Airway Management and Outcomes Reporting

Key Points

• Adequate documentation of airway management outcomes supports the goal of never having an unanticipated difficult airway.

• Parallel documentation of data in different sections of an electronic medical record allows for cross-checking of information, potentially increasing its reliability, but also increasing methodologic confounding if the sources do not agree.

• Automatization of clinical documentation is a particularly important function of an anesthesia information management system (AIMS)—the AIMS can be used to record objective physiologic data during periods when the anesthesiologist’s attention is focused on the patient and procedure.

• The AIMS should seek to create discrete data (i.e., a menu of options for recording laryngoscope type is better than a free-text field, because the resulting data will be easier to analyze).

• Whenever possible, difficult airway management should be defined in terms of highly objective data such as video recording and automatically captured vital signs.

• Implementation of objective and standardized definitions of airway management outcomes will increase the validity of results obtained in quality improvement projects and academic research.

Introduction

Airway management is a core skill of anesthesia professionals and something we take justifiable pride in doing well. This textbook illustrates the importance of airway management in clinical practice, and the many papers cited provide ample evidence of the growth of scientific understanding in this domain. This chapter will focus on the methodology behind clinical research in airway management, summarizing the data elements and metrics used to evaluate success and presenting options for future research in the era of electronic healthcare records, national registries, and comparative effectiveness research fueled by big data.

Documentation of Airway Management Outcomes

Documentation of airway management outcomes and the techniques used to achieve them serve two important purposes. First is the traditional role of medical documentation in supporting continuity of care. Future providers can learn from the experience of those who have gone before. While past returns of the stock market do not predict future performance, a past history of easy intubation is the best predictor that a future intubation attempt will be straightforward. And the situations where this might not be true—say when there is an expanding mass in the airway or active bleeding—are usually obvious to the clinician.

Even more important than evidence supporting easy airway management is the opposite: documentation of previous difficulties. Because airway management outcomes are likely to be better when the clinician can plan ahead, foreknowledge of anatomic abnormalities can be crucial in supporting the patient safety goal of never having an unanticipated difficult airway.

The second role of documentation is to support clinical research, with the goal of continuously improving patient care. Published studies of airway management techniques number in the thousands and extend back in time for decades. Historically, data have been captured from clinical records (in retrospective studies) or by direct observation and contemporaneous documentation. While some of the outcomes and metrics observed are “structured” (i.e., objectively defined in a digital format), a frustrating number of key elements are subjective in definition or documentation. “Laryngoscope blade used” is an objective data element, often structured in electronic records by inclusion in a list of menu options. “Mallampati score” is a structured element (a common, numeric definition exists), but it is subjectively measured (different providers may score the same patient differently), whereas “Difficult intubation” lacks both a common definition and interrater reliability. Difficulty can vary based on the skills and experience of the providers, as well as on the initial approach; a patient who is difficult to intubate via direct laryngoscopy (DL) might be easy when a video-assisted laryngoscope (VAL) is used. A practitioner using VAL as the initial plan would never know that airway management with DL would be difficult.

The history of airway management outcomes documentation is, thus, a quest for better and more objective methods of defining the patient and clinical experience. The purpose is to develop performance data that can be used to assess different techniques and devices in an evidence-based fashion. These data enable design of instruments, development of protocols and algorithms, and continuous quality improvement of both institutions and individuals. In the modern era of electronic record-keeping, the potential for passive, automatic uptake of large quantities of structured data is enormous but still largely unrealized. We can see the potentials but not yet grasp the prize.

The most important element of airway management documentation remains the clinical narrative, the story of what happened. Paradoxically, it is becoming harder to reconstruct a clinical narrative in the Information Age, because the electronic medical record (EMR) fragments information across multiple forms and screens or hides ad hoc comments in out-of-the-way places. Yet the ability to retrospectively understand the course of airway management in a given patient—especially if difficulties are encountered—remains critical to our ability to improve. This is why initiatives, such as the Anesthesia Incident Reporting System (AIRS) and the Anesthesia Closed Claims Project (CCP), remain so important to ongoing quality improvement. Each of these programs captures narrative detail about unusual cases. AIRS is an online system ( http://www.aqiairs.org ) that enables immediate reporting of adverse events, near misses, and interesting cases. The narratives are captured in a deidentified registry maintained by the Anesthesia Quality Institute, secure from legal discovery, and are used to generate illustrative case reports and teaching exercises. Now in its 30th year, CCP is a retrospective review of malpractice activity involving anesthesiologists, powered by expert review of detailed clinical and insurance company records. Airway cases captured in CCP are, thus, the worst of the worst, almost always resulting in death or serious injury. Neither system can accurately estimate the rate of problems in airway management, but each provides important information about what can happen. For rare events, such as patient injury from airway management, these narratives are an important source of learning and have been used to design and promulgate clinical countermeasures against identified risks. The goal of incident-report collection systems is to never make the same mistake twice.

Quality Improvement in Anesthesia

The medical specialty of anesthesiology has a laudable record of continuous process improvement based on self-examination of outcomes and development and application of evidence-based guidelines and protocols. Anesthesia is arguably safer than ever, enabling complex procedures on very sick patients. Advances have been achieved dating back to at least 1954 and the work of Henry Beecher in defining perioperative mortality in a coalition of major teaching hospitals. There have been numerous subsequent studies of anesthesia patient safety, ranging from descriptions of serious adverse events (e.g., the many reports from the Closed Claims Project) to prospective randomized trials of new medications, monitors, and devices. All are based on the collection of clinical data, systematic analysis, and academic reporting to the professional community.

Collecting Data

Assessing the outcomes of airway management is one facet of this overall quality improvement effort, now accelerating in the Information Age. Registries of clinical information create the capability to simultaneously link patient and procedural risk factors with anesthesia interventions, then examine the outcomes achieved. This process of using available medical documentation rather than painstakingly abstracted research data to compare interventions is known as administrative database research. While in theory it is straightforward and inexpensive, the results are subject to a number of methodologic issues:

• Data points must be commonly defined across all records.

• Definitions must be applied in a uniform way by all observers.

• Outcomes must be observed at similar times in all locations.

• Sufficient information must be gathered to understand differences in patient, procedure, and facility variables, and then used to provide valid risk adjustment of the outcomes.

For airway management, the ultimate outcomes of interest include survival, avoidance of major complications (e.g., hypoxic brain injury), avoidance of cricothyroidotomy, and patient satisfaction. Intermediate outcomes include the time taken to achieve a stable airway, the number of attempts, the need to change technique or operator, and the stability of vital signs. Variables that influence risk include patient age, sex, BMI, anatomic presentation, and comorbidities, as well as other elements such as emergent status, facility type, and type of surgery being performed.

Anesthesia Information Management Systems