Alfred E&TC Airway Audit

Emergency Department Intubation (EDI) Audit Form (Updated for COVID19)
Gender*
Age*
years
Date*

DayMonthYear
Date
Estimated Weight*
(Kg)
COVID Status*
How many people in the room?*
Team Leader / Drug administrator *

First NameLast Name
Specialty & Seniority*
Of the team leader
Airway assistant*
Typically nursing staff
Patient room.*
Which cubicle was the patient intubated in
Indication For Intubation
Indication Category*
Head injury – reduced LOCHead injury – airway not patentNeck / facial traumaBurn / inhalationDrowningChest traumaShockTraumatic cardiac arrestOther
Respiratory failureAirway obstructionAnaphylaxisCardiac failureSepsisGI bleedSeizureICH/strokeAltered mental status – not overdoseOverdose / ingestionCardiac arrestOther
Assessment & PPE
Was laryngoscopy predicted to be difficult?*
Why Difficult? e.g LEON criteria
Eye protection (visor/goggles)HatGownGlovesSurgical face maskFFP2/N95 face maskPowered Air Purifying Respirator (PAPR)None of the above
Observations at time of decision to intubate
Pre intubation GCS*
Pre intubation RR*
bpm
Pre intubation SBP*
mmHg
Pre intubation HR*
bpm
Pre intubation SaO2*
%
Observations - first set after intubation
Post intubation SBP*
mmHg
Post intubation HR*
bpm
Post intubation SaO2*
%
Pre-Oxygenation & Apnoeic Oxygenation
NRBMBVMBVM + PEEPNIVSGA (Supra-Glottic-Airway)
NILNPBVMNIVSGA (Supra-Glottic-Airway)
FlatBed tilt head upPillow or occipital padRamped or head up
RSI Checklist & Drugs
Was the Pre-RSI COVID Checklist used?*
Time of Induction*

:HourMinutes
Time of Intubation*

:HourMinutes
Primary Sedative Agent Used*
If fentanyl was also used, still select the primary sedative agent - i.e ketamine / thio and click yes for fentanyl below.
Dose (mg)*
mg
Was a pre-treatment dose of fentanyl used?*
If fentanyl was also used, still select the primary sedative agent - i.e ketamine / thio and click yes for fentanyl below.
Dose (mcg)*
mcg
Other (state)
(including pre-treatment)
Muscle Relaxant Used*
Dose (mg)*
mg
Other (state)
Induction Drugs Decision
i.e who selected the induction drugs
Was there any conflict within the team?
Yes or No. Can add details in free text comments at the end of the form
RSI Attempts & Details
Attempt 1*

First NameLast Name
First Pass Success?*
Specialty & Seniority*
e.g ED Registrar
No. of previous intubations*
Macintosh (direct)CMACCMAC + D-BladeOtherOther
Direct Vision or Video*
Cormack & Lehane Grade for DL*
Grade( 1-2-3-4)
POGO for VL
Percentage of glottic opening (%) - see image below
Adjunct*
e.g Bougie / Stylet
NILExternal Laryngeal ManipulationCricoid PressureManual In-line Stabilisation
NILGuedel / NPA inserted post inductionBVM ventilation after failed attemptCricoid pressure removedSGA inserted post inductionPatient position changedSurgical airway
Attempt 2*

First NameLast Name
Successful on this attempt?*
Specialty & Seniority*
e.g ED Registrar
No. of previous intubations*
Macintosh (direct)CMACCMAC + D-BladeOtherOther
Direct Vision or Video*
Cormack & Lehane Grade for DL*
Grade( 1-2-3-4)
POGO for VL*
Percentage of glottic opening (%) - see image below
Adjunct*
e.g Bougie / Stylet
NILExternal Laryngeal ManipulationCricoid PressureManual In-line Stabilisation
NILGuedel / NPA inserted post inductionBVM ventilation after failed attemptCricoid pressure removedPatient position changedSGA inserted post inductionSurgical airway
Attempt 3*

First NameLast Name
Successful on this attempt?*
Specialty & Seniority*
e.g ED Registrar
No. of previous intubations*
Macintosh (direct)CMACCMAC + D-BladeOtherOther
Direct Vision or Video*
Cormack & Lehane Grade for DL*
Grade( 1-2-3-4)
POGO for VL*
Percentage of glottic opening (%) - see image below
Adjunct*
e.g Bougie / Stylet
NILExternal Laryngeal ManipulationCricoid PressureManual In-line Stabilisation
NILGuedel / NPA inserted post inductionBVM ventilation after failed attemptCricoid pressure removedPatient position changedSGA inserted post inductionSurgical airway
Attempt 4*

First NameLast Name
Successful on this attempt?*
Specialty & Seniority*
e.g ED Registrar
No. of previous intubations*
Macintosh (direct)CMACCMAC + D-BladeOtherOther
Direct Vision or Video*
Cormack & Lehane Grade*
Grade( 1-2-3-4)
POGO for VL*
Percentage of glottic opening (%) - see image below
Adjunct*
e.g Bougie / Stylet
NILExternal Laryngeal ManipulationCricoid PressureManual In-line Stabilisation
NILGuedel / NPA inserted post inductionBVM ventilation after failed attemptCricoid pressure removedSGA inserted post inductionPatient position changedSurgical airway
Attempt 5*

First NameLast Name
Successful on this attempt?*
Specialty & Seniority*
e.g ED Registrar
No. of previous intubations*
Macintosh (direct)CMACCMAC + D-BladeOtherOther
Direct Vision or Video*
Cormack & Lehane Grade for DL*
Grade( 1-2-3-4)
POGO for VL*
Percentage of glottic opening (%) - see image below
Adjunct*
e.g Bougie / Stylet
NILExternal Laryngeal ManipulationCricoid PressureManual In-line Stabilisation
NILGuedel / NPA inserted post inductionBVM ventilation after failed attemptCricoid pressure removedSGA inserted post inductionPatient position changedSurgical airway
Post Intubation
Waveform capnographyColour change capnometryClinical confirmation alone
NILPPE Failure (please provide detail in comments)Aerosilation event (e.g cough / tube disconnect with O2 on)Equipment Failure – state what in commentsDesaturation – Sa02 < 93%Bradycardia –HR < 60bpmHypotension – requiring IV fluid/pressorsDental trauma due to intubationAirway trauma by intubatorSecond dose of paralytic agentOesophageal intubationMainstem bronchial intubationAspiration eventLaryngospasmMedication errorCardiac arrestOther (State in Comments)
ICUTheatre / Angio / Cath LabTransferred to other hospitalRequired subsequent re-intubation in EDExtubated in EDDied in ED
Comments*
E-mail address*
Please enter your email address
Information provided to the best of my knowledge
Should be Empty:

Emergency Department Intubation (EDI) Audit Form (Updated for COVID19)

Indication For Intubation

Assessment & PPE

Observations at time of decision to intubate

Observations - first set after intubation

Pre-Oxygenation & Apnoeic Oxygenation

RSI Checklist & Drugs

RSI Attempts & Details

Post Intubation