Difficult Airway Awareness QI project Residents: Jillian Vitter, Steve Bourland, Joe Morabito Faculty Advisors: Dr. Ana Fernandez-Bustamante, Dr. Steven Zeichner

The QI Problem Poor communication between anesthesia providers, patients, and other care providers about difficult airways (DA) A difficult airway can result in major morbidity or mortality to the patient, practitioner, and the health care system. 2005 closed claims analysis, brain injury or death accounted for >50% of all perioperative care claims & all claims for events outside of the OR. Payments ranged $2,200 - $8.5 million Unanticipated DA are reported at a rate of 1-3% among hospitalized patients Facemask ventilation fails 1:1,500 cases Tracheal intubation fails 1:1,000-2,000 cases LMA placement fails 1:50 cases Can’t Intubate Can’t Ventilate 1:5,000-10,000 cases

The QI Problem History of difficult airway is the greatest predictor of future difficulty. Currently, we rely on patients to provide information about their surgical and anesthetic history at outside hospitals. They cannot provide a difficult airway history if they were not effectively informed. Other in-hospital teams who may need to manage the patient’s airway may not have access or know where to locate old airway records.

Who does this affect? Anesthesia care team Patient Surgeon Directly impacted. Allows prevention and planning instead of urgent reaction. Primary caregiver responsible for identifying and communicating DA Patient At risk for morbidity or mortality with a DA that could be prevented or reduced had the prior difficulties been identified. Surgeon May need experienced surgeon at bedside for induction ( i.e. ENT, TACS) in high-risk patients for surgical airway. Unanticipated difficult airways can delay, cancel cases. May impact consideration for surgery in elective or palliative circumstances.

Who does this affect? Nurses Family Gain awareness of difficult airway. May incorporate into code status in event of a cardiac arrest/code blue (call anesthesia & ENT earlier for airway management). Decrease threshold for contacting providers when patient having respiratory decline. Family Future providers, out-of-OR sedation by non-anesthesia providers, EMT, outside hospitals Risk Management/QI Near miss: important to document as intra-operative event given potential complications. May help disseminate information re: DA to patient and hospital teams.

Current ASA recommendations for disseminating DA information Written report or letter to patient Report to medical record Chart flag Communication with surgeon, primary care physician (PCP) Notification bracelet or equivalent

Is this system implemented? 50% of patients remember having a DA conversation with an anesthesiologist post-operatively. 80% of patients remember receiving a DA letter. 41% PCPs are aware of their patient’s DA history. 23% of patients register with a Medic Alert system. 20% of anesthesiologists consistently write letters informing their patient’s other physicians of a DA.

How to address this? DA registries (nationwide, hospital-wide) Survey provider’s knowledge about how & where to document difficult airways. Survey non-anesthesia providers about where airway records are located in EPIC. Potentially add this information to the code status? Chart review on submitted DA QI report patients. Was there any missing information that would have predicted the DA? Documentation: giving patients a card with their airway information. Discuss DA during time out, placed within code status, potentially an FYI like at Children’s Hospital. DA registries (nationwide, hospital-wide)

Our Intervention Customize a letter and wallet-sized card for all patients with difficult airways. What was tried, what was successful, recommendation for future management. Methods: Intraoperative anesthesiology providers submit DA in the QI system. All DA submissions are reviewed by members of the DA Committee. The intraoperative team is contacted as needed for additional information. Information is streamlined in EPIC to populate a letter and wallet card, which are mailed to the patient.

Example of card

Our Intervention Findings: Increase rate of successful DA communication to patients at UCH compared to national rates. We currently do send a letter but do not have data on usefulness of this letter. Metrics: survey patients at 3 months & 6 months: DA information received? Carrying wallet card? Communicated with PCP? Used this information at another hospital or in emergency?

Conclusions & Recommendations We are the airway experts! New role of anesthesiologists as patient safety advocates and perioperative care coordinators. Our responsibility to ensure that patients and other physicians are informed about DA. Knowledge of prior DA will allow a plan with precautions in order to decrease morbidity and mortality. Awake fiberoptic, ENT standby, etc. Sustainability: currently funded by anesthesiology department. Change in DA reporting may catch previously missed patients and increase cost of new notifications.

References ASA “Practice Guidelines for Management of the Difficult Airway.” Anesthesiology 2013, 118 (2). Baker et al. “How do anaesthetists in New Zealand disseminate critical airway information?” Anaesth Intensive Care 41, 2013: 334-343. Feinleib et al. “What we should all know about our patient’ airway. Anesthesiology Clin 33, 201: 397-413. Wilkes M et al. “Difficult airway communication between anesthesiologists and general practitioners.” Scott Med J 2013, 58 (1): 2-6. NAP4: Major Complications of Airway Management in the UK.