The Critical Response Team in Airway Emergencies



 

John F Damrose, MD, FACS1; William Eropkin, RRT, RCP2; Serena Ng, MD3; Sheik Cale, DO4; Subhendra Banerjee, MD, FACS5

Perm J 2019;23:18-219 [Full Citation]

https://doi.org/10.7812/TPP/18-219
E-pub: 06/07/2019

ABSTRACT

Successful outcomes of airway emergencies (AEs) in the hospital depend on rapid recognition and intervention before patients become unstable. We describe our medical center’s experience with a coordinated rapid response to AEs, including an illustrative case. This approach emphasizes early recognition of impending AEs and instantaneous activation of a team of specialists and operating room personnel to rapidly respond to AEs anywhere in our medical center.

The literature on critical response teams for AEs is reviewed.

Case Example

A 46-year-old woman with lupus receiving long-term immunosuppressive therapy was brought to the Emergency Department (ED) with a fever, hypotension, and altered mental status. She had retrognathia and a short thyromental distance. Two experienced providers attempted orotracheal intubation for airway protection but could not place the endotracheal tube. Airway edema ensued, further making intubation difficult. The responding intensivist placed a laryngeal mask airway, but adequate positive pressure ventilation and tidal volumes could not be maintained. An airway emergency (AE) (“Condition A”) was declared, the critical response team was mobilized, and the patient was evaluated quickly by the responding on-call anesthesiologist and otolaryngologist. The patient was transported to the operating room for further airway management, including a possible tracheostomy. She was successfully intubated by the otolaryngologist through the laryngeal mask airway using an Aintree intubation catheter over an intubating bronchoscope. A 6.0-mm endotracheal tube was passed over the catheter, and the airway was secured. The patient remained intubated for several days and was extubated uneventfully. She recovered fully and was discharged home without sequelae.

INTRODUCTION

AEs are critical events that can occur at any time in the hospital or clinic. First responders often vary in their level of expertise and confidence in managing AEs. Ideally, rapid assessment and intubation of the airway will occur while the patient is still cooperative and breathing spontaneously. At times, a surgical airway must be obtained when other means fail. Inexperience, inadequate equipment, and a lack of trained support staff can complicate an already tenuous situation. Time is probably the most crucial factor that must be managed to resolve an AE successfully. When time is squandered, options rapidly diminish, and the risk of a poor outcome rises. The morbidity associated with unplanned procedures is well known.1-3 Mortality is especially high if the patient is in cardiopulmonary arrest at the time the emergent surgical airway is attempted.1,2,4,5

This article describes our medical center’s approach toward a coordinated response to AEs. The emphasis of this approach is on early recognition of impending AEs and instantaneous activation of a team of specialists and operating room personnel to rapidly respond to them anywhere in our medical center. Early recognition is reinforced through education and periodic drills. Confidence is encouraged through an expansion of privileges. Sequential improvement is maintained through structured debriefings. Any medical center can benefit from such a program, especially smaller hospitals and those without dedicated in-house resident support. The challenges in those facilities of handling low-frequency, high-acuity events make the implementation of such a program even more appropriate.

CRITICAL RESPONSE TEAM AND “CONDITION A”

The Kaiser Permanente Fresno Medical Center is a 169-bed, not-for-profit community hospital with maternity, emergency, intensive care, outpatient, radiology, laboratory, pharmacy, and health education services. Located in the San Joaquin Valley of California, the medical center supports 3 additional outpatient satellite facilities in Selma, Oakhurst, and Clovis with a total member service population of approximately 145,000. Level 1 trauma is managed by other area hospitals, and there are no surgical residents or critical care fellows in the facility. Head and neck surgeons do not take “in-house call.”

In 2010, a group of medical center leaders met to review and improve the management of AEs. The impetus for this work was a conference from the prior year addressing hospitalwide safety. A near-miss that occurred in the ED illustrated the need for a more coordinated response in our facility to AEs, a process we named Condition A. In 2012, the Medical Executive Committee approved a policy creating a critical response team for AEs. This policy is reviewed every 3 years and requires ongoing approval by the committee. On average, approximately 4 Condition As are called per year in our facility. This situation does not include stat anesthesia calls, awake tracheostomies, or fiberoptic intubations that may occur outside the scope of a Condition A call.

When an impending or actual AE is identified, the page operator is notified and broadcasts an alert (“Condition A”) on the overhead paging system throughout the medical center. In addition, pages are sent to the members of the AE critical response team (Table 1). Their respective roles have been clarified formally in the policy and are reinforced through mock drills and real-life emergencies.

On activation, the team converges on the location of the AE prepared to assist in intubation of the patient or to perform a surgical airway if needed. If the AE occurs in the ED or Intensive Care Unit (ICU), the physician in charge of the patient activates the Condition A and directs care until the critical response team assembles. These physicians are skilled at noninvasive airway management but may be called on to obtain a surgical airway if a head and neck surgeon is not immediately available. If the AE occurs in the hospital floor or clinic, the initiating responder evaluates and treats the patient until more experienced help arrives.

To enhance their confidence and skills with performing surgical airways, the clinical privileges of ED and ICU physicians have been expanded to include assisting head and neck surgeons in the operating room on elective tracheostomies. Although cricothyrotomies are more likely to be done by nonsurgeons, it is believed that mastery of the technique of tracheostomy provides adequate training for both procedures.

In the ED and ICU, all the equipment necessary for oral or nasal intubation, as well as emergent surgical airway intervention, is maintained in those departments. Each setting has its own intubating bronchoscopes with video monitors, portable videolaryngoscopes (GlideScope, Verathon Inc, Bothell, WA), and jet ventilators. Elsewhere in the hospital, this equipment is brought via cart to the bedside by the respiratory therapist on duty. Figures 1 and 2 depict the cart in detail, and Table 2 lists the standardized equipment carried in each cart. Fiberoptic intubations are typically carried out by Anesthesiology Department staff or a head and neck surgeon.

Both physician and nonphysician health care providers may call a Condition A. Respiratory distress resulting from angioedema, deep neck space infection, tumor, active bleeding, and recognized anatomical factors that lead to a “cannot intubate, cannot ventilate” scenario are all reasons to initiate a Condition A (Table 36-11). Physician and staff education about AEs is performed periodically with an emphasis on these risk factors. Stat calls for anesthesia, the rapid response team, and the Code Blue team are separate from Condition A calls. To differentiate them, we have encouraged staff to identify those patients with anticipated or evolving airway distress combined with risk factors for a difficult airway (Table 3). However, it is recognized that a Condition A may also evolve out of these other calls in conjunction with the emergency being treated. Other authors have published similar criteria for activating their critical incident response teams.8,12,13

If time allows, AE cases are typically managed in the operating room where lighting, equipment, and trained personnel are optimal. Transportation occurs via gurney with monitoring, anesthesiology staff, the surgeon, and a respiratory therapist usually in attendance. Culturally, there is a strong tradition of teamwork among operating room staff and providers that is enhanced through a TeamSTEPPS (Team Strategies & Tools to Enhance Performance and Patient Safety) approach to communication. TeamSTEPPS is “an evidence-based teamwork system to improve communication and teamwork skills among health care professionals.”14 TeamSTEPPS training is mandatory for all physicians and staff who work in the operating room. AE simulations are also conducted in the operating room and recovery room. For more acute emergencies, active airway intervention occurs at the patient’s bedside.

After an AE, a debriefing is performed to assess the team’s responsiveness and to identify areas for improvement. This includes completing a formal feedback questionnaire, which is downloaded from our medical center’s Web site. This information is reviewed with respective department leads, and changes are made when necessary.

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CHALLENGES OF IMPLEMENTATION

Implementation of the Condition A policy was not without challenges. Engaging the principal stakeholders was an early barrier, but this was overcome by emphasizing the critical lifesaving work of the initiative. The respective roles and skill sets of the involved providers were already established, albeit their execution in the event of a true AE could be uncoordinated and inconsistent. Bringing organization to these efforts through a coherent policy with clearly defined roles helped overcome this problem. Equipment was already in place and was of high quality to begin with, so no additional expenditures were needed in this area. Expansion of privileges to allow ED and ICU physicians to accompany head and neck surgeons to the operating room required revision of existing privileges through our Credentials and Privileges Committee.

Education and standardization of practice has been slow but steady and relies on periodic drills, presentations of the Condition A initiative at departmental meetings, and sharing of lessons learned from each Condition A occurrence. A homepage on the medical center Intranet was created that outlines the goals of the Condition A policy, identifies medical center leaders, and has an online feedback form to submit after each event. An ongoing barrier has been maintaining awareness among new physicians, nurses, and ancillary staff as they onboard into our medical center. Incorporating this information into the onboarding process has not been done but is certainly a worthwhile endeavor that we continue to explore.

EXPERIENCE SINCE IMPLEMENTATION

Since this policy was adopted in our medical center in 2012, we have had 24 Condition A calls, or 4 on average per year. The numbers of calls per year ranged from 1 (in 2014) to 7 (in 2017). Patient demographic characteristics were not routinely collected on these patients, which limits our analysis. However, 54% of patients came from the ED; 29%, from the ICU; and 17%, from the wards. None came from the clinics. All were adults. Of the 24 Condition A calls, 13 (54%) occurred from 7 am to 7 pm and 11 (46%) occurred from 7 pm to 7 am, which is consistent with what other authors report.15 Angioedema and deep neck space infections accounted for most of these cases, which is seen in other studies.13 Excluded from these numbers are patients who may have been brought directly to the operating room for airway intervention by the attending otolaryngologist. These calls would not necessarily have triggered a Condition A call if the patients were stable and breathing on their own. Examples include patients seen in the clinic for routine cancer follow-up only to be found to have stridor caused by an obstructing tumor or patients in the ED with deep neck space infections (eg, Ludwig angina) but without increased work of breathing.

There has been one death after a Condition A was called because of an inability to secure the airway. This patient had been electively decannulated after tracheostomy. The patient experienced cardiac arrest secondary to respiratory failure and could not be intubated. An emergent surgical airway was attempted but could not be obtained.

All other cases of AEs managed with the new critical response team had good outcomes, including the illustrative case presented in the abstract. Consistent with the experience of other groups,7,16 it is our perception that the need for emergent surgical intervention has decreased. Those surgical airways that have been obtained have not resulted in substantial morbidity or mortality.

DISCUSSION

Review of Literature

AEs are infrequent but life-threatening events that can occur without warning at any time in the hospital. Nearly all these events will occur in relatively resource-rich areas such as the ED, ICU, or Pediatric ICU. Concentrating equipment, training, and personnel in these areas will address most AEs. However, a sizable minority can occur in more isolated areas of a hospital.7,12 In a study by Hillel et al,7 39% of AEs occurred on the hospital wards and only 5% were from the ED. In our experience, 17% of AEs occurred on the wards. This necessitates a mobile team capable of responding in a timely manner to any area in the facility.

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Risk factors for a difficult intubation have been reported by many authors.6-11 When known in advance, detailed plans can be made for successful airway management. Dissemination of this information early and widely in a patient’s hospitalization may involve numerous approaches (see Sidebar: Communication Enhancers for Use with Difficult Airway Cases). There are various screening approaches to attempt to identify potential difficult intubations, such as the Mallampati oropharyngeal classification or the Wilson risk score, but these suffer from poor to moderate diagnostic accuracy.17 Furthermore, a large number of patients may have no identifiable risk factors. For this reason, the ability of a critical incident response team to assemble and intervene quickly at the patient’s bedside to stabilize the airway becomes essential.

Common features of most critical airway response teams include: 1) a dedicated multidisciplinary team with defined roles for each team member; 2) involvement of anesthesiology, surgery, critical care, respiratory therapy, and nursing; 3) activation of the team through a centralized paging system; 4) ability of the team to respond anywhere in the hospital; 5) equipment for airway management that is brought directly to the patient’s bedside; and 6) education for physicians and staff on AE recognition and how/when to activate the critical response team. Furthermore, critical airway teams must be skilled in all aspects of airway management (Table 4). Most team members become proficient in these skills by the end of their residencies. However, specialty courses dedicated to management of the difficult airway are offered by many leading institutions and through specialty-specific boards.

The most comprehensive examples of critical airway teams have been reported by authors from large Level I trauma centers with academic affiliations.6,8,10,11,13,18,19 These institutions may have an oversight committee responsible for data acquisition, quality improvement, training, and education. In addition to physician representatives, membership may also include personnel as diverse as human factors engineers, Lean Six Sigma experts, safety officers, and risk management specialists. The core critical response team is responsible for direct patient care and may be composed of numerous medical and surgical disciplines with support from nurses, respiratory therapists, pharmacists, radiologists, and even chaplains. In addition to active intervention in an emergency, these teams may offer in-depth consultation services. Nykiel-Bailey and colleagues10 have reported on their Difficult Airway Service with an emphasis on advanced identification and planning for difficult airways. Their average daily census at Washington University in St Louis, MO, was 9 patients per day. The chief role is to review patient airway status, communicate recommendations to the consulting service, round daily, and maintain an accurate inpatient census list. They then assist the primary team in airway management as needed.

Medical centers specializing in pediatric care have benefited from critical airway teams. Congenital abnormalities of the upper aerodigestive tract and trachea can make intubation/extubation uniquely challenging. Pediatric patients may desaturate quickly and are more prone to respiratory arrest than are adults. Furthermore, most algorithms for managing the difficult airway focus on adults rather than pediatric patients.10,11 Although the reported mortality for adults after the implementation of critical response teams has generally been very low in most institutions, the findings of Sterrett et al11 indicate that mortality in pediatric AEs can still be substantial. Compared with other studies of similar size, they reported a mortality rate of 6% (10 patients of 162 activations) related to the AE itself. In a study by Mark et al,8 surgical airway rescue was less common in children than in adults (4 vs 29) and was related to high mortality (75%), possibly because it was performed too late in the critical airway event and/or after respiratory arrest had already ensued. The authors suggested that earlier surgical airway intervention may be an opportunity for improvement.

In these institutions, the benefit of a prospective consultation service has been demonstrated. The Difficult Airway Service at Washington University in St Louis, MO, may be consulted regarding patients who present with risk factors for difficult intubation.10 A plan for airway management is formulated in advance, and the patients are followed-up through their hospitalization. If intubation is required, this service may be directly involved and will also help outline a plan for safe extubation.

The presence of a head and neck surgeon on the critical airway response team has been reported to reduce the need for emergent surgical intervention8,11 and has resulted in decreased morbidity and mortality.7 In the study by Hillel et al,7 the percentage of cricothyrotomies performed decreased by 71%, perhaps because of increased comfort by the team with fiberoptic nasal intubation.

In the work by Sterrett and colleagues,11 head and neck surgeons managed most AEs in children through intubation with the assistance of laryngoscopy (rigid and flexible). Only a small number needed a surgical airway. Having a member skilled in the surgical airway may help move teams faster along the difficult airway algorithm, with less wasted time on redundant and ineffective steps. Timely surgical intervention has been shown to reduce mortality and morbidity. However, once cardiopulmonary arrest has occurred, the mortality rate rises significantly.3,11,18

Mark and colleagues8,9 have argued persuasively for the implementation of a critical airway team. Death and anoxic brain injuries arising from AEs constitute a large proportion of malpractice claims inside and outside the operating room. Having a reliable and robust response system in place to deal with low-frequency but high-acuity events is important for maintaining good quality outcomes. Survival from cardiac arrest has also been shown to improve with the presence of a dedicated airway team.18

Project Strengths and Limitations

This article reviews the development of a specialized critical airway response team in a small hospital where surgical expertise is not in-house, events are few, and there are no residents. Our critical response team has several strengths. The development of our team did not require additional capital expenditures on any equipment or personnel. Instead, existing resources were reorganized via a coherent policy so that lifesaving interventions are completed in parallel rather than sequentially. This team encompasses the use of an otolaryngologist, which has been supported in other publications as an important quality measure.7 Our approach involves the simultaneous activation of the operating room and the ICU in conjunction with the critical response team, and it expands privileges for the ED and ICU physicians to enhance their surgical airway skills should they be needed. Finally, a culture of teamwork exists in our operating rooms that has helped improve the response to AEs.

Although the initiation of a critical response team in our facility has been viewed as a marked improvement in patient care, some opportunities for further improvement remain. Our approach is solely a rescue model and needs to evolve to a preemptive model. This change would entail the systematic identification of patients at risk of difficult intubation and the communication of plans among various staff members should airway intervention become necessary. Additionally, data acquisition for quality improvement was not envisioned at the start of this initiative and should include the analysis of specific patient identifiers for systematic review. Furthermore, there is presently no oversight group dedicated to monitoring AEs in our facility. Instead, individual team members disseminate information on quality improvement, a process that can be haphazard at times. Finally, a more robust training program for frontline staff and physicians remains a work in progress.

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CONCLUSION

AEs are life-threatening events that are infrequent and often unpredictable. When an AE is managed poorly, the consequences can be devastating for the patient and the hospital.8,20 Larger, academically affiliated, Level I trauma centers encounter these events more frequently and tend to be better equipped with more in-house staff to respond. Smaller community hospitals generally have fewer resources and personnel. Ensuring that providers maintain optimal performance levels is a challenge in both settings and mandates the development of specialized critical incident response teams.

Initiation of a critical response team in our medical center has been viewed as a marked improvement in patient care. The need for emergent surgical intervention appears to have decreased, and surgical airways that were obtained have not resulted in substantial morbidity or mortality. However, opportunities for improvement exist, including better identification of AE risk factors, acquisition of specific patient data, and a more robust training program.

Disclosure Statement

The author(s) have no conflicts of interest to disclose.

Acknowledgments

Kathleen Louden, ELS, of Louden Health Communications performed a primary copy edit.

How to Cite this Article

Damrose JF, Eropkin W, Ng S, Cale S, Banerjee S. The critical response team in airway emergencies. Perm J 2019;23:18-219. DOI: https://doi.org/10.7812/TPP/18-219

Author Affiliations

1 Head and Neck Surgery, Fresno Medical Center, CA

2 Respiratory Therapy, Fresno Medical Center, CA

3 Anesthesiology, Fresno Medical Center, CA

4 Emergency Medicine, Fresno Medical Center, CA

5 General Surgery, Fresno Medical Center, CA

Corresponding Author

John F Damrose, MD, FACS (john.f.damrose@kp.org)

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Keywords: anesthesiology, emergency

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