Application of the PDCA cycle management in quality improvement of endotracheal intubation in emergency department among standardised training residents

Endotracheal intubation (ETI) stands as a cornerstone intervention within the emergency department, yet its efficacy can be undermined by a myriad of variables. For patients teetering on the brink of critical illness, securing the endotracheal tube during the initial attempt is not merely preferable but imperative. Consequently, elevating the first-pass success (FPS) rate achieved by emergency physicians becomes a vital strategy to curtail adverse outcomes and safeguard patient stability. The plan-do-check-act (PDCA) cycle, also known as the “quality loop”, is a management approach for continuous improvement. This study aimed to improve the FPS rate of ETI performed by standardised training residents(STRs) in the emergency department using the PDCA cycle management approach. It also sought to increase the difficult airway identification success rate while reducing the multiple-attempts rate and overall complications. This is a single-center, retrospective before-and-after study. We collected and compared data from STRs rotating through the emergency department before (January 2021 - December 2022, control group, n = 36) and after (January 2023 - December 2024, experimental group, n = 44) implementing the PDCA cycle. The PDCA plan included: Plan: Set goals for standardized operations, skill advancement, and refined complication prevention; establish key indicators including FPS rate, multiple-attempts rate, difficult airway identification success rate, and overall complication rate. Do: Implement a tiered training system (admission system + graded practice), standardized operating procedures (SOP), and comprehensive quality control (use of video laryngoscopy, difficult airway protocols). Check: Monitor how well the procedures were followed in real-time (completeness of steps, correctness of equipment use). Act: Keep improving training based on feedback from the data. Compared to before PDCA implementation, the FPS rate of the experimental group increased significantly from 55.6% (control group, 20/36) to 86.4% (38/44) (P < 0.01). The rate of complications included esophageal intubation (6.8% vs. 27.8%) and laryngeal edema/vocal cord injury (4.5% vs. 30.5%), both of which decreased significantly compared to the control group, which was statistically significant (P < 0.01). The difficult airway identification success rate between these two groups were 30.8% and 92.9%, respectively, with statistical significance (P < 0.01). Results by experience level showed that the FPS rate for third-year STRs increased from 50.0% to 85.2%, while the FPS rate for second-year STRs increased from 62.5% to 88.2%. The PDCA cycle management significantly improves the FPS rate of ETI and contributed to operational safety through a tiered training system, standardized procedures, and dynamic quality control. This approach provides a reference model for developing technical talent in emergency medicine and holds potential value in managing airways of critically ill patients.