Evaluation of a Performance Improvement Bundle to Achieve DASHH-1A Success

Background

DASHH-1A is a quality metric used across HEMS and CCT programs to evaluate the safety and effectiveness of their airway management performance. The ability to achieve DASHH-1A success is multifactorial. This quality improvement project aimed to improve our program's DASHH-1A success rate.

Local problem

With excellent airway practitioners on our staff, we were perplexed as to why we did not meet the GAMUT achievable benchmark of care in DASHH-1A airway management. Our objective was to determine what may be impacting our success rates, both negatively and positively, to ultimately improve our DASHH-1A success rates.

Methods

Four investigators each reviewed a different patient population (interfacility trauma, interfacility medical, scene trauma, scene medical) to evaluate trends in their respective cohorts which may impact our DASHH-1A success. A brief literature review of current RSI practices was also conducted. Following these studies, we implemented a performance improvement plan and compared our adult DASHH-1A success rates for the 16 month periods pre- and post-intervention. All pediatric and crash airways were excluded.

Interventions

We revised our RSI protocol to include a bundle of care for all RSI airway attempts, which was then reviewed monthly at department CQI meetings. In addition to prior RSI mandates, we specified parameters to initiate additional airway, ventilation, and/or hemodynamic resuscitative efforts; mandated bag-mask ventilation during the period between paralytic administration and initiation of laryngoscopy; mandated use of a real-time, call-and-response RSI checklist; and implemented a standardized documentation template to capture those interventions performed.

Results

Pre-intervention DASHH-1A success rate was 63% (38/60 advanced airways). This improved to 72% (39/54 advanced airways) in the post-intervention period. This resulted in an improvement of our DASHH-1A success, with an absolute difference of 8.9% and a relative increase of 14%. A notable finding revealed that we had a 92% compliance rate with the utilization of our full DASHH-1A bundle.

Conclusions

The implementation of a DASHH-1A bundle of care had a high degree of compliance and was shown to improve our program's overall adult DASHH-1A success rate. A limitation of our study was our small sample size, n = 114 total patients. Recommendations for further studies would include a multi-center pre/post study to review similar programs’ DASHH-1A airway success.