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Kuhar HN, Bliss A, Evans K, Besecker B, Spitzer C, Lyaker M, Schofield M. Difficult Airway Response Team (DART) and Airway Emergency Outcomes: A Retrospective Quality Improvement Study. Otolaryngol Head Neck Surg 2023; 169:325-332. [PMID: 37125624 DOI: 10.1002/ohn.358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 03/28/2023] [Accepted: 04/06/2023] [Indexed: 05/02/2023]
Abstract
OBJECTIVE Difficult airways can be associated with significant morbidity and mortality, particularly in the event of a delay in securing the airway. To improve the airway metrics at our institution, we implemented a multidisciplinary team of airway providers to respond to difficult and emergent airways, or the Difficult Airway Response Team (DART). The purpose of the present study is to assess the feasibility of a DART program at a tertiary care center. STUDY DESIGN A retrospective study evaluating the outcomes of emergent airway cases using the DART protocol. SETTING Single tertiary academic care center. METHODS In August 2019, a DART program was implemented at a tertiary academic medical center. In order to assess the feasibility and effectiveness of this system, data were collected to assess DART outcomes through chart review and surveys following each event, and analyzed in Microsoft Excel. RESULTS A total of 161 DART events (average 4.6/month) took place from August 2019 to June 2022. Anesthesiologists secured the airway in 71 events (51%), otolaryngologists in 38 (27%), and pulmonary/critical care in 12 (9%). Seventy-three activations were not labeled as a difficult airway. Pre-DART, 19 cases required more than 3 attempts to secure the airway compared to 11 cases after DART. Transoral intubation was the most common intervention. Thirteen cases required surgical intervention. CONCLUSION Implementing a multidisciplinary team-based approach for managing emergent difficult airways at a tertiary care institution was feasible and resulted in a decreased number of airway attempts in difficult airway patients. Continuous process improvement is essential for the ongoing enhancement of DART systems.
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Affiliation(s)
- Hannah N Kuhar
- Department of Otolaryngology-Head and Neck Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Alessandra Bliss
- Department of Otolaryngology-Head and Neck Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Kimberly Evans
- Department of Anesthesia, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Beth Besecker
- Division of Pulmonary and Critical Care Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Carleen Spitzer
- Division of Pulmonary and Critical Care Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Michael Lyaker
- Department of Anesthesia, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Minka Schofield
- Department of Otolaryngology-Head and Neck Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Himmler A, Mcdermott C, Martucci J, Rhoades E, Trankiem CT, Johnson LS. Code Critical Airway: A Collaborative Solution to a Catastrophic Problem. Am Surg 2022:31348221101485. [PMID: 35562112 DOI: 10.1177/00031348221101485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In 2006, a multi-disciplinary "Code Critical Airway" (CCA) Team was created at our institution. The objective of this study is to examine the demographics and outcomes of the patients for whom a CCA is activated. METHODS A retrospective review was conducted of patients for whom a CCA was activated from 2008-2020. Data from 2006-2008 was not available due to timing of the implementation of the hospital's electronic medical record system. The early period of the experience with CCAs (2008-2014) was compared to the later period (2015-2020) CCA activations. RESULTS There were 953 CCA activations. Over time, there was a statistically significantly increase in the number of CCA activations. CCAs occurred in the emergency department in 274 (29.0%), intensive care unit in 255 (27.0%), step-down unit in 60 (6.4%), wards in 294 (31.1%), and elsewhere in 61 (6.5%) cases. CCAs were managed with direct laryngoscopy in 97 patients (10.2%), video laryngoscope in 160 patients (16.8%), fiberoptic bronchoscopy in 179 patients (18.8%), bougie in 7 patient (0.7%), replacement of a prior tracheostomy in 262 patients (27.5%), and creation of a new surgical airway in 95 patients (10.0%). The definitive management of the CCA was not recorded in 76 patients (8.0%). Seven patients required removal of a foreign body (0.7%). There was no intervention in 70 patients (7.3%). There was an increase in successful first attempts at obtaining an airway comparing our experience in the early period (2008-2014) compared to the later period (2015-2020) (P < 0 .001). There was also a decrease in number of CCAs requiring a surgical airway (P = .030). CONCLUSION Inculcation of aggressive early escalation of airway emergencies through implementation of a CCA Team has resulted in significant improvement in first attempt airway stabilization and a decrease in surgical airways.
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Affiliation(s)
- Amber Himmler
- MedStar Georgetown University Hospital-Washington Hospital Center Residency Program in General Surgery, 71541Washington, DC, USA
| | - Chelsea Mcdermott
- MedStar Georgetown University Hospital-Washington Hospital Center Residency Program in General Surgery, 71541Washington, DC, USA
| | | | - Emily Rhoades
- Department of Surgical Critical Care, MedStar Washington Hospital Center, Washington, DC, USA
| | - Christine T Trankiem
- Division of Trauma, MedStar Washington Hospital Center, Washington, DC, USA.,Department of Surgery, Georgetown University School of Medicine, Washington, DC, USA
| | - Laura S Johnson
- Division of Trauma, MedStar Washington Hospital Center, Washington, DC, USA.,Department of Surgery, Georgetown University School of Medicine, Washington, DC, USA.,The Burn Center, MedStar Washington Hospital Center, Washington, DC, USA
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Hynes AM, Lambe LD, Scantling DR, Bormann BC, Atkins JH, Rassekh CH, Seamon MJ, Martin ND. A surgical needs assessment for airway rapid responses: A retrospective observational study. J Trauma Acute Care Surg 2022; 92:126-134. [PMID: 34252060 DOI: 10.1097/ta.0000000000003348] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Airway rapid response (ARR) teams can be compiled of anesthesiologists, intensivists, otolaryngologists, general and thoracic surgeons, respiratory therapists, and nurses. The optimal composition of an ARR team is unknown but considered to be resource intensive. We sought to determine the type of technical procedures performed during an ARR activation to inform team composition. METHODS A large urban quaternary academic medical center retrospective review (2016-2019) of adult ARR patients was performed. Analysis included ARR demographics, patient characteristics, characteristics of preexisting tracheostomies, incidence of concomitant conditions, and procedures completed during an ARR event. RESULTS A total of 345 ARR patients with a median age of 60 years (interquartile range, 47-69 years) and a median time to ARR conclusion of 28 minutes (interquartile range, 14-47 minutes) were included. About 41.7% of the ARR had a preexisting tracheostomy. Overall, there were 130 procedures completed that can be performed by a general surgeon in addition to the 122 difficult intubations. These procedures included recannulation of a tracheostomy, operative intervention, new emergent tracheostomy or cricothyroidotomy, thoracostomy tube placement, initiation of extracorporeal membrane oxygenation, and pericardiocentesis. CONCLUSION Highly technical procedures are common during an ARR, including procedures related to tracheostomies. Surgeons possess a comprehensive skill set that is unique and comprehensive with respect to airway emergencies. This distinctive skill set creates an important role within the ARR team to perform these urgent technical procedures. LEVEL OF EVIDENCE Epidemiologic/prognostic, level III.
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Affiliation(s)
- Allyson M Hynes
- From the Division of Traumatology, Surgical Critical Care and Emergency Surgery (A.M.H., D.R.S., B.C.B., M.J.S., N.D.M.), Nursing Rapid Response Team (L.D.L.), Department of Anesthesiology and Critical Care (J.H.A.), and Department of Otorhinolaryngology: Head and Neck Surgery (C.H.R.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Pandian V, Zhen G, Stanley S, Oldsman M, Haut E, Mark L, Miller C, Hillel A. Management of difficult airway among patients with oropharyngeal angioedema. Laryngoscope 2018; 129:1360-1367. [PMID: 30588625 DOI: 10.1002/lary.27622] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2018] [Indexed: 12/19/2022]
Abstract
OBJECTIVE The objective of our study was to assess the impact of a multidisciplinary difficult airway response team (DART), a quality improvement program, in the management of patients with difficult airway associated with oropharyngeal angioedema patients. METHODS Individual retrospective cohort study. Retrospective review of patient charts from July 2003 to June 2008 (pre-DART) and retrospective review of prospectively collected data from July 2008 to June 2013 (post-DART). Patients with angioedema were identified using International Classification of Disease codes 995.1 and 277.6. Patients were included in the study if an otolaryngologist was consulted for airway management. Patients were excluded if they had a history of angioedema but no active issues. Patient characteristics, airway evaluation, and interventions (intubation/surgical airway) were compared between the pre-DART and post-DART cohort. RESULTS The DART team attended to 27 patients with advanced oropharyngeal angioedema. Response time averaged 3.36 minutes. Preintubation fiberoptic airway evaluations were performed in 81% of the post-DART cohort and 56% of the pre-DART cohort. The incidence of patients requiring intubation was higher in the post-DART cohort (18 out of 27 [67%]) than the pre-DART (14 out of 36 [39%]) cohort. One emergency cricothyroidotomy was performed in each of the post-DART and pre-DART cohorts. CONCLUSION Angioedema of the larynx is a predictor of intubation or cricothyroidotomy. Fiberoptic-guided intubation is primarily used for establishing airway in angioedema patients. A multidisciplinary standardized approach such as the DART program offers adequate time and resources for airway evaluation prior to intervention and allows fewer number of attempts to secure an airway. LEVEL OF EVIDENCE 3 Laryngoscope, 129:1360-1367, 2019.
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Affiliation(s)
- Vinciya Pandian
- Johns Hopkins School of Nursing, Baltimore, Maryland.,Outcomes After Critical Illness and Surgery (OACIS) Research Group, Johns Hopkins University, Baltimore, Maryland
| | - Gooi Zhen
- University of Chicago Medicine, Chicago, Illinois, U.S.A
| | - Stanola Stanley
- Johns Hopkins School of Nursing, Baltimore, Maryland.,Outcomes After Critical Illness and Surgery (OACIS) Research Group, Johns Hopkins University, Baltimore, Maryland
| | - Marco Oldsman
- Johns Hopkins School of Nursing, Baltimore, Maryland.,Outcomes After Critical Illness and Surgery (OACIS) Research Group, Johns Hopkins University, Baltimore, Maryland
| | - Elliott Haut
- The Division of Acute Care Surgery, Department of Surgery; Department of Anesthesiology and Critical Care Medicine; Department of Emergency Medicine, Baltimore, Maryland.,The Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland.,The Department of Health Policy and Management, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Lynette Mark
- The Department of Anesthesiology and Critical Care Medicine, Baltimore, Maryland
| | - Christina Miller
- The Department of Anesthesiology and Critical Care Medicine, Baltimore, Maryland
| | - Alexander Hillel
- The Department of Otolaryngology Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
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Emergency Airway Response Team (EART) Documentation: Criteria, Feasibility, and Usability. Crit Care Nurs Q 2018; 41:426-438. [PMID: 30153187 DOI: 10.1097/cnq.0000000000000230] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Patients in an acute care hospital who experience a difficult airway event outside the operating room need a specialized emergency airway response team (EART) immediately. This designated team manages catastrophic airway events using advanced airway techniques as well as surgical intervention. Nurses respond as part of this team. There are no identified difficult airway team documentation instruments in the literature, and the lack of metrics limits the quality review of the team response. This study identified EART documentation criteria and incorporated them into a nursing documentation instrument to be completed by a nurse scribe during the event. The EART instrument was tested by nurses for usability, feasibility, and completeness. Twenty-one critical care nurses participated in this study. The results confirmed good usability, positive feasibility, and 79% documentation completeness using this tool. These criteria and this instrument can be important in documenting the EART and in evaluating the quality of the team performance.
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Mark L, Lester L, Cover R, Herzer K. A Decade of Difficult Airway Response Team: Lessons Learned from a Hospital-Wide Difficult Airway Response Team Program. Crit Care Clin 2018; 34:239-251. [PMID: 29482903 DOI: 10.1016/j.ccc.2017.12.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A decade ago the Difficult Airway Response Team (DART) program was created at The Johns Hopkins Hospital as a multidisciplinary effort to address airway-related adverse events in the nonoperative setting. Root cause analysis of prior events indicated that a major factor in adverse patient outcomes was lack of a systematic approach for responding to difficult airway patients in an emergency. The DART program encompasses operational, safety, and educational initiatives and has responded to approximately 1000 events since its initiation, with no resultant adult airway-related adverse events or morbidity. This article provides lessons learned and recommendations for initiating a DART program.
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Affiliation(s)
- Lynette Mark
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medicine Multidisciplinary Airway Programs, Difficult Airway Response Team (DART) Program, Johns Hopkins Medicine, 1800 Orleans Street, Baltimore, MD 21287, USA; Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medicine Multidisciplinary Airway Programs, Difficult Airway Response Team (DART) Program, Johns Hopkins Medicine, 1800 Orleans Street, Baltimore, MD 21287, USA.
| | - Laeben Lester
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medicine Multidisciplinary Airway Programs, Johns Hopkins Medicine, 1800 Orleans Street, Baltimore, MD 21287, USA; Department of Emergency Medicine, Johns Hopkins Medicine Multidisciplinary Airway Programs, Johns Hopkins Medicine, 1800 Orleans Street, Baltimore, MD 21287, USA
| | - Renee Cover
- Johns Hopkins Health System Legal Department, The Johns Hopkins Hospital, 1800 Orleans Street, Baltimore, MD 21287, USA
| | - Kurt Herzer
- Oscar Health, 219 Withers Street, Brooklyn, NY 11211, USA
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