Dissemination of Critical Airway Information

Key Points

The consequences of a difficult airway (DA) may include minor or major adverse medical events or death, professional liability to the practitioner, and direct and indirect costs to the patient and healthcare system. DA still accounts for the highest percentage of closed claims in anesthesia.
The American Society of Anesthesiologists (ASA) Practice Guidelines for the DA recommend the following components for dissemination of critical airway information: (1) a written report or letter to the patient, (2) a report in the medical record, (3) a chart flag, (4) communication with the patient's surgeon or primary caregiver, and (5) a notification bracelet or equivalent identification device. MedicAlert is currently the only organization that can readily provide this service.
The MedicAlert Foundation, founded in 1965 and endorsed by the ASA in 1979, is the only 501(c)(3) nonprofit organization that provides a comprehensive medical service to members, in the form of visible medical ID, a separate wallet card, a Web-accessible personal health record, and a 24/7 live emergency response service. It is accessible at http://www.medicalert.org/difficult-airwayintubation-registry .
The Airway APP and international Airway Collaboration is data collection for Emergence Surgical Airway:Front of Neck Access. One is able to follow results on www.airwaycollaboration.org .
The foundation has an updated National DA/Intubation Registry form available on both its website and that of the Society for Airway Management ( www.samhq.org ).
Development of an Airway Lead or Airway Team within each individual hospital can serve to guide the alert process and subsequent patient action plan.

Introduction

All airway practitioners encounter a difficult airway (DA), and likely encounter a failed airway, during their career. The consequences of failed airway maintenance and endotracheal intubation are devastating to the patient, the practitioner, and the healthcare system. Complex airway management is a multifaceted problem involving healthcare providers in a variety of clinical settings. Although a large percentage of difficult intubations can be predicted via a careful review of history and airway examination, unanticipated DAs are still reported at a rate of 1% to 3% among hospitalized operative patients. Since Cooper's classic 1978 paper on human errors, anesthesiology has made great strides to reduce preventable harm. A history of a DA and its recognition as a risk factor for future airway management have been helpful in the mitigation of risk in the clinical management of the DA patient. ^, Additionally, technology and new devices have improved anesthesiologists’ ability to secure airways. Remaining difficulties include the cryptic anatomy encounter or other anatomic barriers to airway maintenance that were not communicated. Thus, a new “human error” of airway safety is poor forward information transmission. The critical data lacking often include identification of such patients along with the complete documentation of airway management techniques that failed and those that were successful. The effective and efficient dissemination of this critical airway information to healthcare providers and patients is the current task set to our interdisciplinary professions.

Although a patient's DA was most likely first made evident in the setting of an operating room, subsequent events could occur in a variety of settings (even in the home or in public places) and could involve physician or nonphysician providers, such as paramedics, emergency room physicians, physicians of other specialties (e.g., otolaryngology), certified registered nurse anesthetists, and/or anesthesiologists. Therefore, it is incumbent on airway practitioners to make every effort to identify DA patients in and out of the operating room and transmit this knowledge in widely accessible forms using terminology that is directed toward other airway specialists, healthcare providers, and patients or laypersons. The fundamental differences between the successful management of known versus unanticipated DAs are clearly seen in the enhanced patient outcomes observed in the former scenario. ^, ^,

Currently, numerous DA communication reporting mechanisms exist, including airway databases and registries, although the field is migrating from a nascent stage toward a more nationally and internationally integrated stage. This transition is nonetheless still characterized by many competing elements, fractured systems, and diverse goals. We present a taxonomy of DA databases, registries, and clinical practices that have been successfully implemented.

Current Difficult Airway Databases

Systems in Place

There are two major goals of DA databases: (1) to identify specific patients for their protection and future care and (2) to collect data to study the epidemiology and cause of DAs to improve systems of care and clinical practice. Based on these goals, there are three types of DA databases: (1) patient protective DA database; (2) epidemiologic and etiologic DA database; and (3) combined patient protective, epidemiologic, and etiologic DA database. The first two accomplish one, but not both, of the aforementioned goals as would be the ideal. Other important features include the time frame (either time limited or perpetual) and accessibility for data reporting and retrieval. Data reporting can be restricted to predetermined institutions and patients or may be broadened to include global data reporting and retrieval. The data elements that are collected obviously determine the use of that databank. For incidence and prevalence calculations, the denominator of the total number of airway management occurrences is needed, along with the numerator of untoward airway events. To illustrate this taxonomy of DA databases, we have reviewed and analyzed multiple examples, highlighting their strengths and weaknesses. The databases are grouped according to the criteria, and at the end of each synopsis any additional factors defining that airway database are encapsulated. This discussion is not an exhaustive listing of all DA databases but covers the most substantial ones. This analysis also provides a framework for the evaluation of such databases and guidance for future discussions about DA database goals and their future use.

Type I: Patient Protective Difficult Airway Database

These databases are organized to identify and protect individual patients during their hospitalization and for their future care. It has long been the practice of many anesthesiology groups to keep an informal record of patients with DAs. Over time, many groups formalized this collective knowledge into more comprehensive databases, patient record flags, and patient notification systems. These databases are usually limited to a specific location or anesthesiology practice, and access to this information is usually confined to that group.

Single In-Hospital Difficult Airway Registry

In 2005, the Johns Hopkins Hospital in Baltimore, Maryland, developed an emergent call system to notify and engage a multidisciplinary difficult airway response team (DART). A DA registry note and local EMR registry were also developed with the DART, and additional notifications were employed to ensure that all hospital personal are aware of the patient DA status. Over the ensuing years, this system has been fully or partially replicated by many other healthcare systems.

Database factors: Access, limited; Timeframe, ongoing; Denominator, not included .

Veterans Affairs Healthcare System

In 2012, the Veterans Affairs (VA) Healthcare System (approximately 150 hospitals) set forth a comprehensive series of airway management standards through the Out of Operating Room Airway Management Directive (VHA Directive 1157). Included in this series of standards were guidelines stating that all VA hospitals had to have “a plan for managing the known or emergently identified difficult airway” and “a process for notifying such patients.” The implementation method of these guidelines was left to the individual VA hospitals to determine. Most VA hospitals now have a DA patient electronic flag; however, these flags are only local VA flags and do not attach to the patient's national electronic record. The establishment of a national patient record flag requires congressional assent. Additionally, the airway information collected by each VA hospital is not standardized, nor is there a searchable database of the information collected across the VA system. Although this directive sought to improve patient safety at local VA hospitals, it failed to create a nationally integrated system, which has impeded the ability to ascertain the issues of DAs within the VA system through data collection and analysis.

Database Factors: Access, limited; Timeframe, ongoing; Denominator, none .

Type II: Epidemiologic and Etiologic Difficult Airway Database

These databases are organized to determine the epidemiology of DAs or to catalog DA events to identify etiologic factors. The selection of patient characteristics, airway management techniques, and providers that are included in these databases determines their use for analyzing airway events. Further differentiation between these types of databases can be made in reference to their temporal framework and their accessibility.

American Society of Anesthesiologists Closed Claims Project

The American Society of Anesthesiologists (ASA) Closed Claims Project is the most widely recognized and fully established database of this type. Since its inception in 1984, this group has analyzed anesthesia-related events resulting in completed legal claims in the United States. The results of these multiple rounds of analysis have had a profound and positive impact on the practice of anesthesiology worldwide. ^, However, the usefulness of these data in the context of airway management is somewhat limited. The only airway management data included in this sample is that of failed airways that resulted in patient harm, and that by definition resulted in a legal contest. Such bias to the most extreme airway events lacks the inclusion of a total number of airway management attempts needed to determine an event incidence. Moreover, because these data are based on insurance claims, rich clinical detail may be lacking.

Database Factors: Access, limited; Timeframe, ongoing; Denominator, none.

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