The infusion after the bolus: a quality improvement programme to support emergency department airway governance in Ireland.

BACKGROUND

Emergency department (ED) intubations are high-risk procedures with wide variability in training and governance. Although emergency physicians (EPs) in Ireland are trained to intubate, structured airway governance within EDs is not well described. This quality improvement project aimed to develop and evaluate a sustainable airway governance framework in a large Irish ED.

METHODS

Using the model for improvement, sequential interventions were implemented between May 2024 and October 2025. Interventions evolved across cycles and included appointment of an emergency medicine (EM) airway lead, Emergency Medicine Airway Registry Ireland (EMARI)-linked QR code data capture, standardised checklists and airway equipment, video laryngoscopy with recording, daily intubation drills, competency-based sign-off and structured multidisciplinary teaching with feedback (Airways, Biscuits, Caffeine). Primary outcome measures were first-pass success (FPS) and complication rates.

RESULTS

Across 156 intubations in 154 patients, EPs were primary intubators in 82.7%. Overall mean FPS was 91.7% and complication rate was 12.3%. Performance metrics were maintained within predefined safety targets (>90% FPS, <15% complications) across all four Plan-Do-Study-Act (PDSA) cycles, despite staff turnover and progressive introduction of interventions. Following implementation of daily drills, senior airway supervision and competency sign-off (PDSA cycle 2), FPS remained consistently above target and complication rates remained low through subsequent cycles. EMARI data capture reached 99.4%, and video capture increased over time to 72%.

CONCLUSIONS

A structured airway governance programme combining leadership, checklist standardisation, simulation and continuous feedback was associated with maintenance of FPS>90% with low complication rates over successive PDSA cycles. This pragmatic, replicable framework supports establishment of national EM airway governance standards to maintain procedural competency and patient safety and is replicable in international EDs with similar pre-existing airway management practices.