EXECUTIVE SUMMARY

While emergency providers are trained in the management of difficult airways, there are times when added multidisciplinary expertise can be essential to ensuring a good outcome. To address these instances, some medical centers have established rapid response teams that will come to the bedside of patients with known difficult airways or new complications that make airway access problematic.

  • Investigators at the Hospital of the University of Pennsylvania (HUP) in Philadelphia developed an airway rapid response (ARR) system after quality reviews determined that ad hoc processes were contributing to delays in assembling the appropriate expertise and equipment in cases in which emergency intubation had failed outside the operating room environment.
  • In addition to a trauma surgery attending provider, the ARR team at HUP includes an anesthesiologist, pharmacist, radiology technician (along with a portable X-ray machine), respiratory therapist (along with a battery-powered bronchoscope), a rapid response coordinator, and an otorhinolaryngology - head and neck surgery resident and/or attending. Also, nursing staff respond along with equipment, including a surgical airway tray.
  • Johns Hopkins Hospital in Baltimore developed its difficult airway response team (DART) in 2005, and it is now a part of the culture in the ED. In fact, emergency medicine providers are part of the DART team, although they only respond to activations in the ED.
  • Experts note that successful deployment of a rapid-response approach requires clear designations of responsibility to the players involved when activation occurs, and an active review process for ongoing improvement.

Emergency situations can escalate into crises quickly if early attempts to establish an airway fail, depriving a patient’s brain of needed oxygen. This is why some academic medical centers have developed specialized rapid response teams to deliver expertise and equipment to the bedside of patients with difficult airways. While not all hospitals are equipped to deploy such a team, facilities can borrow some best practices that have been learned from others. Some medical centers have been fine-tuning their rapid response approaches for difficult airways over many years.

Emergency providers are better trained than many other clinicians in establishing airways. Still, investigators note that emergency providers can benefit from the multidisciplinary skill set provided through a rapid response approach, especially when surgical intervention is required. However, the implementation of such an approach requires carefully developed criteria on when a rapid response team should be activated, and a willingness to opt for this kind of assistance quickly in appropriate circumstances.

Consider Required Surgical Expertise

Investigators at the Hospital of the University of Pennsylvania (HUP) in Philadelphia recently reported on their experience with an airway rapid response (ARR) system. A group developed this system after quality reviews determined that ad hoc processes were contributing to delays in assembling the appropriate expertise and equipment when emergency intubation had failed outside the operating room environment.1

“The number one obstacle to implementation of a system like [ours] is whether or not the hospital has an in-house surgical presence 24/7,” explains Joshua Atkins, MD, PhD, the lead author of this research. Atkins serves as an associate professor in the department of anesthesiology and critical care and the department of otorhinolaryngology - head and neck surgery (ORL-HNS) in the Perelman School of Medicine at the University of Pennsylvania. Atkins notes that the presence of a surgeon is critical if a patient who cannot be intubated by other means requires emergency surgical airway access, best accomplished through an incision to the neck with a scalpel. Atkins says anesthesiologists and emergency physicians in the United States tend to be well trained to provide similar emergency airway access using a needle. Still, Atkins adds there have been fewer opportunities for them to receive surgical training in this area, and the scalpel technique is more effective.

In addition to a trauma surgery attending provider, the ARR team at HUP includes an anesthesiologist, pharmacist, radiology technician (along with a portable X-ray machine), respiratory therapist (along with a battery-powered bronchoscope), a rapid response coordinator, and an ORL-HNS resident and/or attending. Also, nursing staff respond along with equipment, including a surgical airway tray.

Facilitate Education

When implementing the ARR system, one challenge at HUP involved educating all hospital units about the team and when it should be activated. Atkins notes that a clinical emergencies committee provided this education unit by unit. Further, descriptive flyers were distributed and posted in all units. (Editor’s Note: See “Activating the Rapid Response Team” at the bottom of this article for more details.)

If an anesthesiologist has arrived at the bedside already, the flyers indicate that the ARR team should be called in the event the anesthesiologist is unable to ventilate the patient. For example, a first attempt at intubation might fail, there may be an inability to ventilate, or oxygen saturation does not improve despite ventilation. In addition to their display in hospital units, flyers are available online, and are used during training sessions.

Expedite Care Decisions

In practice, when the ARR team is activated, the team members will assess the patient jointly with the primary team. Then, the group determines what action is needed based on a series of activation pathways. This may involve no airway intervention, some type of intubation, replacement of an existing tracheostomy, or a bedside surgical airway. Alternatively, the patient may be transported to the operating room for a surgical airway, a surgical direct laryngoscopy, a rigid bronchoscopy, or extracorporeal membrane oxygenation.

In a retrospective review of 117 ARR-involved events that took place during a 40-month period between August 2011 and November 2014, investigators found that an airway was secured in all patients for whom the ARR team attempted airway management.

Investigators noted that a surgical airway was completed in five patients; seven patients were transported to the operating room for airway management procedures.

“Many of our surgical airways actually occur in the operating room. In other words, they start on the floor or the ICU or the ED, and then the actual surgical airway takes place in a controlled setting by surgeons in the operating room,” Atkins explains. “The other thing that our research highlights is that many of the [airway] emergencies were actually patients with existing tracheostomies. What we have learned that is as important, if not more important than actual skill set in actually performing a surgical airway, is the interdisciplinary experience with airways.”

Atkins notes that by assembling a multidisciplinary team quickly, appropriate care decisions can be expedited. “You can come to a rapid team discussion and arrive at a quick plan instead of an ad hoc, sort of haphazard, sequential sort of activation of various exercises, which leads to a less efficient solution of the problem,” he adds.

Address Activation Delays

In the early stages of implementation of the ARR system, investigators found instances when clinicians thought that calling ENT and anesthesia was equivalent to activating the ARR system. “We had to go back and do some education [noting] that this was not the case,” Atkins notes.

Investigators also saw some other cases when activation of the ARR team was delayed incorrectly. Atkins recalls one such case that resulted in a poor outcome. “[The treating clinicians] first went to anesthesia, and then they called ENT. They eventually activated the ARR system when the patient actually met the criteria for activation from the beginning,” he explains. “Then, we had almost the exact same type of case where clinicians activated [the ARR team] from the beginning, and there were two different outcomes.”

Atkins observes that this reluctance to activate the ARR team when indicated has decreased, but he notes that the unit where this reluctance tends to be the highest is in the ED. “I think this is unique somewhat to the academic medical center because part of the issue is that emergency physicians are, to some extent, airway experts themselves. There has been some reluctance at times to engage other airway experts,” Atkins offers.

To address the issue, the hospital is implementing an interdisciplinary surgical airway team training simulation program. Clinicians are invited to participate in complex circumstances that would require the activation of the ARR team. “Then, we bring the ARR team in real time down to the ED, and we work through these issues,” Atkins notes. “Then we debrief, highlighting the criticality of the interdisciplinary conversation.”

Atkins observes that even hospitals without resources to implement a rapid response team can improve outcomes. For instance, he explains that one of the most successful improvements at HUP was the creation of an interdisciplinary airway safety committee, which Atkins co-chairs.

“That actually gets all the personalities and players in the room regularly so that they are much more prepared,” he says. “We found that we identified many more issues than people thought there were. Now, within 24 hours I hear of almost any unusual airway situation in a huge health system.”

An airway safety committee should incorporate representatives from anesthesia, ENT, surgery, the ED, respiratory therapy, and rapid response nursing, Atkins advises. If a committee is integrated across a large health system involving multiple hospitals challenges are more likely to come to light so they can be addressed specifically, Atkins says.

“Our committee hosts a system-wide interdisciplinary airway seminar once a year. We introduce new protocols that we have developed, and we also review multiple airway cases for everyone’s edification,” Atkins reports.

Another important step hospitals can take is to try to standardize the equipment and processes used to address difficult airways. Further, if clinicians and specialists move between hospitals within a larger health system, then standardization should encompass the entire system, Atkins advises.

For example, the same bronchoscopes and laryngoscopes should be used in every setting so clinicians are not asked to rescue a patient using tools they have never seen before.

“We had one device in the ED and the ICUs, [and] another device that was used in the operating room that the anesthesiologists used,” Atkins recalls of one such episode. “Now that we have the whole hospital on the same equipment, there is a lot more working familiarity on everyone’s part with the equipment so that issue doesn’t become an obstacle.”

Difficult airway incidents may not occur often in some hospitals, but Atkins notes that these events occur in large medical centers like HUP more often than many surmise.

“By bringing attention to these events, we have been able to catalyze interest in potentially designing an interdisciplinary training program for this,” Atkins says.

The difficult airway response team (DART) at Johns Hopkins Hospital dates to 2005, explains Susan Peterson, MD, associate medical director for patient safety and quality in the department of emergency medicine. “It has been a part of the culture of the ED ever since I have been here,” she explains.

Unlike the ARR team at HUP, emergency medicine physicians were part of the team that developed DART. Other DART developers included anesthesiologists, otolaryngologists, trauma surgeons, and risk management professionals. However, the ARR and DART missions were similar in that clinicians were endeavoring to develop a multidisciplinary approach to difficult airways and to standardize the emergency response process throughout the hospital.

Peterson acknowledges that even with the involvement of emergency medicine in DART’s creation, there were some initial concerns among emergency physicians about the prospect of implementing a rapid response approach in this area. “A difficult airway is something that we train extensively in,” Peterson explains. “There was certainly hesitancy when these discussions started. But as most things like this start, the origins were in cases where additional help would have been useful.”

Further, early scrutiny of the approach demonstrated that the DART approach is valuable. Investigators at Johns Hopkins tallied 360 activations of the DART team over a five-year period (July 2008-June 2013), finding that there were no airway management-related deaths, sentinel events, or malpractice claims in DART team-managed patients.2

While the DART process is firmly ingrained at Johns Hopkins Hospital, there is an ongoing, iterative process that refines and improves policies and practices related to the approach. A review committee studies every DART case with an eye toward further optimizing the process, Peterson adds. A major component of DART is the deployment of special carts throughout the hospital. These carts are equipped with all the supplies that potentially will be needed to address a difficult airway situation. Over time, significant detail has been added to the policy regarding this aspect. “We have two DART carts that exist in the ED — one in the main area, and one over by our critical care trauma base,” Peterson explains. “All of the details regarding if [the carts] get opened, who then resets [the carts], and who cleans up the equipment ... needed to get put into the process over time. The scopes [used to open airways] don’t belong to the ED. Details that one wouldn’t perhaps think of initially have evolved over time.”

One particularly important issue that was highlighted and resolved through the review process was determining who should be in charge when this giant DART team responds to a case in the ED.

“It was something that came out of cases where anesthesia attending physicians would come down,” Peterson notes. “They are used to being in charge in the operating room.”

However, the review committee process determined that the emergency attending physician for a patient should remain in charge, clearing up any confusion that might arise when a DART team is dispatched to the ED. Emergency medicine providers are part of the DART group; however, they generally do not respond to DART calls when they occur outside the ED, Peterson explains.

“This is related to the fact that we simply can’t have our emergency physicians constantly leaving the ED to respond to things around the house because there are too many emergency patients coming through the front door of the ED,” she says. “For those [DART calls] that are in the ED, the attending physician for that patient is the one who is ultimately responsible — and is also the most familiar with the techniques that have already been tried.” While a DART team can be activated any time an attending physician believes it is warranted, there are specific indications when a DART activation is recommended. For example, Peterson notes there is a process in the Hopkins electronic medical record (EMR) through which patients who have demonstrated historically difficult airways can be flagged.

“It could be that they have a neck tumor or an anatomic bone entity,” Peterson says. “If [patients] are flagged as [exhibiting] a difficult airway and require urgent intubation, that alone — even with the emergency physician not attempting intubation initially — would be appropriate [for a DART call].”

In emergent situations, the emergency physician would initiate a trial of rapid sequence intubation while calling DART simultaneously, Peterson observes. Patients who have not been flagged for difficult airways, but nonetheless present with recognized deformities, injuries, or other issues that suggest that the airway is going to be difficult, also would be candidates for a DART response.

“There is also a separate pediatric DART team ... that has its own criteria that pertains to activations,” Peterson adds.

Since DART is unique to Johns Hopkins Hospital, there are ongoing efforts to ensure the constant flow of residents and other incoming clinicians understand the process and related policy requirements. “On an annual basis, when the new interns come in, they get hit with a lot of information, and there is specific education related to DART included,” Peterson explains. “[Also,] we have physician advisors for each department who are responsible for discussion and communication of policy requirements if any new faculty have joined.”

Peterson’s advice to other hospitals considering rapid response approaches to difficult airway situations is to establish a clear understanding of who is involved and everybody’s specific role. Also, she advises working into the process both an immediate debrief and a later review of all rapid response situations.

“The best versions of this that we have had have always involved some sort of debrief to learn from any real-time issues that have occurred,” Peterson notes. “You always want to make sure that the residents who are directly at the bedside get some real-time feedback about the issue that is going on.”

In its review of all incidents, the DART committee can study broader issues that may come out of a specific response, Peterson adds. Instituting mechanisms for ongoing education about the rapid response process is critical because activations of any DART-like process are likely to be infrequent.

“On a daily basis, the number of those that are actually happening in the ED is low, so that education is very important,” she says. “People need to know the resource exists [and] when it should be used. Then, if it is activated, everyone needs to understand what their role is.”

REFERENCES

  1. Atkins JH, Rassekh CH, Chalian AA, Zhao J. An airway rapid response system: Implementation and utilization in a large academic trauma center. Jt Comm J Qual Patient Saf 2017;43:653-660.
  2. Mark LJ, Herzer KR, Cover R, et al. Difficult airway response team: A novel quality improvement program for managing hospital-wide airway emergencies. Anesth Analg 2015;121:127-139.

SOURCES

  • Joshua Atkins, MD, PhD, Associate Professor, Department of Anesthesiology and Critical Care, Department of Otorhinolaryngology - Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia. Email: Joshua.Atkins@uphs.upenn.edu.
  • Susan Peterson, MD, Associate Medical Director, Patient Safety and Quality, Department of Emergency Medicine, Johns Hopkins Hospital, Baltimore. Email: Speter14@jhmi.edu.

Activating the Rapid Response Team

At the Hospital of the University of Pennsylvania, administrators have posted descriptive flyers in all hospital units. These flyers include the numbers to call to activate the airway rapid response team and spell out the indications for when activation is warranted. These indications include:

  • a history of failed or difficult intubation or severe tracheal stenosis;
  • significant bleeding from the mouth or nose;
  • a fresh tracheostomy or other surgical airway;
  • recent surgery to the neck or intraoral surgery;
  • an inability to open the mouth;
  • severe swelling around the mouth or neck;
  • severe subcutaneous emphysema around the neck;
  • leakage of fluids into the neck;
  • severe acromegaly (the overproduction of growth hormone).