Crashing Slowly

Al , this rant was music to my ears. I'm a patient safety and QI fellow at Kaiser in Northern California and am working with RT to implement this region wide in the ED (agree, should be RT driven with ED/ICU backing). The NNT to save one life for LPV for all comers is 23 - if this were a drug we would all be clamoring for it. But it's not, and often invisible as we don't communicate about TVs in ml/kg of predicted body weight. Also, a fair segment of our patients in the ED already has ARDS on admission and we are under recognizing and under treating it (NNT for one life saved bumps up to 12 for these folks). To add fuel to the fire, it becomes a disparities issue as women, Asian, and Hispanic patients tend to be shorter and get their lungs blasted. But there's an easy fix in the ED - for volume control we have had success with a 350/450 ml protocol until a height can be obtained. It's 350 ml for female patients and 450 ml for male patients (based on 6 ml/kg predicted body weight for average American heights) with a rate of 20, chased by an ABG/VBG 15 min later. Like so many therapies, what we do in the ED really matters and we have this opportunity to set up patients for success. Tidal volumes are rarely dialed down in a timely manner even once they hit the ICU, and that's not even considering patients who are boarding in the ED. Let's recalibrate our settings and save some lives.

Sounds like a smooth work flow that's making a huge difference! Your RTs are so on top of it for measuring during the intubation. Right now the order in our EHR is for RNs to measure height and that's probably a mistake (not my choice, political decision). We went with disposable paper tape measures because of infection control issues and RT badge cards for the TV/PBW chart as well as EHR support as not all of our EDs only intubate in designated resuscitation rooms. These are tiny variations on the same theme but workflow matters for successful implementation and remains site specific.