Good communication, heralded as the cornerstone of patient safety, remains something of a hurdle in the healthcare industry. While medicine advances on a daily basis, miscommunication is widely recognized as the most common cause of preventable medical errors, which account for more deaths annually than breast cancer, automobile accidents, or drowning. Of the endless factors that demand good communication in the hospital setting, a patient’s difficult airway status is one that many hospitals know intimately. As many as 8.5 percent of patients have difficult airways, and approximately 25 percent of those are not detected until it is too late.Unfortunately, when one South Florida hospital researched best practices for communicating a patient’s difficult-to-intubate (DTI) status, its nationwide search was less than fruitful.
The team at the Memorial Healthcare System in Hollywood, Fla., knew that even after a successful procedure, poor communication may still lead to medical errors and fatalities. But when miscommunication contributes to 43-91 percnet of adverse events and near misses in the operating room, how could hospital staff possibly communicate a patient’s DTI status across six hospitals that provide varying levels of services and an aggregate care of more than 35,000 surgical cases per year while also ensuring that each team has all the necessary equipment readily available in every hospital?
Over several years, Memorial’s multi-disciplinary team explored how a patient’s DTI status could be communicated to the numerous hospitals and even more hospital staff members in its system. Chaired by the Chief of Anesthesia and including members from nursing, IT, purchasing, respiratory therapy, and physicians from the ED, ICU & Trauma surgery, Memorial’s team was faced with the challenge of establishing a method of communication that evolved from the traditional “difficult airway” notification, which focused on informing only the patient and perhaps the anesthesia team. Because the primary responsibility for the intubation of patients outside of the OR rested with non-anesthesia providers, the team had to understand how to provide cross-specialty communication. They also had to address the inconsistency in the availability of advanced airway equipment in the ICU's and ER's throughout the healthcare system, as well as the inconsistency in utilizing a combination of electronic and paper documentation, a common stage in the transition from paper to electronic health record technology. Taking these factors into consideration, Memorial’s team created a system to manage a patient’s DTI status that focused on identification, communication, and equipment.
To establish the identification and communication of this status, the terminology was defined so that physicians could write an order in the chart deeming the patient a DTI. Here, a DTI was defined as a patient for whom a conventionally trained laryngoscopist experiences difficulty with mask ventilation, difficulty with tracheal intubation, or both. Because patients travel throughout the facility for tests and procedures, the team understood that the traditional whiteboard would not be sufficient since the DTI-identifier needs to remain with the patient constantly. Therefore, a blue bracelet with the verbiage "difficult to intubate" was placed on the patient and remained in place for the duration of the hospitalization. Concurrently, a DTI notation was placed in the allergy section of the electronic health record to ensure the information is available for subsequent visits to any facility in the system, providing cross-specialty communication. And since the DTI designation became treated as an allergy, a DTI patient is banded upon any future entrance into the healthcare system.
In a progressive move to also ensure appropriate equipment throughout Memorial’s six hospitals, a standardized DTI cart was developed to function as a "code" cart, meaning the carts at all facilities are stocked identically and are returned to a centralized location when opened to be cleaned or sterilized, restocked and resealed. The team included a variety of airway equipment in the DTI cart to allow healthcare professionals access to essential equipment. With this standardized, ready-to-go DTI cart, healthcare professionals can stay ready for an emergency so that they can avoid always getting ready as a reactive, rather than proactive, measure during an emergency.
This protocol was a hard-won and substantial accomplishment. The multiple discussions amongst the medical staff, as well as the extensive educational efforts to the nursing staff, have raised the level of awareness within the healthcare system of risk factors concerning patients who may have tenuous airways. Much of the success of this implementation relied on the ability to make airway management an important focus of every healthcare provider. Without such cross-level buy in, it is difficult to develop initiatives that can successfully create a new set of appropriate actions and move healthcare staff to be more safety-conscious of any patient they touch throughout their day. Over time, best practices like Memorial’s will provide advantages across the nation as more hospitals adjust their processes to address the needs and roadblocks that their physicians, hospital staff, and patients face.
