NEAR Operational Definitions Version 6 February 10, 2012
Encounter
An “ENCOUNTER” of advanced airway management refers to complete sequence of events leading to a placement of an advanced airway
The “time” for the encounter is when the team collectively decided to intubate the patient.
Encounter is completed when a stable airway is achieved and no further immediate airway management is needed.
Course and Attempt
A “COURSE” of advanced airway management refers to ONE method or approach to secure an airway AND ONE set of medications (including pre-medication and induction). Each COURSE may include one or several "attempts" by one or several providers.
If the method or approach is changed in one encounter of advanced airway management, then it should be considered as different course.
Example1:
There was a New Intubation (ORAL) with plans to immediately change the tube from Oral to Nasal. An ENCOUNTER completed after immediate tube change (ORAL to NASAL) finished.
COURSE 1: New Intubation (ORAL) with successful ET tube placement.
COURSE 2: Change of Tube (ORAL to NASAL)
Example 2:
There was a New Intubation (ORAL) with a plan to immediately change the tube from Oral to Nasal. However, during this process of tube change from ORAL to NASAL, they fail to place the tube NASALLY. The team provided bag-valve-mask ventilation to maintain Saturation. Then the team changed their plan and placed Tracheal tube ORALLY.
COURSE 1: New Intubation (ORAL) with successful ET tube placement
COURSE 2: Change of tube (ORAL to NASAL) unsuccessful
COURSE 3: New Intubation “Oral” with successful ET tube placement
An "ATTEMPT" is a single advanced airway maneuver (e.g. tracheal intubation, LMA placement), beginning with the insertion of a device, e.g. laryngoscope (or LMA device) into patient's mouth or nose, and ending when either the device (e.g.laryngoscope) is removed or the advanced airway is placed.
Relationship of Encounter, Course and Attempt
Diagnostic Category (in Patient Information)
Place the most significant diagnosis category at the time of the ENCOUNTER
Example: 16 yo female with history of Hypoplastic Left Heart Syndrome status post Fontan at 3 year old, now getting intubated due to right pleural effusion due to high transpulmonary pressure.
This should be considered as Cardiac-Medical (since Surgical History is remote).
If the tracheal intubation is associated with the recent cardiac surgery, then choose Cardiac-Surgical.
Teamwork Evaluation (in Encounter)
This needs to be reported by “Event Reporter” defined as:
(in order of priority)
1. Documenter during resuscitation or sedation when tracheal intubation occurred
2. Clinical Resource Nurse/Charge Nurse involved in this encounter
3. Supervising Respiratory Therapist
4. Attending Physician involved in this Encounter
COURSE
Difficult Airway Evaluation
1. Known history of Difficult airway? (*At the time of the intubation course)
2. Widest Mouth Opening (*Note:This evaluation is not always possible before the course. If so, evaluate during the attempt. Remember that the fingerbreadth is the PATIENT’s fingerbreadths, not yours.)
3. Evidence of upper airway Obstruction or anatomical barrier to visualize glottic opening?
(*If the patient showed stridor during pre-intubation evaluation, please check “YES”)
COURSE Success
COURSE Success is defined as a successful establishment of advanced airway within the course. If the COURSE was not satisfactory and required another course, the first COURSE should be considered failure.
A “COURSE” of advanced airway management refers to ONE method or approach to secure an airway, so if the plan was changed during the ENCOUNTER, then it is considered as a new COURSE.
Example:
Primary Nasal intubation was attempted, but failed. Orotracheal intubation was performed successfully immediately following primary Nasal intubation attempt.
First COURSE (Primary Nasal) should be considered failure.
If Nasal Intubation was successful after a few attempts, this Second COURSE should be considered as success (with a few attempts).
Medication
Please specifically state the medication used during this Course.
Please DO NOT include the medications not given for airway management (epinephrine, lidocaine for dysrhythmia, etc)
Select NO Drugs Used when “immediate change of tube” was performed after primary intubation and no additional drugs were used.
No need to choose medication if the patient continues to receive infusion medication in the PICU.
Method and Device
Nasal Full sedation and paralysis: Select this option if medications were administered during New Intubation and was followed immediately by change of tube.
Example: If the patient was ORALLY intubated and followed by immediate change of tube to Nasal. During the change of tube, no additional medications were given.
Tracheal Intubation Confirmation
COLORIMETRIC: Detection of Exhaled CO2 by a color change
CAPNOGRAPHY: Detection of the amount of Exhaled CO2 by a device that senses the CO2 level.
USE primary confirmation when EtCO2 detection was not used as a secondary confirmation (such as cardiac arrest).
Tracheal Intubation Associated Events
Check all that apply and link it to the attempt #(number)
We consider a TIAE is an unwanted event (not necessarily avoidable) which occurred as a consequence of intubation, or simply seen during or after the intubation. This needs to be a change from pre-intubation status.
The time frame for TIAE is from the beginning of the Course till 20 minutes after securing airway (e.g. successful tracheal intubation).
There may be an occasion that TIAE (such as lip swelling) may not be linked to a particular number of attempts. If this is the case, please document the last attempt number as associated with the TIAE.
Cardiac arrest is defined as chest compression >=1 minute
Death is defined as persistent CPR condition led to the termination of effort with or without return of spontaneous circulation < 20 minutes.
Return of spontaneous circulation (ROSC) is defined as return of pulse without CPR effort for at least 20 minutes.
Esophageal intubation with delayed recognition: If the esophageal intubation led to deterioration in patient condition (desaturation<80%, hemodynamic instability, emesis with or without aspiration), this should be considered as delayed recognition.
For bradycardia requiring chest compression less than 1 minute, classify as dysarhythmia if there was a pulse throughout (or pulse oxymetry waveform, arterial line waveform with native rhythm). If there was no pulse (or not sure), classify as cardiac arrest with survival.
For bradycardia or tachycardia requiring chest compression more than 1 minute, classify the TIAE as cardiac arrest (either with survival—if ROSC>20 min, or with death).
Here are some examples:
Example 1: If a patient was already in cardiac arrest and the team intubated as a part of cardiopulmonary resuscitation. This is NOT considered as a TIAE because cardiac arrest occurred before airway management was started.
Example 2: When the patient develops pulmonary hemorrhage followed by severe bradycardia leading to cardiac arrest during intubation, this is considered as a TIAE.
Example 3: TIAE should include all the events that occur from the start of the COURSE of Intubation (starts when preoxygenation or an administration of medications occurs). When the patient develops pneumothorax during bag-valve-mask ventilation as an initiation of COURSE, this should be considered as a TIAE.
Pulse Oxymetry
Highest Value: Highest Level of saturation of oxygen during/immediately after preoxygenation.
Lowest Value: Lowest Level of saturation of oxygen during the course of Intubation.
PGY Level (Post Graduate Year)
This should reflect their PCCM training level. If they join PICU fellowship after one of the fellowships, then they should be considered as the second year fellow (PGY-5).
Here is a proposed solution.
1st year PCCM Fellow: PGY-4
2nd year PCCM Fellow: PGY-5
3rd year PCCM Fellow: PGY-6
Chief resident: PGY-4
Fast track ( the PCCM Fellow who completed other fellowship first, then joined PCCM fellowship)
1st year PCCM Fellow-PGY-5
2nd year PCCM Fellow-PGY-6
Nurse Practitioner (NP, CRNP, CRNA)
The PGY level for NPs is considered the years experience as an NP. This does not include the amount of years as an RN.
Other Info
Length of PICU Stay: Limit to current PICU stay. Less than 24 hours=0 day, 24-48 hours=1day, 48-72 hours=2 days
Length of current Intubation: Duration (days) until successful extubation (defined as Extubation >24 hours)