Abstract SNACC-89

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A Multi-Disciplinary, “Difficult to Intubate” Communication system in the OR/ICU Setting for the Immediate Identification of Patients at Risk for Extremely Difficult Reintubation

1Mueller R, 2Todd M, 2Hurst K, 2Smith R
1University of Iowa COllege of Medicine, Iowa City, IA, USA; 2University of Iowa College of Medicine, Iowa City, IA, USA

Background
Tracheal reintubation after planned extubation occurs in up to 25% of post-surgical patients in the ICU.1,2 There have been several complications including sentinel (“Cannot Intubate, Cannot Ventilate”) events associated with extubation in patients known to be difficult to intubate (DI) to the care team in the operating room (OR). Inadequate day-to-day handoffs in the ICU, combined with a failure of hand-off to call or “Rapid Response” teams, and a poor appreciation of the degree of difficulty of intubation led to lack of planning for failed extubation and morbidity, mortality or a near-miss during reintubation. We modified2 and implemented a communication method for the clear identification of patients who are at risk for extremely difficult reintubation and are transferred intubated from the OR to an ICU.

Methods
We identified 8 categories of patients likely to be extremely difficult to intubate due to anatomical or post-surgical changes and added a 9th open category based on faculty discretion. Patients within these categories who remain intubated at the end of surgery receive bright red “Difficult to Intubate” wristbands and sticker tape on the endotracheal tube and a red bedside warning sign from Anesthesia or Otolaryngology staff. A “DI Red Tag” Communication Kit containing these items was placed in every main OR and emergency airway cart. Anesthesia, Otolaryngology, ICU, select surgical and nursing staff were educated about this initiative. As most extubation failures occur within 2 hours of extubation,1 we also advised that planned extubation in these patients occur early during the workday.

Results and Conclusion
Since inception (March 2014), this method has been used in 10 patients. Six (6/7) were safely extubated in an ICU according to our recommendations. One patient was compassionately extubated for his terminal disease. Another patient received a planned tracheostomy. There were no airway mishaps in any of these “red-tagged” cases. Two patients were erroneously “red-tagged.” We have provided further education to our team members about appropriate patient selection.

The electronic medical record (EMR) is being configured to display “Difficult to Intubate” banner alerts. The anesthesia record will designate the patient as a “red-tagged” airway. A list of in-house, red-tagged patients will be provided to teams on call for the ICU and emergency airway assistance.

Currently, the DI diagnosis is relayed through notes in the EMR and during verbal hand-off, and may be missed, especially in an emergency, and by providers who are unfamiliar with the patient. Our system will alert trainees to have clinicians skilled in advanced airway management involved in reintubation. Nursing staff will be vigilant to prevent premature self-extubation.

This is a simple, inexpensive and, we believe, effective system to quickly identify extremely difficult airways in patients going intubated from the OR to the ICU. It will foster awareness and preparation and thus prevent critical errors and life-threatening airway catastrophes.

References:
1. Cavallone LF et al: Anesth Analg 2013;116:368
2. Kadis J et al: APSF Newsletter: Fall 2012;32


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