By Brenda L. Mooney

On average, more than 30 times a day across the VHA, patients outside the operating room require emergency-airway management. It is literally a life-or-death situation, as failure to establish an airway can result in brain damage or death within minutes.

How that situation is handled in the VA system has undergone dramatic changes during the past decade, primarily because of a 2005 directive from top VHA management. Now, new guidelines are being proposed to assure even better training of non-anesthesia personnel and make the process safer than ever.

In the not-too-distant past, care for a VAMC patient in respiratory distress outside the operating room was somewhat hit-or-miss.

Out-of-operating-room airway management in the VA system has undergone dramatic changes over the last decade, and more directives are on the way.

“Codes” occurring during regular hours often were handled by a team including a certified registered nurse anesthetist or other professional highly experienced with airway management. Situations occurring after hours or in smaller facilities were more complicated, however.

A 2002 survey by the National Center for Patient Safety (NCPS) found that non-OR intubations were not uncommon, with more than 11,000 a year at the VA. Of those, 12% were deemed unusually difficult, yet no equipment was used to confirm proper tube placement 30% of the time.

In addition, protocol was unclear as to who should handle the emergency if the “code” team was unavailable; 55% of facilities reported then that anesthesia staff was unavailable outside regular hours. Therefore, the responder could be anyone from a resident to a critical-care physician to a respiratory therapist.

Because of inconsistent training, mistakes were being made. A published review of the VA’s tort claims database found 65 settlements for improper intubations or inductions, from 1988 to 2000, totaling $5,129,852, or an average settlement of $78,921.

In response to concerns such as these, the directive went out from the VHA in 2005, requiring each inpatient facility to create a written policy by the end of that year, ensuring the competency of staff performing out-of-operating room airway management. Among the requirements was that those performing intubations must have privileges or scope of practice to perform intubations.

The directive:

• Established the criteria for privileging clinicians;

• Ensured there be a training program for those seeking to be privileged in intubations at each VA facility; and

• Required that an adjunctive device be used to confirm tube placement.