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Difficult airway events are common and can have significant consequences for patient safety. A difficult airway response program developed at Johns Hopkins Hospital was adapted to the resources and needs of a small regional hospital in Coeur d’Alene, Idaho. The adoption and diffusion of this innovation for the regional hospital involved gaining hospital leadership’s support and approval, assembling the necessary equipment, cross-discipline training, patient labeling, and building a culture of collaboration. The program illustrates the potential for additional adaptations of large urban hospital programs to meet the needs of rural America.
Introduction
Difficult airway adverse events are the fourth most common event in the American Society of Anesthesiologist Closed Claims Database, with detrimental or devastating consequences to patients, their families, health care providers, and hospitals.1 In response, Johns Hopkins Hospital conducted a two-year evaluation of actual and near-miss events related to emergency difficult airway management in non-OR areas. The comprehensive review revealed a set of critical challenges: inconsistent communication processes (including paging issues and delays), lack of knowledge among providers in non-OR areas on when and how to activate airway support, limited accessibility and availability of surgical emergency equipment, lack of defined roles during difficult airway events, and lack of familiarity with specialized airway techniques. The hospital created a Difficult Airway Response Team (DART) program to prevent related morbidity and mortality. Their system-based approach resulted in a reduction in adverse events.²
Difficult airway adverse events are not limited to large institutions and occur at hospitals of all sizes. Adapting a DART program established at a major metropolitan research hospital for use in a small regional hospital is both a significant challenge and an important opportunity. Regional hospitals have limited financial resources, no residents or fellows, and fewer in-house medical staff. Yet scaling a successful large-hospital program to meet small regional hospital needs can result in improved patient safety, provider efficiencies, and institutional quality.
The Adoption and Diffusion of Innovations
One strategy for developing such scaled programs is to consider the challenge as an “adoption and diffusion of innovations” problem. In the social sciences, significant research literature provides theory and evidence as to how innovations are initially adopted and then, over time, diffused throughout a social system. Everett Rogers’ Diffusion of Innovations (now in its fifth edition) provides a general introduction and a wide set of examples, beginning with the 18th century adoption of oranges and lemons prescribed as part of a sailor’s diet by a British Navy physician to prevent scurvy.³
Rogers identifies several key elements of a successful adoption including: 1) characteristics of the innovation itself, 2) characteristics of the organization considering the innovation, 3) the role of change agents in encouraging adoption, and 4) characteristics of the individual adopters. For example, innovations that are perceived to be of relative advantage to the adopter, not complex to execute, culturally appropriate within the organization, and observable (i.e., adopted from existing use elsewhere) are more likely to be successful. Adapting a metropolitan hospital DART program to a regional hospital is an adoption and diffusion challenge, and this general strategic approach guided the program developed by Anesthesia Associates of Coeur d’Alene (AACDA) for Kootenai Health Hospital in Coeur d’Alene, Idaho.
Kootenai Health Hospital and AACDA
Kootenai Health is a 331-bed community-owned hospital located in Coeur d’Alene, Idaho, 105 miles south of the Canadian border. The region has experienced significant population growth and the city of Coeur d’Alene has approximately 50,000 residents. Kootenai Health services a large radius of rural communities for trauma and has made rapid expansions to its service lines over the past decade to accommodate the increasing population and health needs (https://www.kh.org/).
Anesthesia Associates of Coeur d’Alene (AACDA) is a private practice under contract with Kootenai Health. AACDA is a 41-provider anesthesia practice comprised of both independently practicing anesthesiologists and certified registered nurse anesthetists (https://www.aacda.com/). The development of the Kootenai Health DART program was led by Sarah Pierce of AACDA and involved several steps, each focused on adapting the Johns Hopkins DART program and having the innovation adopted by Kootenai Health.
Making the Argument for a DART Program
The need for a DART program was motivated by a difficult airway event. A local surgeon subsequently learned about the Johns Hopkins DART program and approached AACDA about working to implement a similar program for Kootenai Health. Significant modifications were needed in order to make the Johns Hopkins DART program compatible for the smaller facility. A multidisciplinary task force was established, composed of important stakeholders and leaders in airway management, including the medical director of the Intensive Care Units, the medical director of the Emergency Department, an Ear Nose and Throat surgeon, and an anesthesia professional. Over the following year, we developed a plan that would be feasible for the facility and worked to gain momentum and recognition from key hospital administrators. This included presenting the plan to the Surgery Committee, at quarterly Medical Staff meetings, to joint operating committees, and ultimately to the Board of Trustees for submission as a “Pillar of Safety” for the institution. After an in-depth presentation of how this program could be adapted and implemented for our regional hospital with a staged approach and modifications, we received unanimous approval and a starting budget of $500,000 for equipment and training (see table 1).
Table 1: Key Components for Developing a DART Program at Regional and Rural Hospitals.
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Assembling the Equipment
It was imperative that we provide the most up-to-date equipment for providers. We had a blended group of medical staff (including emergency medicine [EM] physicians, anesthesia providers, and intensivists) that would be managing airways; so it was imperative that the equipment would be easy to use for all specialties and agreed upon by all. After much research and several trial evaluations of equipment, we selected a disposable video laryngoscopy and bronchoscopy system with dual view capability. This allowed for two providers to work together on establishing an airway.
We began the adoption process by building a fleet of “ideal” difficult airway carts. Each cart contained standard and advanced airway equipment as well as video laryngoscopes and bronchoscopes.⁴ Our goal was to provide uniform, standardized airway equipment throughout the hospital so that no matter where a response to a difficult airway or intubation was needed, the same equipment was always available. We created identical DART carts to be located in our three Intensive Care Units (ICU), Obstetrics (OB), Emergency Department (ED), Operating Room (OR), as well as a travel cart and one for exchange in Central Supply.
These carts remain locked until use (similar to a code cart) and restocked after every use by the hospital’s central supply utilizing a standardized checklist and two-person verification. Each DART cart has a video laryngoscope with every size of intubating handle and pediatric and adult bronchoscopes. Roll out of the equipment required significant communication and educational support to increase awareness and familiarity with the equipment for the nursing staff, rapid response team, medical staff, anesthesia professionals, and respiratory therapy staff. Demand for the new DART carts was high and, therefore, the response within the hospital resulted in the purchasing of a second exchange cart for Central Supply as well as an additional cart for our COVID-19 ICU. Prior to this program, each unit had their own airway cart that was often lacking equipment, disorganized, and not routinely re-stocked; the new standardized carts were rapidly recognized as providing a distinct advantage and extremely well received.
Training for the Program
Training for the program was a key element of the adoption and diffusion strategy. An annual multidisciplinary Difficult Airway Workshop was established; so far three have been conducted. Each workshop focused on core difficulty airway topics, tools and procedures including awake fiber-optic intubation, the “can’t intubate/can’t ventilate” algorithm, the difficult airway cart, emergency cricothyrotomy and tracheostomy, and difficult airway scenarios. The workshop has had an exceedingly positive response within the institution. Ear, Nose, and Throat (ENT) surgeons from two separate surgical groups participated and helped to teach the cricothyrotomy and tracheostomy portion of the course. Attendees were placed in multidisciplinary groups (EM physician, anesthesia professional, intensivist, paramedic, rapid response nurse, respiratory therapist, and ENT surgeon) to perform cricothyrotomy on pig tracheas and practice simulated airway emergencies. The workshop provided pig tracheas for all participants to practice the surgical airway procedures, and therefore better understand the process. Participants included individuals that would not be performing the surgical airway procedure, because this helps them better collaborate and assist with actual difficult airway events. Over 50 intubating providers of different specialties attended. At the end of the workshop, the ENT surgeons discussed different difficult airway cases encountered throughout the year in a roundtable format.
The results have been dramatic. In 10 months of operation, the DART carts have been used 167 times. Based on anecdotal evidence and written comments by medical staff, there has been a profound improvement in our collaborative culture and in patient safety. Intensivists and EM physicians are more likely to reach out to anesthesia professionals with a potentially difficult airway situation, do so early, and use a team approach for securing the airway. Communication between disciplines and in emergencies has significantly improved. Surgeons of other specialties are reaching out to participate in our annual Difficult Airway Workshop, and we anticipate continued multidisciplinary growth. After a full year of operation, a quality improvement survey that covers such topics as program barriers and limitations, improvements in patient safety, and reduction of adverse airway events will be administered to all intubating providers and support staff.
Labeling of Patients
Another key element of our DART program has been improved identification of high-risk patients. This has been a particular challenge with significant staffing shortages and scarce resources related to COVID-19 cases and has required improvisation for success. Patients who meet established criteria for “difficult airway” (such as BMI >50, sleep apnea, or recent neck surgery) have a blue sign placed above the head of their bed that reads “Please call anesthesia for any imminent, or emergent airway concerns” with a phone number that goes to a designated in-house anesthesia professional 24/7. We have encouraged our Rapid Response and ICU nurses to call anesthesia for respiratory- or airway-related concerns and for any patients that meet the criteria for “difficult airway.” From this point forward, all patients admitted to the hospital will be screened for “difficult airway” and those meeting criteria will have an indicator placed by the provider in the electronic medical record (much like an allergy). This will also help establish a data collection process for clinical evaluation of the efficacy of the DART program over time.
Building the Culture
Adoption of new innovations is never easy or straightforward, and the DART program was no exception. The COVID-19 pandemic led to significant supply chain issues for airway supplies and the need to increase ICU capacity to care for critically ill COVID-19 patients. Higher than anticipated demand for DART equipment meant frequent exchange of carts. The transition from physicians working independently to manage all airways toward a team approach and pre-emptive requests for assistance was a significant change in operational style.
While the DART program has been the initial focus in the adoption process, the development of a culture that emphasizes collaboration between specialties with an emphasis on patient safety is the ultimate goal. The development of a collaborative culture in small regional hospitals extends beyond managing difficult airways and can and will be instrumental in many medical emergencies.
In order to develop a multidisciplinary team capable of functioning well under extreme pressure, we needed to be able to train together, recognize each other’s strengths and limitations, understand how to perform as a collective team, know when to ask for help, and communicate effectively. The innovative DART program has helped establish these practices within our institutional culture. As new providers join the medical practices at Kootenai Health, and are brought into the program alongside early adopters, patient safety and a multidisciplinary, collegial culture will be built and sustained.
Conclusion: Call to Action
The DART program at Kootenai Health, a small regional hospital in Idaho, was adapted from a successful program at Johns Hopkins, a major metropolitan research hospital. It required a strategic effort to propose a plan suitable for the institution, assemble the necessary equipment in usable form, invest in team-based training, improvise with patient labeling, and build a culture of patient safety and cross-disciplinary collaboration. Kootenai Health can now manage difficult airway situations more effectively and safely. Next steps include 1) conduct a survey of participants and a retrospective study of adverse airway events, DART usage, and mortality, 2) use the results to improve the DART program effectiveness, 3) expand training to include additional workshops and advanced simulations, 4) provide additional training for regional Emergency Medical System (EMS) and pre-hospital providers, and 5) respond to assistance requests from other regional and small rural hospitals interested in developing their own DART program.
But beyond difficult airways scenarios, the adoption and diffusion of programs and practices from large research hospitals to small regional facilities—and even smaller rural hospitals and clinics—has significant potential to improve health care throughout the smaller cities and rural communities of America. It is both a challenge and opportunity.
Sarah K. Pierce is the chair of Anesthesia Associates of Coeur d’Alene and medical director of the Difficult Airways Response Team Program at Kootenai Health in Coeur d’Alene, ID.
Gary E. Machlis is university professor of Environmental Sustainability at Clemson University, Clemson, South Carolina, USA.
Sarah K. Pierce, CRNA, initiated into a contract as an independent contractor for Verathon (the makers of GlideScope) as of December 2020. As a Verathon independent contractor focused on providing education, the contractor is not considered an agent, representative or employee of the company.
Gary E. Machlis, PhD, has no conflicts of interest.
References
- Metzner J, Posner KL, Lam MS, et al. Closed claims analysis. Best Pract Res Clin Anaesthesiol. 2011;25:263–76.
- Mark L, Lester L, Cover R, and Herzer K. A decade of difficult airway response team: lessons learned from a hospital-wide difficult airway response team program. Crit Care Clin. 2018;34:239–251.
- Rogers EM. Diffusion of innovations. Fifth Edition; 2003. Free Press, New York.
- An inventory of the Kootenai Health DART cart equipment is available from the first author at [email protected].