A surgical needs assessment for airway rapid responses: A retrospective observational study

Code Critical Airway: A Collaborative Solution to a Catastrophic Problem

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.

System-Based Multidisciplinary Initiatives for Improvement in Tracheostomy Care and Safety: Experience of an Academic Health Institution Hospital Network

Tracheostomized patients represent a unique patient population at risk of life-threatening airway compromise. There can be a presumption that these patients have a “safe” or low-risk airway. Clinicians and other care providers may be unfamiliar with both tracheostomy tubes and best practices for tracheostomy maintenance, assessment, and emergency triage or resuscitation. A review of the highest- acuity emergency airway calls at our university hospital revealed that well over 20% of the emergencies that triggered these activations were in patients with existing tracheostomy tubes. Further analysis of the tracheostomy-related airway emergencies at that time was very informative. Under the auspices of our multidisciplinary airway safety committee, we developed a core tracheostomy-focused team and implemented numerous quality and safety initiatives. Here we present a focused review and discussion of tracheostomy-related clinical issues at the University of Pennsylvania Health System (UPHS) and a summary of quality and safety improvement efforts related to the care of tracheostomized patients based on responses to locally identified safety opportunities. Our experience with tracheostomy-related quality improvement (QI) efforts led us to reach out to the Patient Safety Authority. The Pennsylvania Patient Safety Reporting System (PA-PSRS) data presented by Gardner et al. highlights the categories of airway-related events documented across a range of facilities in the Commonwealth of Pennsylvania. We frame our efforts in the context of both the PA-PSRS data and international perspectives from the U.K. and highlight barriers to implementation and learnings from our iterative and interdisciplinary approach to tracheostomy-related challenges.