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
Trauma

Other
Medical

Other
Assessment & PPE
Was laryngoscopy predicted to be difficult?
Why Difficult? e.g LEON criteria
Personal Protective Equipment Used
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
*Pre-Ox Final Device Used
†Apnoeic O2
Patient Position
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
Laryngoscope Type

Other
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
Modifications
Intubation Manoeuvres
Attempt 2

First NameLast Name
Successful on this attempt?
Specialty & Seniority
e.g ED Registrar
No. of previous intubations
Laryngoscope Type

Other
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
Modifications
Intubation Manoeuvres
Attempt 3

First NameLast Name
Successful on this attempt?
Specialty & Seniority
e.g ED Registrar
No. of previous intubations
Laryngoscope Type

Other
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
Modifications
Intubation Manoeuvres
Attempt 4

First NameLast Name
Successful on this attempt?
Specialty & Seniority
e.g ED Registrar
No. of previous intubations
Laryngoscope Type

Other
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
Modifications
Intubation Manoeuvres
Attempt 5

First NameLast Name
Successful on this attempt?
Specialty & Seniority
e.g ED Registrar
No. of previous intubations
Laryngoscope Type

Other
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
Modifications
Intubation Manoeuvres
Post Intubation
ETT Placement Confirmation
Complications
Disposition
Comments
E-mail address
Please enter your email address
Declaration
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