Introduction with a case
I once admitted a patient in transfer for the management of heart failure. Prior to transfer, he was intubated at a community hospital. There was extreme difficulty intubating him, which apparently required an hour and led to substantial airway bleeding. Eventually he was intubated by an anesthesiologist using a bougie. The transferring physician wasn’t involved in the intubation, but attributed this difficulty to an airway polyp.
A few weeks later, while covering a night shift in the ICU, I was called to evaluate a patient in respiratory distress who required intubation. While preparing to intubate him, I asked the resident to check whether there were any records regarding prior intubation difficulty. There were none. We are about to initiate rapid-sequence intubation when the charge nurse walked by and asked “Hey Josh, isn’t this the guy with a terrible airway that took an hour to intubate?” Sure enough, it was him.
Given this history, we changed our strategy to an awake intubation. He did indeed have a mass affixed to his epiglottis which distorted his airway anatomy. However, he was awake and breathing, helping me to proceed without stress. With a Glidescope it was possible to position his head to allow visualization of the posterior cartilages (the view of the vocal cords was entirely obstructed). An endotracheal tube was gently slipped anterior to the posterior cartilages, and he was intubated safely within a few minutes (1).
Traditional documentation fails us in emergencies
There is agreement about the following:
- If difficult airway anatomy is encountered, this should be documented in the patient’s records.
- Prior to intubation, the patient’s records should be reviewed to see if the patient was previously difficult to intubate.
This is obvious. Unfortunately, in practice this information is scattered around a patient’s chart. For example:
- Difficult intubation in the OR: This information is typically buried within a several-page anesthesiology report. In many hospital charting systems, the anesthesiology records are difficult or impossible to retrieve.
- Difficult intubation in the ER or ICU: This information may be included in the emergency medicine admission note or in-hospital procedure notes.
- Difficult intubation at an outside hospital: This might be found in an admission note, but it is frequently lost entirely. Some patients may be aware of a history of difficult intubation, but most are too ill to tell us.
Intubation is often required urgently. It is usually impossible to hunt through all of these different locations in the chart beforehand.
Existing communication strategies are uncommonly used
Several approaches have been proposed for communicating about difficult airways, including the following: (Barron 2003)
- “difficult airway” sticker attached to the endotracheal tube to remind providers prior to extubation
- plastic “difficult airway” bracelet worn in the hospital
- “airway alert” built into the electronic medical record
- national difficult-airway registries
- metal MedicAlert bracelets worn outside the hospital
- informing the patient and primary-care provider
A new “human error” of airway safety is poor forward information transmission – Feinleib 2015
The following strategy is intended as an addition to the strategies listed above. Using several redundant strategies reduces the risk that all strategies will fail simultaneously.
A simple solution to organize this information within the electronic medical record is as follows:
- If a patient has difficult airway anatomy, this can be entered in the chart as an “allergy” to rocuronium. Under the comments section, describe the difficulty encountered and refer to other notes which provide additional details.
- This “rocuronium allergy” will naturally be carried forward in the chart.
- Prior to intubation, the chart may easily be checked for a “rocuronium allergy.”
The “allergy” section of the electronic medical record is an ideal place to put this information because it will follow the patient everywhere they go. Every electronic medical record system has a place to put this information, allowing for seamless transitions between different hospitals and various settings (e.g. OR, ED, ICU, etc.). Physicians and nurses frequently review the allergies, so listing a rocuronium allergy could promote ongoing awareness about airway difficulty across the entire treatment team. Finally, patients are usually aware of their allergies, so this might even facilitate communication about airway problems if the patient presented to a different hospital.
But… it’s not a true allergy?
Purists might protest that this is not a true “allergy,” making it inappropriate to file this information in the allergy section. Perhaps it might litter the allergy section of the patient’s chart? Well, we’ve all seen allergies ranging from “broccoli” to “non-dilaudid opioids” to “haloperidol.” Most entries in the allergy section aren’t true allergies. Adding one additional entry for rocuronium won’t change this.
- Documentation and retrieval of information about airway anatomy is a critical task that we often fail at.
- If a patient has a difficult airway, this can easily be documented in the electronic medical record as an “allergy” to rocuronium, with an accompanying description of difficulties encountered.
- Using the allergy section of the chart may facilitate propagation of this information across different settings (OR, ER, ICU), rapid retrieval, and ongoing reminders to the treatment team.
- This strategy may be used in combination with other strategies (e.g. informing the patient, MedicAlert bracelets) to reduce the likelihood of a breakdown in communication.
- As with all cases from the Genius General Hospital, specifics of the case including dates, gender, and hospital identification have been scrambled to protect patient confidentiality. A case resembling this case occurred at some point in time, somewhere in the Northeast United States, within the past fifteen years.
Image Credits: Sign created at www.mysafetysign.com. Difficult intubation image on ETT from the Journal of the Anesthesia Patient Safety Foundation here. Difficult intubation bracelet intubation is from the same journal, here.
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