Improvement of communications with subsequent anesthesia personnel concerning a patient who is discovered to have a difficult airway is the goal of a new program designed to help warn of identified anesthesia risks. Very often today, even if it is explained to the patient in detail and he/she is given a letter to carry, the patient cannot be relied upon to transmit information to subsequent anesthesia providers. If the previous anesthetic record is at another institution, or, sadly, often even in the same institution, it is frequently not available to anesthesiologists making preanesthetic evaluations. Thus, critical information about difficult conditions or past overt adverse events may not reach the personnel most in need of it to safely anesthetize the patient.
The Division of Critical Care Anesthesia at Johns Hopkins Medical Center has been working with Ms. Joyce Drake of the Medic Alert Foundation International to insure that once an airway event happens, consistency in documentation and an easily accessible central data bank are available. From experiences and questions raised by the work of the American Society of Anesthesiologists Difficult Airway Task Force, and Drs. Benumof, Norton, Ovassapian, and others, we specifically addressed the question ‘Is there a uniform way that patients and physicians can be informed of critical information?”
Existing practices for the dissemination of information include: anesthesia record (non uniform, handwritten, not easily interpreted); progress notes (not consistently entered, questions about intent and content); and post-operative patient visit (not consistent, questions about purpose, questions about patient understanding or retention).
New directions that we have been working on include: The Anesthesiology Consultant Report (ACR). The ACR is a brief, 1-2 page report that conveys information about perioperative evaluation and preparation, operating room techniques and management, and perioperative recommendations for future anesthetics to our medical, surgical, and anesthetic colleagues. The ACR is intended to supplement the intra-operative anesthesia record, not replace it, although it could conceivably replace the postanesthesia note. This project is supported by an Education Research Grant from the Foundation for Anesthesia Education and Research.
We will have a full report on it within the year. To date, we have identified issues and limitations of the ACR: acceptance by anesthesia colleagues to change existing practice; time to generate an ACR; question of relative worth versus aggravation of excessive paperwork in the medical record system. We have, however, identified a critical group of patients in which a document such as the ACR becomes eminently worthwhile those with difficult airways or intubations. We felt that identification and documentation of events relating to these patients was so critical that we developed an in-hospital identification system as described below.
Difficult Airway/Intubation : Patient Wrist Band and Chart Label. We received institutional review board approval to place a highly visible temporary bracelet on any patient identified as having a difficult airway or intubation and a special label on the hospital chart. (An existing model to compare is the “allergy alert bracelet” that many hospitals already use). Select patients are recommended for and enrolled into the permanent Medic Alert Foundation International emergency medical ID system.
Difficult Airway/Intubation Alert: Medic Alert Foundation International. We officially established a category, ‘difficult airway/intubation,’ and created a brochure to explain to physicians and patients about difficult airway/intubation and Medic Alert. Medic Alert is a non-profit international organization that provides health care personnel with immediate 24 hour access to a computerized medical record/data bank. The patient is given a wallet card containing his or her medical record and a highly visible permanent bracelet or necklace to attract the attention of health care personnel should the patient fail to or be unable to relate his/her problem. The one-time enrollment fee of 0.00 is traditionally paid by the patient. Indigent patients may be enrolled at no fee if the application is accompanied by a letter from the enrolling physician. The application requires patient consent. Yearly, the patient receives an updated wallet card; physicians can update the medical record any time (the fee for updating is $7.00).
The Medic Alert data bank is in existence and functioning. Use of the brochure simplifies patient management, but patients can be enrolled without the specialized application by completing a standard Medic Alert application and identifying: Difficult Airway/Intubation; Medical Institution and medical record #, procedure and date, clinically applied algorithm, recommendations for colleagues, and significant medical conditions. Additionally, the application should be mailed to the attention of Joyce Drake.
For further information regarding enrollment of patients or to receive the specialized application, contact Dr. Lynette Mark, Johns Hopkins University (410-955-6482/80) or Ms. Joyce Drake, Medic Alert, Chicago Regional Office (312-2806366).
Future directions for study include revision of the Medic Alert application to include ‘research questions” to begin to amass a data bank of information that may ultimately help facilitate the prospective identification of difficult airway/intubation patients, help devise new technologies and airway/intubation strategies, etc.
The Hopkins Division of Critical Care Anesthesia conducted a survey during the March International Anesthesia Research Society Annual Meeting using a ‘Difficult Airway/Intubation Alert, Dissemination of Information Questionnaire.’ Eighty-five people responded and 80 supported the concept of Difficult Airway/Intubation Alert, Medic Alert.
This project has now considerably evolved and the investigators are formulating a prospective study to access the acceptability, implementation, and efficacy of the Difficult Airway/Intubation Alert with at least five major institutions that we anticipate will include Hopkins, Massachusetts General (Dr. Roberts), University of Michigan (Dr. Norton), George Washington (Dr. Epstein), and the Chicago V.A. (Dr. Ovassapian).
Dr. Mark is a member of the Division of Critical Care Anesthesia, Johns Hopkins Medical Center, Baltimore, MD.