Elsevier

Journal of Critical Care

Volume 47, October 2018, Pages 238-244
Journal of Critical Care

Pulmonary
Safety incidents in airway and mechanical ventilation in Spanish ICUs: The IVeMVA study

https://doi.org/10.1016/j.jcrc.2018.07.012Get rights and content

Highlights

The whole process of mechanical ventilation (MV) and airway management is full of risk moments. The IVeMVA study explores the safety incidents in 104 Spanish ICUs related to this process. Main results:

  • Incidence rate of 2 safety incidents per 100 patients and hour of mechanical ventilation or airway isolation.

  • 59% of incidents were non-harm-events, but almost 1% endangered the live, left severe sequelae or were related to death.

  • Most events were reported during MV period, followed by tracheotomy, NIMV, weaning/extubation, intubation and prone position.

  • The most dangerous moments to suffer harmful incidents to the patient were intubation, prone maneuvers and weaning.

  • A high percentage (73%) of incidents was considered avoidable.

Abstract

Purpose

To assess incidence, related factors and characteristics of safety incidents associated with the whole process of airway management and mechanical ventilation (MV) in Spanish ICUs.

Materials and methods

Observational, prospective, 7 days cross-sectional multicenter study. Airway and MV related incidents were reported using structured questionnaire. Type, characteristics, severity, avoidability and contributing factors of the incidents were assessed.

Results

Participant ICUs: 104. Inclusion of 1267 patients; 745 (59%) suffered one or more incidents. Incidents reported: 2492 (59% non-harm-events, 41% adverse events).

Individual risk of suffering at least one incident: 66.6%. Incidence ratio (median) of incidents: 2 per 100 patient-hours. 73.7% of incidents were related to MV process, 9.5% to tracheostomy, 6.2% to non-invasive MV, 5.4% to weaning/extubation, 4.4% to intubation and 0.8% to prone position.

Temporary damage was produced in 12% incidents, while 0.8% was related to permanent injuries, risk to the patient's life or contributed to death.

Incidents were considered avoidable in 73.5% of cases. 98% of all incidents had 1 or more contributing factors.

Conclusions

MV is a risk process in critical patients. Although most incidents did not harm patients, some caused damage and a few were related to the patient's death or permanent damage. Preventability is high.

Introduction

Management of airway and mechanical ventilation (MV) is one of the most common procedures in ICU. Although the percentage of patients needing MV varies depending on the studies and the specific characteristics of each ICU, it is estimated to oscillate between 40 and 50% of admissions [[1], [2], [3], [4]]. Moreover, respiratory failure and need for MV constitutes one of the principal reasons for admission to ICU [5, 6].

The MV process in critical patients is complex, invasive, and fraught with multiple interactions. This process encompasses a series of phases in which dynamism and interventionism are of utmost importance. This, coupled with the frequent severity of the patient's condition, may produce a multitude of incidents that put patient safety at risk regarding potential or real harm which may trigger severe sequelae or even death.

To date, there have been few published studies on incidents related to MV and airway in ICU. There have been more studies published on the subject of surgical anaesthesia, mainly regarding intubation and airway management [[7], [8], [9], [10], [11]]. In intensive care, much of the data is derived from multicenter patient safety studies (ICUSRS [12], SEE [13], SYREC [14]), or from an individual center [15], or from international epidemiological studies on MV that do not contain a detailed analysis of problems concerning patient safety [16, 17]. Other ICU studies focus on some of the phases of the process (principally on airway management) without seeking out incidents from the rest of the phases [[18], [19], [20], [21]].

The objective of the IVeMVA study (Spanish acronym for “Incidents involving Mechanical Ventilation and Airway”) is to learn about the incidence of non-harm events (NHEs) and adverse events (AEs) related to the whole process of airway management and MV in Spanish ICU, and also to analyze the types of incidents that occur, their severity, avoidability, the professionals who report them, communication with family members and contributing factors.

Section snippets

Design

7-day observational, multicenter study in a prospective cohort carried out from 24/03/2014 to 30/03/2014. During this period, safety incidents related to airway and MV were voluntarily and anonymously collected by any ICU professional (specialist doctors, residents, nurses, nurses' aides, etc.). The principal researchers (intensivists experts in patient safety and MV from the Spanish Society of Intensive Care Medicine, “SEMICYUC”) had previously consensually compiled a list of the most common

Results

One hundred and four (104) ICUs participated in the study (83.6% polyvalent, 10.6% mixed, 5.8% monographic) from 94 hospitals out of a total 237 Spanish hospitals with at least one ICU [25] (39.7%). The characteristics of the participating ICU are reflected in Table 1.

A total of 1267 ICU patients were included out of the 2486 hospitalized during the week of the study (51%, CI 95% 49.1–52.9), 64.2% male, with a median age of 63.4 (SD 14.31). The total number of days of MV or airway isolation was

Discussion

The IVeMVA Project is the first multicenter study on the safety of ICU patients receiving MV carried out in Spain. The 104 participating ICUs represent the 40% of all Spanish ICUs, with sufficiently large diversity in size and type of patients to constitute a valid representative sample. Patients who needed MV (invasive or non-invasive) or airway isolation represented 51% of all patients admitted to the ICU during the observation period, data that concurs with other studies [2].

Safety incidents

Conclusions

There are many incidents that can occur throughout all the moments of the airway and MV management process. Their presentation correlates with the number of days in MV. Although the majority of incidents are not severe, exist moments of special risk (intubation, weaning, tracheostomy and prone position), during which it is necessary to improve preventive measures, since most of incidents were considered avoidable. It should be emphasized that a high number of incidents did not cause any obvious

Authors' conflict of interest (COI)

The authors declare that they have no potential conflicts of interest.

Acknowledgements

The authors would like to acknowledge Cristina Fernández (Preventive Medicine Department, Hospital Clínico San Carlos, Madrid, Spain) for carrying out the statistical analysis and Vicente Aranzana (Department of Information Technology, Hospital Universitario de Fuenlabrada, Madrid, Spain) for the design and maintenance of the web database.

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  • Cited by (5)

    This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. This study has received the scientific endorsement of the Spanish Society of Intensive Medicine (SEMICYUC).

    1

    IVeMVA study investigators are listed in ANNEX 5, in Supplementary data.

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