Joseph Loskove, MD
Chief of Anesthesia
Memorial Healthcare System
Patients designated as “difficult to intubate” (DTI) are more at risk for losing their lives during both emergency and routine surgeries.
Surprisingly, it is not the difficult airway itself that is most life–threatening; modern medical technology allows anesthesiologists to intubate even the most difficult of cases. Rather, deadly mistakes often occur in the process of identifying, communicating, and managing the existence of a patient with a difficult airway, especially among numerous providers.
As the chief of anesthesia at the Memorial Healthcare System, the third-largest public health system in the nation and highly regarded for its exceptional patient- and family-centered care, I drew an interesting and shocking parallel. How is it that UPS can tell us exactly where in the world our package is at any given moment, but at one of the leading hospitals in the area, we may not be aware of a patient’s DTI status if he or she is transferred from one department to the department next door? Memorial Healthcare did not have a proper system in place that ensured that the notation of a patient’s DTI status moved throughout the health care system along with the patient.
This article explains how Memorial Healthcare developed a standardized DTI protocol, how we implemented the protocol and achieved staff buy-in, and the resulting outcomes thus far. I will also share insights I have gained throughout the process, which I believe are relevant to other innovative health care initiatives being developed during this time of rapid change in the industry.
Challenges to Proper DTI Management
The first and greatest challenge that health care providers face when dealing with a difficult airway is effective communication. In today’s landscape, a provider is likely to be part of a much larger health care system made up of multiple facilities that provide care to tens of thousands of patients every year. Traditionally, a patient’s difficult airway was only communicated to the anesthesia team; no effort was made to share this information with other parties, and there was no organized method to communicate the information to other providers.
In this traditional model, a patient’s DTI status is not likely to be effectively communicated in scenarios where the patient is moved to a different department or treated by multiple physician teams. This scenario is not uncommon in the operating rooms (ORs) and emergency rooms (ERs) of large hospital systems.
The second challenge is that the responsibility to intubate a patient outside of the OR often rests with nonanesthesia providers, such as emergency department physicians, intensivists, or trauma surgeons. This poses a challenge because these providers may not know that the patient has a difficult airway, may not be experienced with difficult intubations, and may not have the proper DTI equipment on hand.
The availability of advanced airway equipment (eg, video laryngoscopes, bronchoscopes, surgical airway equipment, and laryngeal mask airways) is a third challenge because such equipment is found inconsistently in ICUs and ERs. Because different facilities have different equipment outfits, an airway management system that has a record of success in one facility may be difficult to apply to other facilities, despite the fact that they appear similar on the surface.
Finally, the fourth challenge is that most health care systems use a combination of electronic and paper documentation. Thorough and consistent documentation is critical for DTI patients, especially for any future admissions to any facility in the system. For obvious reasons, regularly transferring information between electronic and paper systems quickly leads to errors.
Developing a DTI Protocol
A comprehensive difficult airway management program streamlines the identification, communication, and management of difficult airways and thereby reduces life-threatening complications. As chief of anesthesia, I worked with my team of physicians, nurses, and other personnel—along with the Medical Executive Committee of the health care system—to create a series of processes that would address our concerns.
The first step in building an effective, formalized DTI protocol is defining a DTI patient in clear terms that a physician from any department can understand and use (Table). For our purposes, Memorial Healthcare defined a “DTI patient” as a patient for whom a conventionally trained laryngoscopist experiences difficulty with mask ventilation, difficulty with tracheal intubation, or both. Using this definition, any physician from the Departments of Anesthesia, Emergency Medicine, Otolaryngology, Intensive Care, and Trauma may deem a patient DTI and indicate it on the patient’s chart.
Define the DTI patient
Disseminate DTI status
Use a DTI bracelet
Make a notation in the allergy section of the electronic health record
Send a letter about DTI status to the patient or caregiver
Introduce standardized DTI carts throughout the health care system
DTI, difficult to intubate
Once the patient is identified as DTI using this consistent definition, the next step is communicating his or her DTI status to any provider who will be in contact with that patient. Traditionally, the DTI status is communicated by placing a sign over the bed or on the whiteboard in each room. However, because patients may travel throughout a facility for tests and procedures, that method is not sufficient. One of Memorial Healthcare’s successful solutions has been to place a bracelet on the wrist of each patient with “DIFFICULT TO INTUBATE” printed on it, which stays on the patient for the duration of hospitalization. In addition, a notation—“DIFFICULT TO INTUBATE”—is placed in the allergy section of the electronic health record (EHR), ensuring that this information is available for subsequent visits to any facility within the system. Thus, a DTI designation is treated like an allergy—just as a patient is banded with an allergy bracelet on admission to the emergency department or hospital, so too is a DTI patient banded on entrance into the health care system.
Although a DTI airway will likely pose a challenge fewer times in a patient’s life than, say, a penicillin allergy, treating patient education with the same importance that one treats allergy education has significant value.
An unknown DTI is truly a worst-case scenario for an anesthesiologist, so if a patient is informed that he or she has a difficult airway—due to an anatomic trait or past medical experience with neck cancer, etc—and can share that in preoperative conversations, an anesthesia team can proactively create a suitable plan for that patient. Memorial Healthcare established the practice of sending a letter to the patient, his or her family, and his or her caregiver to provide education on a patient’s DTI designation. Including a DTI designation in an EHR takes the onus of communicating the status off the patient or the caregivers, which is particularly important in emergency situations.
In nonemergency situations, ensuring that the patient is fully aware of his or her DTI designation (just as if he or she had an allergy) adds another opportunity for the designation to be communicated, which is especially valuable for health systems that have not yet finalized their DTI system.
Once a system is in place to correctly identify a patient as DTI and band him or her to ensure that the designation is communicated, steps must be taken to obtain the necessary equipment. This can be done by introducing standardized DTI carts throughout all facilities in the system, including the ORs, ERs, and ICUs. The new standardized DTI carts are similar to a “code” cart—the carts at all facilities are stocked identically, and when opened are returned to a centralized location to be cleaned or sterilized, restocked, and resealed.
Implementing a New Procedure
One of the numerous lessons that I learned throughout the process of implementing a DTI protocol is that the application of an idea requires the most work by far, and is the most important piece to get right. A great idea without thorough and lasting implementation is of no use.
To ensure that our implementation was solid, we developed a comprehensive plan to distribute the new protocol throughout the organization. Once the new protocol was approved by the various governing bodies at the hospital, I set about introducing the protocol to all stakeholders and educating them on DTI risks. Many providers outside of the ER and OR are not familiar with difficult airways and the danger they pose, so providing some context to the new protocol was critical as well. I attended meetings for nurses, surgeons, and doctors in other departments in an attempt to educate as many staff members in the hospital as possible.
After the initial introductory sessions, I developed continuous educational sessions throughout the year and established an annual check-in to monitor progress. This training also became a standard part of the onboarding process for new doctors and nurses. This diligent educational effort has paid off, as the DTI protocol is now engrained into the culture at Memorial Healthcare.
Process and Outcome Improvements
The new DTI protocol described in this article was introduced at Memorial Healthcare in February 2012, and began to deliver results almost immediately. Shortly after the program’s introduction, a patient was admitted to the ER of one of the Memorial Healthcare hospitals with an acute myocardial infarction and required intubation. The ER physician encountered difficulty, and the anesthesia team was asked to assist. Subsequent intubation was successful, and the ER physician then wrote an order in the EHR deeming the patient to be DTI.
When the patient was transferred to another Memorial Healthcare hospital for urgent cardiac catheterization, a nurse noted the DTI designation in the allergy section of the patient’s EHR and placed the DTI wristband on the patient. Although this step should have been completed in the first institution where the patient was initially designated as DTI, the extensive educational efforts that took place raised the level of awareness of nursing staff across the hospital and helped the nurse in the second facility to recognize the DTI risk. This outcome was a direct result of our efforts to familiarize all staff with the new DTI protocol.
After undergoing a successful cardiac catheterization and stabilization, the patient was transferred to a third Memorial Healthcare hospital for coronary artery bypass graft surgery. In the preoperative holding area, the anesthesiologist noted the DTI wristband and brought the new DTI cart into the OR. Upon induction of anesthesia, the patient’s airway was found to be challenging, but the anesthesiologist was able to use the equipment available on the DTI cart to successfully and atraumatically intubate the patient. Without the DTI protocol, the DTI cart equipment would not have been so readily available, and that unavailability would have caused delays that could have had negative effects on the patient’s well-being. The patient underwent surgery and was discharged home in good condition.
Implementing this protocol can address the many challenges that a difficult airway presents to hospitals and health care systems. As large networks of hospitals become more common, it will be crucial for physicians, nurses, and technicians to be educated in effective DTI communication methods such as the one instituted at Memorial Healthcare.
To conclude, I’d like to highlight some lessons that were learned while working to establish a DTI protocol at Memorial Healthcare. These lessons are particularly relevant in today’s health care environment where we are all trying to deliver quality care at lower costs.
The first major take-away is that innovative ideas do not need to be complicated. Sometimes the most impactful ideas are also the simplest and the cheapest. With many hospitals looking to innovate on a budget, the DTI protocol is a useful example of the influence of small, standardized procedural changes and heightened awareness about an issue.
A related issue is that hospital personnel should not feel intimidated or helpless to offer suggestions for process improvement. Just as in any large organization, it can be hard to be innovative in a hospital setting—the bureaucracy is daunting, schedules are packed, and staff are focused on patient care first and foremost—but it is important to look for the everyday inefficiencies that could be fixed with a simple solution. The staff on the front lines—especially doctors, nurses, and technicians—are uniquely positioned to identify the small problems that constantly drain efficiency, safety, and profitability from the hospital. When front-line staff share these process problems with management, it becomes easier to create solutions for the hospital’s real productivity challenges. After I gave my first DTI presentation, Memorial Healthcare’s chief of medicine teasingly asked why no one had proposed this solution before. This goes to show that if you have an idea, speak up.
The second key take-away was the enormous amount of work that must go into implementation of a new practice. A new protocol must be tirelessly promoted to become a reality. In hindsight, you will almost always find that having the idea in the first place was the easiest part. The countless educational sessions and training efforts that went into turning that idea into a reality may have seemed repetitive, but that is what it took to ingrain the DTI protocol into the culture at Memorial Healthcare. That hard work has certainly paid off, and I believe that this lesson can apply to change initiatives as a whole.
A third lesson that the DTI protocol highlights is the ways in which EHRs can improve patient safety by facilitating faster and easier communication between physicians and departments. In the example I shared, the nurse in the second facility was able to see the patient’s chart in real time—thanks to the EHR—and aptly spot and manage the DTI designation. This instant exchange of information may have saved the patient’s life.
Lastly, the fourth lesson is perhaps the most important of them all—the power of collaboration. The success of the DTI protocol hinges on cooperation across all levels and departments of the health care system. A successful implementation should be a powerful example of how cross-departmental communication affects patient care in a hospital or health care system. Ten years ago, almost all hospitals had their departments working in silos, but there is a growing movement to break down the barriers that insulate physicians in their own departments and specialties.
Increasingly—whether in anesthesiology, radiology, or critical care—health care leaders are finding that working collaboratively and acting in a consultative capacity with their peers improves patient care, safety, and hospital efficiency. Cross-departmental process improvements are a boon for hospital finances as well, because they ensure that time and resources are not wasted with duplicated efforts.
Difficult airways are not especially dangerous if physicians have a proper warning. The danger lies in the failure to communicate a DTI status as the patient moves throughout a health care system. Through simple, standardized process changes, steadfast implementation, and interdepartmental cooperation, Memorial Healthcare was able to largely eliminate this danger.
My hope is that we will use this model for other patient safety initiatives throughout the health care system, and that other hospital leaders might reevaluate their DTI pro tocol and incorporate these tactics or others that make the hospital safer for DTI patients. I encourage other hospital leaders to use our DTI implementation model as a rubric for their own process improvement efforts.