PERFORMANCE IMPROVEMENT (PI) MONITORING

POPULATION OF INTEREST

Drowning casualties

INTENT (EXPECTED OUTCOMES)

- Transport all drowning victims requiring rescue breathing or resuscitation to the hospital for evaluation and monitoring.
- Intubate obtunded drowning victims early and avoid supraglottic airways.
- Avoid maneuvers that increase risk of emesis (e.g.., Heimlich, head-down, abdominal thrusts).
- Withhold antiarrhythmic medications in severe hypothermia with core temps < 30 °C (86 °F).
- Alert hyperbaric chamber teams in cases of suspected arterial gas embolism.
- Avoid osmotic diuresis, barbiturate coma, hyperventilation, and ICP monitoring.
- Institute active external rewarming for moderate hypothermia and active internal rewarming for severe hypothermia.
- Avoid shivering during rewarming measures. (See Figure 2.)
- Avoid hyperoxia and use lung protective strategies in the critical care setting.
- Delay weaning from mechanical ventilation for the first 48 hours to avoid recurrent pulmonary edema from insufficient pulmonary surfactant.
- Avoid antibiotic prophylaxis except in cases with submersion in water with known high pathogen load.
- Avoid targeted temperature management as a neuroprotective strategy.

PERFORMANCE/ADHERENCE MEASURES

- Number and percentage of drowning victims with documentation of pre-hospital airway management (e.g. NPA or definitive airway)
- Number and percentage of drowning victims with temperatures 30-34°C (86-93.2°F) rewarmed with active external measures.
- Number and percentage of drowning victims with temperatures < 30 °C (86 °F) rewarmed with active internal measures.
- Number and percentage of drowning victims receiving prophylactic antibiotics in the first 24 hours.
- Number and percentage of drowning victims that remain intubated for the first 48 hours.

DATA SOURCE

- Patient Record
- Department of Defense Trauma Registry

SYSTEM REPORTING & FREQUENCY

- The above constitutes the minimum criteria for PI monitoring of this CPG. System reporting will be performed annually; additional PI monitoring and system reporting may be performed as needed.
- The system review and data analysis will be performed by the JTS Chief and JTS PI Branch.
- The Ustein Uniform Reporting Data form for Drowning will be used.

RESPONSIBILITIES

It is expected that medical department personnel, particularly of the sea services (U.S. Navy, U.S. Marine Corps, U.S. Coast Guard, and U.S. Merchant Marine) will become familiar with these clinical practice guidelines and incorporate them into both operational planning and emergency medical response plans.