The causes and effects of airway incidents on Post-surgical ICU patients.

ABSTRACT

Objective: To identify the causes and effects of in airway incident reduction in the post-surgical ICU, Siriraj Hospital. CQI program was gradually implemented to reduce the incidence. Methods: Self-reported of airway incidents ( unplanned extubation, tube dislocation, tube obstruction, unrecognised disconnection etc.) from August 2000-January 2001 were used for data collection and analysis. CQI program was implemented gradually over six months. Results: Among 284 intubated patients in 524 patients admitted to post-surgical ICU, there were 24 episodes of airway incidents during 6 months, 15 episodes in the first trimester and 9 episodes in the second trimester. The incidents happened during afternoon shifts more than other shifts. Five patients experienced moderate cardiopulmonary events (hypoxemia or severe hypo or hypertension) and two resulted in death. Most (23 out of 24) episodes were considered preventable. The causes were; lack of manpower, insecure airways, lack of knowledge, inadequate communication and inadequate sedation. Conclusion: Airways incidents occurred for several different reasons and occasionally resulted in death. Most of the causes were preventable. The CQI program aimed to define preventable causes and improved the quality of care.