New PSMF Challenge to Eliminate in Hospital Air Embolism
The Patient Movement Association recently issued a new challenge as part of its Actionable Solutions program: Challenge 12B Air Embolism with the goal of truly making Air Embolisms a “never (happen) event.” Almost all in-hospital Air Embolisms are preventable and this article documents a practice plan of prevention utilizing education, leadership and safeguard systems such as the ClearLine IV to prevent these events from occurring.
Air embolism is defined as the presence of air (or other gas) in either the arterial or venous circulation. In the hospital setting Air Embolism is usually caused through the inadvertent injection of air into the venous system as a result of medical intervention. These events can occur both suddenly, as from an air-filled syringe or IV pump, or gradually, though a continuous IV infusion. If an Air Embolism occurs, air will enter the venous system and could become trapped in the lungs. In adults with normal anatomy small amounts of air up to 50 mL have been seemingly tolerated. Air Burden will eventually hinder hinders pulmonary circulation resulting in pulmonary hypertension and eventually right-heart failure, leading to circulatory collapse and death. The amount of air it takes for this to occur varies and there is currently not enough scientific evidence to reliably predict instances of catastrophic response. Because of this, prevention is of utmost importance. This risk increases for patients with any type of right to left valve shunt such as PFO, ASD, or PDA. The presence of any of these conditions allows an air embolism to bypass the lungs and enter directly into the arterial circulation in which even minute amounts of air can block circulation to vital organs such as the brain. Over 1 in 4 healthy adults has PFO but is undiagnosed and may be at increased risk of an Air Embolism induced stroke.
With this Challenge, the Patient Safety Movement created a high-level checklist of what should be done in order to move towards a healthcare system with zero preventable Air Embolisms as these events cause serious morbidity and mortality in hospitalized patients. The focus areas rely on leaders who are dedicated to the reduction of Air Embolism to create a plan with their teams on how to best close the performance gap surrounding in this important area in their hospital. This involves the creation of a specific budget, timeline and influential leaders driving who are driving implementation. Hospitals should also have a practice plan for what to do during day-to-day procedures and tasks regarding avoidance of Air Embolism. A large piece of this centers around education of all care providers on both the causes and symptoms of Air Embolisms in order to achieve the most efficient prevention and detection. This education should also extend to patients and their families.
A set protocol should be developed to avoid additional occurrences of Air Embolism. Data tracking additional events should be collected to identify trends and prevent future occurrences.The use of proactive prevention devices as a safeguard should be considered. The ClearLine IV, the only FDA-cleared device for the automatic detection and removal of air from an IV line, is an option. The Patient Safety Movement Foundation also suggests using technology platforms which can host checklists and education in order to improve best practices and team engagement in the efforts to minimize air embolism.
Find the full article for Challenge 12b Air embolism HERE