Airway Risk Reduction at Penn Medicine

Background

In 2012, Christopher H. Rassekh, MD, Associate Professor of Clinical Otorhinolaryngology – Head and Neck Surgery, organized a Penn Medicine research retreat where all the experts in different aspects of airway management were assembled to address the development of clinical practice guidelines. This led to the development of an airway working group which became the formal Airway Safety Committee that oversees clinical activities, quality improvement, education and also research involving complex airway problems across the Health System.

An early QI research project initiated by the Airway Working Group showed that the Activation of the Airway Rapid Response was frequently (more than 20% of the time) related to existing tracheostomies.

Subsequently, the group led by Dr. Rassekh and Joshua Atkins, MD, PhD, Associate Professor in both the Department of Anesthesiology and Critical Care and Otorhinolaryngology – Head and Neck Surgery, along with the hospital patient safety office, Ara A. Chalian, MD, produced two high profile publications – one about the subset of patients who had existing tracheostomy and the other detailing the entire group of patients over a four year period prior to the formation of the committee. These articles have received special acknowledgment by the main journal of the Academy of Otolaryngology-Head and Neck Surgery (former) and the Joint Commission Journal on Quality and Safety (latter).

One of the early objectives of the Airway Safety Committee was to develop guidelines for handling emergencies involving existing tracheostomies. Comprising representatives from all clinical and ancillary support departments involved in airway management, the Committee’s efforts would hasten the creation of several formal airway risk reduction initiatives and the airway rapid response (ARR) system for airway emergencies throughout the hospital system.

The Trouble with Tracheostomies

Loss of the airway is a potentially devastating problem because lack of oxygenation causes brain damage and/or death very quickly.

While they seldom occur, tracheostomy-related emergencies are a source of great anxiety for treatment teams. Every emergency intubation increases the hazard of airway harm for the patient. Airway emergencies are defined by immediacy and urgency. Typically, these events are either unexpected—the rapid loss of airway in an intubated patient—or involve the inability to provide an open airway, often for reasons not immediately apparent or understood. For example, when treating a patient with a difficult airway, an anesthesiologist may be unable to provide ventilation either by mask or by intubation to a patient under anesthesia in an ICU or operating room – necessitating a tracheostomy. Patients with difficult airways possess criteria that make intubation challenging (e.g., large tongue, narrowing of the trachea, or obesity).

A rapid and unexpected airway compromise requiring an emergency tracheostomy can occur anywhere in the hospital even under ideal bedside management. Airway blockage may occur in patients with an existing tracheostomy as a result of mucus plugging, bleeding from surrounding vasculature, pneumothorax, false passage between the trachea and sternum, and accidental removal of the tracheostomy tube, among other events.

These and other tracheostomy-related airway events can be sufficiently managed with adequate training and equipment, the availability of appropriate clinical staff and established emergency protocols—considerations that evolved as separate risk reduction projects within the broader airway safety initiative at Penn Medicine.

Reducing the Incidence of Airway Emergencies

The Penn airway risk reduction initiatives have the objectives of avoiding mortality, morbidity and injury. The motivation for airway risk reduction embraces the immediate life saving benefit, as well as the prevention of the long-term effects of airway blockage, including brain damage, hypoxemia, heart attack, laryngeal injury, and progressive endotracheal and bronchial damage.

Reaching these objectives has involved the establishment of the following:

• The Difficult Airway Program, a strategic initiative that established criteria for difficult airway (challenging endotracheal intubation) and procedures to manage these patients, including a program by which patients who are grade 3 or 4 under the Cormac-Lehane classification system receive a difficult airway identification (DAID) bracelet.
• A key element in the overall risk reduction process of the Airway Safety Committee, Airway Rapid Response (ARR) team respond immediately to airway events and handle the unique clinical challenges of airway crises with a streamlined activation pathway and the necessary equipment and airway expertise including the needed personnel and instrumentation to perform an immediate surgical airway if needed. These ARR teams rapidly gather at the bedside, to perform a surgical airway or manage a tracheostomy emergency. They also help manage intubation in general in patients who are difficult airways.
• ARR activation now brings to the bedside
  
  • an attending trauma surgeon
  • an otorhinolaryngology - head and neck surgery attending (if available)
  • a rapid response nurse coordinator
  • anesthesiologist
  • pharmacist
  • respiratory therapist
  • x-ray technician
  Currently, equipment ready at the bedside for the ARR team includes a battery-operated flexible fiberoptic bronchoscope, a tracheostomy set, a handheld video laryngoscope, a code cart equipped with a surgical airway tray, a portable x-ray machine and a disposable tracheotomy and knife kit.
• The Tracheostomy Card (see below) Project consisting of graphic, highly visible and individualized cards posted at the bedside of patients at risk. Each card contains information relevant to emergency procedures and contacts and an algorithm for care. Includes patients with laryngectomy, percutaneous tracheostomy and open tracheostomy.
• An Extubation Protocol for high-risk ICU patients. One of the elements of this protocol involves consulting the ENT group to be present when a patient’s tracheal tube is being removed so that a surgical airway can be performed, if needed.
• A Perioperative Briefing via email to ensure communication between the principal surgeon and the anesthesiologists, nurses, monitoring team and consultants involved in airway management prior to performing a tracheostomy and other procedures that may impact or involve the airway. Ideally, this communication would arrive early enough that the team members could look at it. Resulting in fewer delays and less confusion in the OR, this protocol has been very successful.

Maintaining Quality in Airway Rapid Response at Penn Medicine

Because each situation offers a unique challenge, the Penn Airway Response Team employs team discussion and in situ simulations of ARR events to reinforce the importance of leadership designation, situational awareness and closed-loop communication throughout an emergency response. In situ simulations are conducted in the medical intensive care unit, the inpatient and outpatient post-anesthesia care units (PACUs), and the cardiac electrophysiology suite to provide guidance for process optimization, systems learning and the understanding of team dynamics.

In addition, multidisciplinary airway safety Grand Rounds have been instituted for case-based discussion and systems improvement. These learning sessions are organized by the Airway Safety Committee and include clinical area nurse managers, perioperative nursing teams, and specialists in otorhinolaryngology – head and neck surgery, anesthesia, respiratory therapy, pulmonary medicine and trauma surgery.

The object of these procedures and measures is to ensure both the ongoing quality of Airway Rapid Response and the safety of intubated patients at Penn Medicine.