Episode #72 Building a Difficult Airway Response Team Program

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. I have a question for our listener? Where do you practice? Are you at a large academic institution in an urban setting or are you at a small regional hospital in a rural setting? Where you practice can have a big impact on your patient population as well as the available resources to treat your patients and these resources may include people as well as physical supplies.

But before we dive into the episode today, you’ve heard me recognize our corporate supporters on this show, but there’s another supporter who is absolutely essential – YOU! Every individual donation matters so much. Please visit APSF.org and click on the Our Donors heading and consider making a tax-deductible donation to the APSF.

On the show today, we are going to return to the June 2021 APSF Newsletter. Our featured article today includes a review of the difficult airway response program at Johns Hopkins Hospital followed by a look at how this program may be modified to fit the needs and resources at a rural hospital. The authors describe this process at their hospital in Coeur d’Alene, Idaho. Before we get into the article, we are going to hear from one of the authors.

[Pierce] “Hi, my name is Sarah Pierce and I am a CRNA with Anesthesia Associates of Coeur d’Alene. I am also the medical director of the Difficult Airway Response Team Program at Kootenai Health, a 331 bed community hospital in northern Idaho.”

[Bechtel] I asked Pierce what got her interested in this topic. Let’s take a listen now.

[Pierce] “I was traveling home on a long flight from Guatemala after a medical mission. The ear, nose, and throat surgeon I had been working with all week was reading an article on the plane highlighting a difficult airway response team program at Johns Hopkins University. While we were talking during our flight, he told me of a patient story where he felt that a program such as this might have prevented a tragic death. He then asked me if I would consider spearheading the development of a difficult airway program at our community hospital. I began researching the Johns Hopkins Program and quickly realized that it would take some significant innovation to implement a program such as this at a community hospital with different resources. I love the idea of needing to be creative and adapting a program to fit the needs of our much smaller hospital. I soon became passionate about this work and felt that if we could save even just one life with this program then all the work would be worth it.”

[Bechtel] Thank you so much to Pierce for helping to kick off the show today. To follow along with us today, head over to APSF.org and click on the Newsletter heading. Fourth one down is the Newsletter Archives. Then, scroll down to June 2021 and click on our featured article today, “Establishing a Difficult Airway Response Team for a Regional Hospital: A Case Study in the Adoption and Diffusion of Innovations” by Sarah Pierce and Gary Machilis. Anesthesia professionals need to be airway management experts in order to keep patients safe during anesthesia care and during emergencies in and out of the operating room. Do you have a difficult airway response program at your institution? If you do, then you likely had to the following:

• Get buy-in and support from the hospital leadership
• Gather and maintain the necessary equipment
• Prepare and roll-out training for the stakeholders and team members involved in the program
• Identify appropriate patients
• And finally, build a culture of collaboration.

Before we go into more details about building this type of program, let’s do a dive into the background about why a difficult airway response team is needed to help keep patients safe. One of the most common adverse events in the ASA Closed Claims database includes difficult airways. In fact, it is ranked as the fourth most common adverse event. Knowing this, clinicians at Johns Hopkins Hospital looked at actual and near-miss events that fell into the category of difficult airway management outside of the operating room over two years. Here is what they found:

• Inconsistent communication processes and this included the process of paging and delays with communication
• 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 finally, lack of familiarity with specialized airway equipment and techniques.

In response to this evaluation, the Difficult Airway Response Team or DART was created to address these issues and help to keep patients safe. The result is some really good news with decreased difficult airway adverse events once the DART was established. If you practice at an institution that is similar in size and resource availability to Johns Hopkins, then you may be able to use a very similar blueprint to create a DART at your institution. The author remind us that adverse events due to difficult airways do not only happen at large academic medical centers. Smaller regional hospitals may benefit from a Difficult Airway Response Team, but the team may look different due to availability of resources including funding and clinical staff. This is an opportunity to adapt the large hospital program to improve patient safety and outcomes at smaller regional hospitals. So, let’s take a look at what this adapted team and response might look like and for this we need to consider the following framework: Adoption and Diffusion of Innovations.

We are going to step back from the Difficult Airway Team for a little bit and do a dive into the social sciences to further develop this framework of first adoption of an innovation which is then followed by diffusion over time. Let’s meet a crucial character, Everett Rogers, the author of “Diffusion of Innovations.” He describes important components for adoption of an innovation. These include the following:

1. The characteristics of the innovation
2. The characteristics of the organization that wants to adopt the innovation.
3. The role of champions of the innovation
4. The characteristics of the individuals who will use the innovation or be impacted by it.

Adoption an innovation is more likely to be successful when it has the following components:

1. Offers an advantage to the individuals who will use the innovation
2. Aligns with the organization’s culture and mission
3. Provides a straightforward implementation and use that builds on prior use.

The authors report that they used this framework as a strategy to adopt the large medical center DART program for use by the Anesthesia Associates of Coeur d/Alene at their smaller regional hospital, Kootenai Health Hospital in Coeur d’Alene, Idaho.

I hope you will join me for a trip to Coeur d’Alene, Idaho, with a population of about 50,000 residents, located a little over 100 miles south of the Canadian border to Kootenai Health Hospital, a 331-bed community-owned hospital. This hospital serves many rural communities and provides trauma care and more to help meet the health needs of a growing population. The anesthesia professionals at this hospital are part of the private practice group, Anesthesia Associates of Coeur d’Alene with anesthesiologists and certified registered nurse anesthetists. I will include a link to the hospital and anesthesia practice website in the show notes as well. Pierce was the leader for the development and implementation of the Kootenai Health DART program.

Now, let’s talk about how Pierce and her team adapted and adopted the Difficult Airway Response Team Program. The first step was the desire to implement a difficult airway response program following an adverse event related to a difficult airway. The second step involved the creation of a multidisciplinary team with the necessary stakeholders including the ICU medical director, the emergency department medical director, an Ear/Nose/Throat surgeon, and an anesthesia professional. This team was charged with adapting the DART program from Johns Hopkins to fit the needs of their smaller community hospital as well as obtaining buy-in from the hospital administration. The team reported to the Surgery Committee, Medical Staff meetings, joint operating committees and to the Board of Trustees seeking to establish a new “Pillar of Safety” for their institution. The team received $500,000 budget for their new initiative including necessary equipment and training.

The authors outline the necessary steps to develop a similar DART program at Regional and Rural hospitals. Check out Table 1 in the article and we are going to run through those steps now.

[Footsteps Sound Effect]

• Treat development of the program as the adoption and diffusion of an innovation
• Identify a provider or physician leader to champion the program development
• Build a multidisciplinary team
• Gain support of key stakeholders (including leaders in airway management) early in program planning
• Conduct a comprehensive assessment of available resources and equipment. This step is so important and will likely lead to modifications of the program depending on this assessment.
• Create a feasible plan scaled to the facility that can be implemented in stages
• Secure administrator’s support via educational presentations and briefings
• Select equipment designed for multidisciplinary teams and agreed upon by all users
• Conduct multidisciplinary team-based training that replicates real-life scenarios. This may be in a dedicated simulation center or can be done in a bay in the emergency department.
• Build an airway management culture that encourages collaboration across provider disciplines
• Encourage early intervention in difficult airway management and proactive use of DART teams
• Continue education, training, evaluation, and program improvement

For a successful DART program, the availability of necessary and up-to-date airway equipment is vital. The equipment should also be easy to use and train clinicians to use especially when team members may include professionals outside the field of anesthesiology including ER physicians and intensivists. Pierce and her team ultimately decided to obtain a disposable video laryngoscope and bronchoscopy system with dual view capability so that two clinicians could work simultaneously to secure the airway if needed.

The advanced equipment including a video laryngoscope with every size of intubating handle, pediatric and adult bronchoscopes should accompany standard airway equipment and be stored in a difficult airway cart. Depending on the hospital size, several difficult airway carts may need to be created and stocked and should look identical so that in an emergency, it is easy to find the necessary and appropriate equipment. Important locations for difficult airway carts include each ICU, the OB ward, the Emergency Department, the OR, a travel cart, and a cart that is ready for exchange in Central Supply. These carts often function like a code cart and remain locked until needed with a system in place to restock using a standardized checklist and two-person verification. Part of the implementation process involved communication and education for awareness and familiarity with the equipment for nursing staff, the rapid response team, medical staff, anesthesia professionals, and respiratory therapy staff. The benefit of the standardized difficult airway carts is to ensure that the equipment is reliably maintained and restocked in the cart, clearly organized, and easily accessible. Another consideration is after the initial roll-out of the difficult airway cart, you may discover additional areas that require this cart such as a remote off-site anesthesia location.

The next resource for the program is the team members and the training that is required for the program to be successful. One component of this is the annual multidisciplinary Difficult Airway Workshop. This workshop involves education related to difficult airway topics, tools, and procedures. Some of the situations covered during the workshop include awake fiber-optic intubation, “can’t intubate/can’t ventilate scenario, overview of the difficult airway cart, emergency cricothyrotomy and tracheostomy procedures (taught by ENT surgeons), and various other difficult airway scenarios. Workshop participants greatly valve this learning opportunity and training. An important part of the workshop included working on a multidisciplinary team (which may include ER physicians, anesthesia professionals, intensivists, paramedics, rapid response nurses, respiratory therapists and surgeons) to perform cricothyroidotomy on pig tracheas and practice simulated airway emergencies. Participants who do not perform surgical airways gained valuable experience from this workshop to be able to collaborate with the other team members and assist during an emergency. The workshop wrapped up with a review of difficult airway cases that occurred over the past year since the last workshop in a roundtable format. Stay tuned because we will hear more about the workshop from Pierce later in the show as well.

The authors report on the experience at their institution with the DART carts. Over a ten month time period, the carts were used 167 times. Feedback related to this innovation revealed improved collaborative culture and improved patient safety. From our Stoelting conference this year, we know that a collaborative culture and patient safety go hand in hand. This was true here too when ICU and ER physicians would reach out to anesthesia professionals for help with potential difficult airways. This led to improved communication and a team approach for difficult airway management. In addition, surgeons and other hospital professionals reached out to take part in future Difficult Airway Workshops, to be part of the growing multidisciplinary team. Another important step after implementation of this new program is to evaluate the program and solicit feedback. This may be accomplished with a quality improvement survey to ascertain program barriers and limitations, improvements in patient safety, and reduction in adverse airway events.

A successful DART program may also include identification of patients who are at risk for being a difficult airway with a plan in place to identify and label these high-risk patients. Some criteria that may be considered includes BMI greater than 50, history of sleep apnea, recent neck surgery, or history of difficult airway in the past. The label for patients may include a designation in the electronic medical record as well as a physical sign placed above the head of their bed with the following instructions: “Please call anesthesia for any imminent, or emergent airway concerns” with the pager number for the designated anesthesia professional covering the difficult airway response team. Anesthesia professionals may need to be available to answer any calls or questions related to respiratory or airway concerns especially in patients who are identified as high risk for being a difficult airway. Pierce and her team have established a process to screen all admitted patients for being a difficult airway and label these patients appropriately. The use of the EMR in this way can help with data collection of clinical evaluation of the DART program over time.

Challenges may be encountered during the adoption of a DART program such as availability of airway equipment due to the supply chain, staffing resources in light of the Covid-19 pandemic, anticipated versus actual demand for the difficult airway carts, and conversion from independent physician managing the airway to a team approach. The foundation of this new program is a culture change to a collaborative, team-based culture with a unified goal of improved patient safety. This is so important in smaller regional hospitals for managing difficult airways as well as other medical and surgical emergencies.

The authors describe the necessary ingredients for this culture change: training together, recognizing team members strengths and limitations, understanding of how the team works together, knowing when to ask for help, communicating clearly and effectively. The culture change associated with the DART program has larger implications for Kootenai Health by fostering a culture of collaboration dedicated to patient safety.

Thank you so much to the authors for sharing their successful adoption and diffusion of this innovation with the result of improved patient safety during difficult airway management. So, what’s next? Follow-up actions include the following:

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

5) respond to assistance requests from other regional and small rural hospitals interested in developing their own DART program.

As we have seen in this featured article, it is feasible to use the adoption and diffusion approach to implement programs in use at large academic medical centers with appropriate modifications at a variety of hospitals and clinics to help improve patient safety.

Before we wrap up for today, we are going to here from Pierce again. I asked Pierce, What’s next for your projects and research? We are going to hear more about her Difficult Airway Response Team Program and how the adoption of this new innovation is going so far.

[Pierce] “This year, we’ve been focused on outreach of difficult airway training. What I’m most excited about is the expansion of this training program to critical access hospitals. Our difficult airway training workshops are a unique design. We train in small multi-disciplinary teams.  All participants get hands on training no matter what their specialty is. We do simulations and a very robust roundtable discussion. Since the APSF publication, we were able to train two Idaho critical access hospitals. Nurses, primary care physicians, surgeons, surgical techs, respiratory therapists, and EMS all participated. For perspective, these two critical access hospitals have primary care providers covering the emergency department thus they are the ones managing traumas and airway emergencies. When there are no volunteer EMS on duty, the nurses actually ride to the scene in the ambulance and retrieve the trauma patients themselves. The continued adaptation of this education program to a variety of sizes of institutions all with very different resources has led to improved patient safety and collaboration between specialties in these facilities. The end result is a team that can perform well in an airway emergency.”

[Bechtel] Thank you so much to Pierce for contributing to the show today. It is really exciting to learn more about your difficult airway response team and the expansion of the workshops.

If you have any questions or comments from today’s show, please email us at [email protected].

Before we go, are there any researchers in the audience?! Don’t be shy! We hope that you will consider applying for the Joint APSF and Foundation of Anesthesia Education and Research Mentored Research Training Grant. This is an exciting opportunity for the next generation of perioperative patient safety scientists. This is a two-year, $300,000 award with a goal for anesthesiologists within 10 years of their first faculty appointment to develop skills and collect preliminary data to go on an become independent investigators in the field of anesthesia patient safety. Mark your calendars for December 1, 2021 and be ready to submit your letter of intent. The submission period will close on January 1, 2022. For more information, head over to APSF.org and click on Grants and Awards Heading.

Visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.  Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. Thanks for tuning in and if you liked this show, please share it with your friends and colleagues, and leaders at your institution.

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

© 2021, The Anesthesia Patient Safety Foundation