It is composed of 12 people voluntarily, including 1 director of nursing department, 1 deputy chief physician of the department, 1 specialist head nurse, 6 neurosurgical medical staff and 3 nursing graduate students. A teacher in the department served as the circle leader, and the deputy chief physician and head nurse of the neurosurgical ICU served as counselors. Through brainstorming and democratic voting, all members of the circle determined that the theme of this activity was “Improving the compliance rate of airway management strategies for adult critically ill patients”. The quality control Circle conducted activities from September 1, 2020 to December 31, 2020, once a week, and a total of 46 cases were investigated.

1) Identify care issues: What is the best evidence for evidence-based airway management strategies for critically ill adults? Whether the best evidence for airway management strategies in critically ill adults is consistent with current clinical status; If not, how can the best evidence be applied to the clinic? 2) Analysis of reasons: The implementation of airway management measures for adult critically ill patients from December 1, 2019 to August 31, 2020 was analyzed. The members of the circle group conducted true cause analysis and fishbone diagram analysis from four aspects: human, physical, legal and environmental, and found that the main influencing factors were: 1) Nurses lacked relevant knowledge of airway management for critically ill patients, and artificial airway lacked understanding of airway management guidelines. 2) There is no uniform airway management standard in the department, and the relevant nursing procedures and rules and regulations are lacking. 3) Nurses are busy, the implementation and record of standardization increase the workload of nurses,

Note: 1) X², 2) t.

and nurses have resistance psychology. 4) Departments do not pay enough attention to airway humidification management. 5) Doctors do not pay enough attention to airway management and the cooperation is not high, and the leadership of managers is insufficient. 6) The department did not introduce products such as subglottic catheter and mouthwash for patients with ventilators.

1) Retrieving evidence

Top-down retrieval based on the “6S evidence resource pyramid model” [9] Computer searches were used for Up To Date, Joanna Briggs Institute(JBI) Centre for Evidence-based Health Care database, British Medical Journal (BMJ), National Guideline Clearinghouse (NGC), society of critical care medicine (SCCM), UK National Insitute for Healthcare Excellence Health and Care Excellence (NICE), Cochrane library, Cumulative Index to Nursing and Allied Health Literature, CINAHL), Medline, PubMed, China Biomedical Literature Database, CNKI, and Wanfang database on airway management in adult critically ill patients, including advanced clinical decision support, guidelines, systematic reviews, evidence summaries, and expert consensus. Inclusion criteria: The subjects were critically ill patients ≥ 18 years old with tracheal intubation or tracheotomy; Exclusion criteria: non-adult patients were excluded, grey literature, original studies, incomplete studies, and studies with low literature quality evaluated by literature quality. The guidelines adopt the AGREE II [10] evaluation scale, an evaluation tool developed by an international cooperative organization, the JBI evidence-based Health Care Center quality evaluation tool [9] for systematic evaluation and expert consensus, and the quality evaluation of advanced clinical decision-making and evidence summary can be traced back to the original literature on which the evidence is based. According to the type of literature, the corresponding evaluation tools are selected for quality evaluation. The strength of evidence recommendation was determined based on the JBI 2014 evidence recommendation level [9] judgment criteria.

2) Formulating Measures

Invite hospital stakeholders to evaluate the FAME [9] of the evidence, namely, the Feasibility, Appropriateness, Meaningfulness and Effectiveness of the evidence, and screen the evidence. 29 pieces of evidence were obtained. Based on the characteristics of departments, 20 localization quality review indicators were determined, as shown in Table 2. Airway evaluation, airway suction timing, air bag management, airway humidification, airway suction, air incision stoma care, oral care and other seven aspects were used as review indicators and improvement measures. Improvement measures: 1) Conduct the best evidence interpretation meeting for airway management in adults with critical illness in the department to interpret the source, level, recommendation strength and specific connotation of the evidence in detail, so that the nurses in the department have a full understanding of the evidence of airway management and strengthen the awareness of airway management; 2) Organize and carry out special training on

adult critical airway management, and incorporate its contents into the pre-job training plan, establish a systematic training plan and conduct post-training assessment. 3) To carry out literature retrieval training courses to improve nursing staff’s literature retrieval ability and update clinical knowledge in a timely and scientific manner; 4) Develop airway management and nursing routine for adult critically ill patients in the ICU, airway management flow chart for adult critically ill patients, teaching videos and Manual for Artificial Airway Management in the ICU, hold regular trainings and push them to the wechat group, send the electronic version to the wechat group, and place the paper version in the nurse station for online and offline learning by nurses. 5) The department is equipped with a mobile nurse station beside the bed to facilitate the operation of nursing staff and reduce workload. 6) Establish an airway management team, take responsibility for people, and set up a PDCA quality improvement project for airway humidification of critically ill patients. 7) By moving into the new hospital equipment introduction plan, the introduction of subglottic catheter, humidification device and other products. 8) The new technology and new business in the department actively organize medical staff to participate, improve their sense of participation, and increase the atmosphere of medical cooperation; 9) Explain the benefits of chlorhexidine mouthwash to the patient’s family, and inform the patient’s family to buy the correct chlorhexidine mouthwash.

The implementation rate of airway management measures for adult critically ill patients refers to the ratio of the number of items correctly implemented by nurses to the total number of items in the practice of implementing airway management measures for adult critically ill patients. Make a registration form for indicator review. The responsible nurse records the implementation of the work every day, the responsible group leader supervises and follows up, and the head nurse collects statistics.

The patient has cough, thick sputum, wet lung sound, and one of the following can be diagnosed: 1) Increased white blood cells and (or) neutrophils; 2) Fever symptoms; 3) X-ray or CT showed inflammatory changes in the lungs [11] . Data were collected by consulting medical records and nursing records.

Total number of days in ICU from the first day of admission to the ICU to the day of departure. Data were collected by consulting medical records and nursing records.

Sputum characteristics of patients on the fourth day after the artificial airway was established were collected through on-site observation records, medical records and nursing records. The characteristics of sputum can be divided into three levels according to the viscosity [12] [13] : 1) Grade I: sputum is like foam or rice soup, and there is no retention of sputum on the inner wall of the suction tube after negative pressure suction; 2) degree II: thicker than degree I, a small amount of retention in the inner wall of the suction tube after negative pressure suction, easy to be washed; Third degree: yellow, obviously viscous, sputum tube inner wall is easy to retain a lot of sputum, not easy to wash, sputum tube is easy to collapse when the negative pressure is too large.

The total implementation rate of airway management measures in adult critically ill patients increased from 23.62% before the development of quality control circle to 88.82%, and the compliance rates of all measures were significantly higher than those before the development, with statistical significance (P < 0.05), as shown in Table 3.

Before the implementation of quality control circle, the pulmonary infection rate of 52 critically ill adult patients with airway management was 42.31%, and the length of hospitalization in NICU was 11.67 ± 5.50 days. After the implementation of quality control circle, the incidence of pulmonary infection in 46 critically ill patients with airway management was 21.74%, and the length of hospital stay in NICU was 10.00 ± 4.91 days. The results of pulmonary infection between the two groups before and after the implementation of quality control circle were statistically significant (P < 0.05). There was no significant difference in hospitalization days between the two groups (P > 0.05), as shown in Table 4.

Before the quality control circle was carried out, 4 cases of grade I, 28 cases of grade II and 20 cases of grade III sputum were included in 52 patients. After the quality control circle was carried out, 33 patients with degree I, 13 patients with degree II and 0 patients with degree III were included. The results showed that there were statistical differences in the results of sputum traits before and after the development of quality control circle (P < 0.05), as shown in Table 5.

Note: 1) X², 2) t.