring an emergency medical technician or certified nurse anesthetist. Duggan found one hospital that shifted the responsibility to their respiratory therapists, which she determined was the most sustainable and cost-effective solution for Brigham and Women’s Faulkner Hospital.
Intubation boot camp
“The hardest part was fitting in enough intubation practice,” Duggan said. “The oversight needs to be significant because you want excellent patient outcomes and you want the respiratory therapists to be comfortable and confident.”
While intubations are in the scope of practice for respiratory therapists, the hospital’s team of six still underwent extensive outside training, including completing 25 successful intubations. Bruce Mattus, the director of respiratory therapy, is pleased with the quality of training the team receives.
“Unique to our respiratory therapist-based program is the competency maintenance requirement to perform two intubations each month following the initial training,” he said. “Typically respiratory department programs require only 5 to 10 intubations a year in the operating room.”
To aid in difficult cases, respiratory therapists were also granted access to advanced video laryngoscopes, which in the past had been used only with patients undergoing surgery. The devices provide the therapists with a clear, real-time view of the patient’s airway.
“Staff were initially worried because it spurred a lot of change,” Duggan said. “We experienced a lot of physician pushback since they are usually the providers intubating and are the only ones allowed to order medication.”
Garnering hospital-wide support
The anesthesia and pharmacy departments collaborated in producing a “med kit” containing the proper medications and dosage instructions for the intubations. The medications are ordered by the patient’s physician since it is out of the scope of practice for respiratory therapists to order medication. Once it is administered the therapist performs the intubation.
“There is a select group of CRNA’s [certified registered nurse anesthetists] and emergency department physicians who want us to do well and are devoted to teaching us all they know,” Mattus said. “Many of them are constantly telling us ‘send your therapists down every day – the more they do, the better they will get.’ ”
Since the project launched in March of 2015, Duggan said the hospital has seen zero complications with intubations. Knowing they can call for backup if necessary, the respiratory therapists have confidence in their new-found responsibilities and have received favorable feedback about their performance.
“Everyone was incredibly respectful of each other’s skill sets when the respiratory therapists were being trained, and it really boosted job satisfaction,” Duggan said. “They were able to work at the top of their license and you could see the great success they felt.”
Determining which providers within Brigham and Women’s Faulkner Hospital were most qualified to perform intubations during off-shift hours and implementing an extensive training program for those providers involving knowledgeable physicians, pharmacists, and anesthesiologists.
Due to reduced staffing at night, only one provider in the hospital during off-shift hours was qualified to perform intubations and would need to leave the emergency department unmanned in the case of an urgent intubation.
Training a team of in-house respiratory therapists to expertly perform intubations and monitor patients during off-shift hours.
Changing physician staffing in the intensive care unit and hiring an emergency medical technician or certified nurse anesthetist are popular, but not cost-effective or sustainable solutions. Designating respiratory therapists to perform intubations, which are already in their scope of practice, and collaborating with other departments increases both patient safety and job satisfaction.