Joseph Loskove, MD, is the chief of anesthesia for 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 physicians to intubate even the most difficult of cases. Deadly mistakes often occur in the process of identifying, communicating and managing the existence of the difficult airway, especially among numerous providers.
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, notification of a patient’s difficult airway includes informing only the anesthesia team; there is a lack of an organized method to communicate the information to other providers. In this traditional model, a patient’s DTI status is not likely to be communicated in scenarios where the patient is moved to a different department, perhaps being treated by a different anesthesia team—not uncommon in the operating rooms (ORs) and emergency rooms (ERs) of large hospital systems.
The second challenge facing providers is that the primary responsibility to intubate a patient outside of the OR rests with non-anesthesia providers, such as emergency department physicians, intensivists and trauma surgeons. This poses a challenge because these providers may not know 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 (e.g., video laryngoscopes, bronchoscopes, surgical airway equipment and laryngeal mask airways) is a third challenge, because such equipment is not always at-the-ready in ICUs and ERs.
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.
Fortunately, there are effective solutions that address each one of these challenges.
Proven Solutions From Memorial Healthcare System
A comprehensive difficult airway management program, like the one instituted at Memorial Healthcare System in Hollywood, Fla., streamlines the identification, communication and management of difficult airways and thereby reduces life-threatening complications.
The first step is to define what a DTI patient is in terms that a physician from any department can understand and use. 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 a DTI and can indicate it on the patient’s chart.
Once the patient is identified as DTI using a consistent definition, the next step is communicating his or her DTI status to any provider that 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 solution with which Memorial Healthcare has found success is to place a bracelet on the wrist of the patient with “DIFFICULT TO INTUBATE,” which will stay 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, ensuring 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, a DTI patient is banded on entrance into the health care system.
To better communicate with patients and their families or caregivers, Memorial Healthcare sends a letter to provide education on their DTI designation. This should coincide with educational efforts throughout the hospital system to train or retrain all staff and physicians on the DTI protocol so that any provider can answer patients’ questions.
Once a system is in place to correctly identify a patient as DTI and band him or her to ensure 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.
Process and Outcome Improvements
The new DTI protocol described in this article was introduced at Memorial Healthcare in February 2012. Shortly after, 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 chart 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 electronic record 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 recognize the DTI risk.
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. 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 healthcare 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 HealthcareSystem.
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