Lynette J. Mark

Need for emergency surgical airway reduced by a comprehensive difficult airway program.

BACKGROUND: Inability to intubate and ventilate patients with respiratory failure is associated with significant morbidity and mortality. A patient is considered to have a difficult airway if an anesthesiologist or other health care provider experienced in airway management is unable to ventilate the patients lungs using bag-mask ventilation and/or is unable to intubate the trachea using direct laryngoscopy. METHODS: We performed a retrospective review of a departmental database to determine whether a comprehensive program to manage difficult airways was associated with a reduced need to secure the airway surgically via cricothyrotomy or tracheostomy. The annual number of unplanned, emergency surgical airway procedures for inability to intubate and ventilate reported for the 4 yr before the program (January 1992 through December 1995) was compared with the annual number reported for the 11 yr after the program was initiated (January 1996 through December 2006). RESULTS: The number of emergency surgical airways decreased from 6.5 ± 0.5 per year for 4 yr before program initiation to 2.2 ± 0.89 per year for the 11-yr period after program initiation (P < 0.0001). During the 4-yr period from January 1992 through December 1995, 26 surgical airways were reported, whereas only 24 surgical airways were performed in the subsequent 11-yr period (January 1996 through December 2006). CONCLUSIONS: A comprehensive difficult airway program was associated with a reduction in the number of emergency surgical airway procedures performed for the inability of an anesthesiologist to intubate and ventilate, a reduction that was sustained over an 11-yr period. This decrease occurred despite an increase in the number of patients reported to have a difficult airway and an overall increase in the total number of patients receiving anesthesia per year.

Disseminating information using an anesthesiology consultant report: impact on patient perceptions of quality of care

STUDY OBJECTIVEnTo determine if providing an Anesthesiology Consultant Report (ACR) to patients would result in enhanced patients perceptions of their knowledge about their care and improve their perception of the quality of their care.nnnDESIGNnRandomized, unblinded study.nnnSETTINGnOutpatient center associated with tertiary care center.nnnPATIENTSn371 outpatients without adverse anesthetic events.nnnINTERVENTIONSnPatients were randomized to receive either routine discharge instructions or routine instructions and an anesthesia discharge summary (ACR).nnnMEASUREMENTS AND MAIN RESULTSnShort questionnaire with discharge packet regarding knowledge of anesthetic and questions regarding satisfaction and perceptions of quality of care was distributed. The patients in the group that received an ACR were more satisfied with the management of their pain and other symptoms (p < 0.05, by Wilcoxon rank sums) and were more satisfied overall with the quality of the anesthesia care (p < 0.01, by Wilcoxon rank sums). Taken another way, significantly more patients deemed the quality of their anesthetic care as excellent in the ACR group compared to control (83% vs. 67%, p < 0.01).nnnCONCLUSIONSnProviding patients, with uneventful anesthetic courses, with information regarding their anesthetic care, in the form of the ACR, results in improved perceptions of the quality of care.

A novel process for introducing a new intraoperative program: A multidisciplinary paradigm for mitigating hazards and improving patient safety

BACKGROUND: Since the Institute of Medicine’s report, To Err is Human, was published, numerous interventions have been designed and implemented to correct the defects that lead to medical errors and adverse events; however, most efforts were largely reactive. Safety, communication, team performance, and efficiency are areas of care that attract a great deal of attention, especially regarding the introduction of new technologies, techniques, and procedures. We describe a multidisciplinary process that was implemented at our hospital to identify and mitigate hazards before the introduction of a new technique: high-dose-rate intraoperative radiation therapy, (HDR-IORT). METHODS: A multidisciplinary team of surgeons, anesthesiologists, radiation oncologists, physicists, nurses, hospital risk managers, and equipment specialists used a structured process that included in situ clinical simulation to uncover concerns among care providers and to prospectively identify and mitigate defects for patients who would undergo surgery using the HDR-IORT technique. RESULTS: We identified and corrected 20 defects in the simulated patient care process before application to actual patients. Subsequently, eight patients underwent surgery using the HDR-IORT technique with no recurrence of simulation-identified or unanticipated defects. CONCLUSION: Multiple benefits were derived from the use of this systematic process to introduce the HDR-IORT technique; namely, the safety and efficiency of care for this select patient population was optimized, and this process mitigated harmful or adverse events before the inclusion of actual patients. Further work is needed, but the process outlined in this paper can be universally applied to the introduction of any new technologies, treatments, or procedures.

The difficult airway: Mechanisms for effective dissemination of critical information

The perioperative management and dissemination of critical information regarding a patient with an unexpected difficult intubation, including successful application of a difficult airway algorithm (Figure 1), are described. Documentation and dissemination of critical information include entry of patient data into an in-hospital computerized Difficult Airway/Intubation Registry, simultaneous application of a highly visible Difficult Airway/Intubation Patient Wrist Band (coded for access to computer registry), summary reports distributed to health care providers, and enrollment of the patient in the Medic Alert Foundation Internationals newly established category difficult airway/intubation for 24-hour access. We postulate that the widespread use of the procedures described in this report may reduce the contribution of unexpected difficult airway/intubation to anesthetic morbidity and mortality.

Difficult Airway Response Team: A Novel Quality Improvement Program for Managing Hospital-Wide Airway Emergencies

BACKGROUND:Difficult airway cases can quickly become emergencies, increasing the risk of life-threatening complications or death. Emergency airway management outside the operating room is particularly challenging. METHODS:We developed a quality improvement program—the Difficult Airway Response Team (DART)—to improve emergency airway management outside the operating room. DART was implemented by a team of anesthesiologists, otolaryngologists, trauma surgeons, emergency medicine physicians, and risk managers in 2005 at The Johns Hopkins Hospital in Baltimore, Maryland. The DART program had 3 core components: operations, safety, and education. The operations component focused on developing a multidisciplinary difficult airway response team, standardizing the emergency response process, and deploying difficult airway equipment carts throughout the hospital. The safety component focused on real-time monitoring of DART activations and learning from past DART events to continuously improve system-level performance. This objective entailed monitoring the paging system, reporting difficult airway events and DART activations to a Web-based registry, and using in situ simulations to identify and mitigate defects in the emergency airway management process. The educational component included development of a multispecialty difficult airway curriculum encompassing case-based lectures, simulation, and team building/communication to ensure consistency of care. Educational materials were also developed for non-DART staff and patients to inform them about the needs of patients with difficult airways and ensure continuity of care with other providers after discharge. RESULTS:Between July 2008 and June 2013, DART managed 360 adult difficult airway events comprising 8% of all code activations. Predisposing patient factors included body mass index >40, history of head and neck tumor, prior difficult intubation, cervical spine injury, airway edema, airway bleeding, and previous or current tracheostomy. Twenty-three patients (6%) required emergent surgical airways. Sixty-two patients (17%) were stabilized and transported to the operating room for definitive airway management. There were no airway management–related deaths, sentinel events, or malpractice claims in adult patients managed by DART. Five in situ simulations conducted in the first program year improved DART’s teamwork, communication, and response times and increased the functionality of the difficult airway carts. Over the 5-year period, we conducted 18 airway courses, through which >200 providers were trained. CONCLUSIONS:DART is a comprehensive program for improving difficult airway management. Future studies will examine the comparative effectiveness of the DART program and evaluate how DART has impacted patient outcomes, operational efficiency, and costs of care.

Comparison of sevoflurane/fentanyl and isoflurane/fentanyl during elective coronary artery bypass surgery

PurposeDue to the progressive aging of the surgical population, the proportion of patients with coronary artery disease (CAD) is likely to increase. The effects of the new inhalational anaesthetic sevoflurane must be determined in patients with known CAD.MethodsThis multicentre, randomized, open-label study compared the haemodynamic and cardiovascular effects of sevoflurane and isoflurane with fentanyl in 284 ASA physical status II–IV patients undergoing elective coronary artery bypass graft (CABG).ResultsSatisfactory records were available in 272 patients, 139 sevoflurane (Group S) and 133 isoflurane (Group I). There were no differences between groups for demographic data except that more patients in Group S were taking preoperative beta-blockers (P = 0.03). The mean end-tidal MAC and MAC · hr requirements between groups were not different (Group S received 0.63 ± 0.02 MAC and 1.00 ± 0.05 MAC · hr while Group I received 0.58 ± 0.02 MAC and 0.92 ± 0.05 MAC · hr P = NS). The preCPB use of intravenous fentanyl was not different between groups. There was a similar decrease in haemodynamic variables in both groups after induction that persisted throughout the preCPB period. The incidence of preCPB myocardial ischaemia, adverse haemodynamic events and use of vasoactive drugs did not differ between groups. The incidence of postoperative myocardial infarction was 2.2% for Group S and Group I was 4.5% (P = NS). There were five postoperative deaths, one of which was attributed to a cardiac cause (Group I).ConclusionIn patients undergoing elective CABG with low risk factors, either sevoflurane or isoflurane, combined with fentanyl, provided an acceptable preCPB haemodynamic profile and cardiac outcomes.RésuméObjectifA cause du vieillissement de la population chirurgicale, une augmentation proportionnelle de patients souffrant de maladie coronarienne athérosclérotique (MCAS) est à prévoir. Les effets des nouveaux agents volatils anesthésiques, tels le desflurane et le sévoflurane, doivent être déterminés chez les patients ayant une MCAS.MéthodeCette étude ouverte, multicentrique, randomisée a comparé les effets hémodynamiques et cardio-vasculaires du sévoflurane et de l’isoflurane en association avec du fentanyl chez 284 patients ASA II–IV subissant une chirurgie de revascularisation myocardique (CABG).RésultatsUn total de 272 patients évaluables ont servi à l’analyse dont 139 patients sévoflurane (Groupe S) et 133 patients isoflurane (Groupe I), Il n ’y avait pas de différence démographique entre les groupes à l’exception d’une utilisation préopératoire plus grande de bêta-bloqueurs dans le Groupe S (P = 0.03). La moyenne du MAC de fin d’expiration et le MAC·hr pour chacun des groupes étaient similaires (Groupe S a reçu 0.63 ± 0.02 MAC et 1.00 ± 0.05 MAC·hr tandis que le Groupe I a reçu 0.58 ± 0.02 MAC et 0.92 ± 0.05 MAC·hr; P = NS). L’utilisation du fentanyl préCEC était similaire. A la suite de l’induction et durant le maintien de l’anesthésie préCEC, une réduction similaire des paramètres hémodynamiques fut enregistrée. L’incidence d’ischémie myocardique préCEC, d’événements hémodynamiques adverses et l’utilisation d’agents vasoactifs étaient similaires. L’incidence d’infarctus du myocarde pour le Groupe S est de 2.2% et 4.5% pour le Groupe I (P = NS). Il y eut cinq décès postopératoires, dont un était attribué à une cause cardiaque (Groupe I).ConclusionPour des patients à bas risque subissant une CABG, le sévoflurane et l’isoflurane, en association au fentanyl, procurent un profil hémodynamique préCEC et des résultats cardiaques acceptables.

A Practical Framework for Patient Care Teams to Prospectively Identify and Mitigate Clinical Hazards

BACKGROUNDnOne of the greatest challenges facing both practitioners and risk managers is the identification of previously unknown clinical hazards and defects. With the rapid proliferation of new health care services, unknown hazards may propagate as new therapies are integrated into the existing health care system. The main goal of risk analysis is to make these hazards visible by proactively searching and probing the system. Yet, a comprehensive approach by which to safely integrate new therapies into the existing clinical environment has yet to be clearly articulated. Patient care teams can use the proposed framework when introducing new therapies.nnnA PRACTICAL FRAMEWORKnThe framework includes a background investigation and literature search; an in situ simulation (in the actual clinical setting used for patients); a Failure Mode and Effects Analysis to determine the severity, probability, and risk of the potential hazards; and a multidisciplinary protocol and safety checklist to standardize practice and ensure provider accountability.nnnCASE EXAMPLESnApplication of this framework to three operative scenarios--intraoperative radiation therapy (IORT), hyperthermic intraperitoneal chemotherapy (HIPEC), and an interventional pulmonology program--demonstrates its flexibility. Its use prospectively identified and mitigated 20 IORT, 5 HIPEC, and 18 interventional pulmonology hazards/defects. Subsequent patient cases were largely uneventful. All cases and patient safety reporting systems are monitored to identify any new defects in an effort to continuously improve patient care.nnnCONCLUSIONnThe use of a comprehensive framework to identify and mitigate hazards in an on-site simulated environment promotes safer care for target patient populations; results in familiarity with procedures, amelioration of staff concerns, and standardization of practice; and facilitates teamwork and communication.

Designing and implementing a comprehensive quality and patient safety management model: A paradigm for perioperative improvement

Objectives: The objectives of this article are to describe the design and implementation of a comprehensive perioperative quality and patient safety management model. This model used a systems approach to integrate (1) multiple data sources of defects, (2) a multidisciplinary team, (3) a quality improvement methodology successful in high-risk industries other than health care, (4) retrospective and near-real-time analyses of defects, and (5) proactive feedback to the team, reporters, and hospital risk managers. Methods: Two primary incident-reporting systems were selected. A multidisciplinary team of physicians, nurses, risk managers, and others was formed. A simple taxonomy was used to categorize defects. Lean Six Sigma methodologies were used to analyze the data. The team calculated a priority score for each defect and developed quality improvement projects for those with the highest priorities. Results: During this study, 532 perioperative defects were captured, with newly captured defects analyzed weekly in near real time. The team created 91 quality improvement projects targeting all defect categories, with 33% focused on patient safety. Many projects were not based on the incident-reporting systems but originated from the models systems approach. Feedback loops proactively revised formats for capturing defects, added patient-specific safety data to individuals medical records, and informed the hospitals risk managers of ongoing quality improvement projects. Conclusions: This comprehensive model used a systems approach to successfully integrate aggregate data from incident-reporting systems, empowered stakeholders from a multidisciplinary team, and Lean Six Sigma methodologies to develop sustainable quality improvement projects to mitigate defects and positively impact perioperative processes.

A novel role for otolaryngologists in the multidisciplinary difficult airway response team

The Difficult Airway Response Team (DART) was implemented in July 2008 to address emergent difficult airway situations. The main objective of this study was to highlight the unique role and skill set that otolaryngologists bring and their impact on patient outcomes.

Safety of Direct Laryngoscopy As an Outpatient Procedure

The safety of outpatient direct laryngoscopy has recently been challenged in the literature. We reviewed the first 589 direct laryngoscopies performed at a new outpatient surgery center. There were nine unplanned admissions to the hospital, including five airway emergencies that developed within the first 30 min after extubation. Three patients required reintubation before leaving the operating room. On postoperative telephone follow‐up, 9% complained of mild to moderate sore throat. There were no major complications after discharge. We conclude that the risk of airway emergencies after direct laryngoscopy is less than 1% in carefully selected patients. The procedure can be safely performed as an outpatient procedure as long as transportation to a hospital is readily available for the few patients in whom complications arise.