Episode #121 Heads Up for Positioning During Airway Management and NORA Patient Safety Wrap-up

Hello and welcome back to the Anesthesia Patient Safety Podcast.  My name is Alli Bechtel, and I am your host. Thank you for joining us for another show. We are wrapping up our series on the 2022 APSF Stoelting conference, “Crucial Patient Safety Issues in Office-Based and Non-Operating Room Anesthesia (NORA).”

Before we dive into the episode today, we’d like to recognize Edwards Lifesciences, a major corporate supporter of APSF. Edwards Lifesciences has generously provided unrestricted support to further our vision that “no one shall be harmed by anesthesia care”. Thank you, Edwards Lifesciences – we wouldn’t be able to do all that we do without you!”

Last week, we dove into the third session, “Designing NORA for Patient safety. Beyond Current State to a Future Best Practice?” Let’s continue the conversation now with Jeff Cooper and his talk, “Teaming and Communication with Strangers in Strange Places.” Cooper tells us that this is harder in NORA locations especially when you don’t know the people on the team and are in an unfamiliar environment. An important key for successful teamwork is building relationships with shared goals, shared knowledge, and mutual respect. Collaboration depends on high quality communication that is frequent, timely, accurate, and problem-solving focused and this is further enhanced with high-quality relationships.  Cooper provides some strategies for improved communication and to build trust for the next time you are assigned to an unfamiliar NORA location:

1. Walk in the room confidently, but not arrogantly
2. Introduce yourself
3. Ask questions about what the proceduralist expects.
4. Read the room and adapt to the environmental needs
5. Identify shared interests to become part of the team.
6. Describe anything that you are going that the rest of the team needs to be aware of, such as checking the IV under the drapes.
7. Ask how you can help other team members with positioning or moving equipment.
8. Be curious and non-judgmental. Show respect for their work.

Let us know if you decide to try any of these strategies the next time you find yourself in an unfamiliar NORA location or on a new team.

Our final speaker for this session is Amy Vinson to talk about creating a culture of wellness. There has been an evolution from thinking about the individual approach to wellbeing to a systemic effort. It is vital that we start to think about medical culture differently. Let’s review the 6 essential elements of resources for the Healthcare Worker Well-Being from the National Academy of Medicine.

1. Advance organizational commitment
2. Strengthen leadership behaviors
3. Conduct workplace assessment
4. Examine policies and practices
5. Enhance workplace efficiency
6. Cultivate culture of connection and support. Some of the keys to creating a culture of support include building a team-based organizational platform with no fear of reprisal, accountability, transparency, and close partnership between clinical staff and leadership.

In addition, ASA recommendations include removing the stigma associated with mental healthcare for healthcare workers, accommodating flexible schedules, considering changes in academic productivity due to COVID, and more. The big question is “What culture do we want to create in Anesthesia?” and moving towards a culture of wellness is absolutely necessary to keep anesthesia professionals and patients safe.

Our final session for the conference is “Impending Issues: Disruptors and Innovation” moderated by Richard Urman. The first speaker is Aman Mahajan to talk about “Remote Patient Monitoring: The Hospital at Home.” Remote patient monitoring involves connecting the electronic health monitoring with medical data in one location that is reviewed by a healthcare professional in different location. There is a lot of technology involved with the biosensors. Going forward, these biosensors may be more sensitive with advanced monitoring and improved care delivery including cell phone enabled BP monitoring or AI-enabled voice biomarkers for mental health. What we have learned with increased remote patient monitoring during the covid pandemic is that there are benefits for acute and chronic conditions including reduced admissions, improved patient satisfaction, and reduced cost. This success is due to patients feel connected and engaged and involved in their care. For remote patient monitoring programs to work, the right work flow is important including setting appropriate triggers with a designated time frame for response by the healthcare team which may include nurses, hospitalists, and perioperative physicians. These programs may be able to address social determinants of health as well. There are some challenges that will need to be addressed before we move the hospital into the home such as accuracy, privacy and security, oversight, accessibility, cost, acceptability, use of technology, lack of standards, scientific peer-reviewed evidence for safety and efficacy. Another important question is, “How can we use these new technologies in expanding the scope of the practice and keeping patients safe with quality care?”

The next talk is about the use of algorithms and AI to support safe practice by Piyush Mathur. We know that algorithms can be used to guide safe clinician decision making, just take a look at the surviving sepsis guidelines. In addition, there is newer technology available with automated echocardiography and ultrasound algorithms to help with guided nerve blocks and IV placement. These algorithms may be particularly useful given the current work force challenges. Other examples includes algorithms that run in the background of the electronic medical record to improve safety event reporting for critical events such as episodes of cardiac arrest, hypotension, and airway events or algorithms that evaluate patient comments to improve quality and patient satisfaction. The future of algorithms to improve patient safety must include

• Patient-and care provider centric so that we first do no harm
• Clinician leadership
• Rigorous model development and testing and validation
• Explainable or interpretable solutions and avoidance of a black box
• Clinical validation for generalizability and scalability
• Cost-effective solutions

Mathus reminds us that for IT, Information Technology, IT is up to us to design the solutions.

Monty Mythen is our next speaker and his talk offers a new perspective on providing sedation for patients undergoing procedures. Let’s start with the definition of procedural sedation as that which supports the delivery of investigations and procedures that patient might be otherwise unable to tolerate while maintaining airway patency, spontaneous respiration, protecting airway reflexes, and maintaining hemodynamic stability while alleviating anxiety and pain. Next, Mythen highlights the scope of the problem of anesthesia professionals providing sedation given the current and future projected work force shortages and the controversies about who can provide sedation and what medications, such as propofol, can be used. For example, in endoscopy, nurses may be able to provide light to moderate sedation under the direction of a GI physician, but anesthesia professionals need to be present for patients who require deep sedation or general anesthesia. How can we keep patients safe during procedural sedation and address the significant workforce shortages? One option may be to design appropriate training for full perioperative physicians, anesthetists including sub specializations, and sedation-ists. It will be vital to maintain safe sedation practices for healthcare procedures across all areas of healthcare.

Our next speaker, Patricia Fogarty-Mack, is here to talk about, “Measuring Success: NORA-Appropriate Metrics: Current and Future.” Important metrics may include operational, safety, and quality. Let’s take a look at some examples. Operations metrics include utilization reports including timing of utilization, start times, and ability to end of time. Documentation of start and end times and proceduralists may be challenging given the wide variety of NORA locations. This information can help to facilitate anesthesia coverage in NORA locations and improve patient safety. Quality metrics that are important for NORA locations may include identifying the same level of preop assessment and optimization, completion of a history and physical exam, risk stratification, same NPO criteria, same PACU discharge criteria, and same postop assessment. Other important considerations for NORA patient safety and metrics include recovery from anesthesia in NORA locations. Going forward, some questions include:

• Is there a quality metric that we should be requiring for NORA recovery spaces especially since anesthesia recovery criteria needs to be adhered to in all areas where patients receive anesthesia.
• What are the hours for NORA recovery areas? This depends on staffing and patient acuity.
• What is the appropriate documentation for sedation cases when the patient loses consciousness and ability to respond purposefully? Options may include general anesthesia with any type of mask, GA with endotracheal tube, TIVA, or GA with natural airway.

An example of a safety metric includes the amount of support persons available in ORA locations. How many anesthesia techs are available to staff NORA locations at your institution? Other examples include reviews of significant and rare events and outcomes. The future of patient safety in NORA locations requires patient-centered data leading to safe and high-quality patient care and patient satisfaction and don’t forget to share NORA metrics with your procedural colleagues.

We covered so many important topics related to keeping patients safe during NORA care. We will have some final NORA practice recommendations on a future show. So, stay tuned. The good news is that we still have more to talk about today! Let’s review the APSF article between issues from 12 September 2022, “Patient positioning is 90% of the airway management battle. “How goes your battle?” by James Gayes. To follow along with us, head over to APSF.org and click on the Newsletter heading, second one down is articles between issues and then scroll down to our featured article today. I will include the link in the show notes as well.

Have you had to manage a difficult airway recently? Did you follow the new 2022 ASA Difficult Airway Algorithm? We covered it on episodes 113 and 114 if you need a refresher. One critical area that is not mentioned is patient head and neck positioning during difficult airway management. Ten years ago, Gayes wrote a letter to the Editor of the American Society of Anesthesiologists Newsletter to ask why head position was not included as a preplanned strategy in the 2012 ASA Difficult Airway Guidelines since the consideration for appropriate patient positioning is just as important as the newer intubating devices. The response at that time was that patient positioning would be reviewed and considered for the next update. Well, the 2022 Guidelines have been published and there is a noticeable lack of emphasis placed on patient head and neck positioning. Let’s review some of these considerations now. For obese patients, positioning in the head elevated laryngoscopy positioning is important to improve spontaneous and controlled ventilation as well as airway axis alignment leading to better laryngoscopy views and increased first pass successful intubation. Elevation of the upper body increases upper airway dimensions, decreases the upward diaphragmatic push by abdominal adipose tissue, and decreases the incidence of airway-related complications during emergency intubation. Another important consideration is prevention of hypoxemia during airway management. The good news here is that the head-elevated position leads to higher oxygen tensions with a clinically significant increase in the time to desaturation thus keeping patients safe for longer during airway management. Not every difficult airway can be anticipated or predicted. It is vital to ensure that alternative airway devices or tools are immediately available to allow for timely management and prevent complications. Head elevated patient positioning may be considered an immediately available tool for clinicians especially in the setting of an unanticipated difficult airway. Remember, appropriate patient positioning is imperative even if you have a video laryngoscope immediately available since good positioning helps with any airway management technique including mask ventilation, direct laryngoscopy, video laryngoscopy, and laryngeal mask airway placement. This is not an either or situation. Appropriate positioning and airway tools can and should be used together to ensure a successful first pass intubation. The only mention of positioning in the 2022 guidelines is in a footnote, but going forward this valuable tool may be better recognized as a Standard in the management of difficult airways. There is a call to action to use all of the tools in our toolbox to keep patients safe during airway management and this must include appropriate patient positioning.

That’s all the time we have for today. If you have any questions or comments from today’s show, please email us at [email protected]. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.

The October 2022 APSF Newsletter just dropped and we are so excited to feature many of these great articles on our upcoming shows. So, mark your calendars. In the meantime, you can head over to APSF.org and click on the Newsletter heading. First one down is the current issue. Go ahead and check it out!!

Until next time, stay vigilant so that no one shall be harmed by anesthesia care.

© 2022, The Anesthesia Patient Safety Foundation