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Paediatr Anaesth. 2017 May;27(5):451-460. doi: 10.1111/pan.13128. Epub 2017 Feb 28.

Implementation of NAP4 emergency airway management recommendations in a quaternary-level pediatric hospital.

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Department of Emergency Medicine, The Royal Children's Hospital, Parkville, Vic, Australia.
Murdoch Children's Research Institute, Parkville, Vic, Australia.
Department of Paediatrics, Faculty of Medicine, Dentistry, and Health Sciences, University of Melbourne, Melbourne, Vic, Australia.
Department of Neonatal Medicine, The Royal Children's Hospital, Parkville, Vic, Australia.
Paediatric Intensive Care Unit, The Royal Children's Hospital, Parkville, Vic, Australia.
Department of Anaesthesia and Pain Management, The Royal Children's Hospital, Parkville, Vic, Australia.


Emergency airway management, particularly outside of the operating room, is associated with a high incidence of life-threatening adverse events. Based on the recommendations of the 4th National Audit Project, we aimed to develop hospital-wide systems changes to improve the safety of emergency airway management. We describe a framework for governance in the form of a hospital airway special interest group. We describe the development and implementation of the following systems changes: 1. A local intubation algorithm modified from the Difficult Airway Society's plan A-B-C-D approach, including clear pathways for airway escalation, and emphasizing the concepts of resuscitation prior to intubation, planning for failure, and avoidance of fixation error. 2. Simplified and standardized airway equipment located in identical airway carts in all critical care areas. 3. A preintubation checklist and equipment template to standardize preparation for airway management. 4. Availability of continuous waveform endtidal capnography in all critical care areas for confirmation of correct endotracheal tube placement. 5. Multidisciplinary team training to address the technical and nontechnical aspects of nonoperating room intubation. In addition, we describe methodology for ongoing monitoring of performance through a quality assurance framework. In conclusion, changes in the process of emergency airway management at a hospital level are feasible through collaboration. Their impact on patient-based outcomes requires further study.


child; emergency service; health care; hospital; intratracheal; intubation; patient safety; quality assurance

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