1997 OPEN FORUM Abstracts
TWO-TIERED RESPONSE FOR EMERGENCY AIRWAY MANAGEMENT.
John D. Hussey MBA, RRT, Lewis Massey, S. Lakshminarayan MD, James Joy MD, Jennifer Finley MD, Michael Bishop MD, Veteran Affairs Puget Sound Healthcare System, Seattle, Washington.
Because of the potential for airway emergencies to result in serious morbidity and mortality, personnel trained in emergency airway management must be available at all times. Faced with reductions in available anesthesia personnel at our medical center we evaluated possible models to ensure safe and timely care of airway emergencies without requiring around the clock presence of a physician trained in airway management. We hypothesized that a hybrid two-level model of emergency airway care would result in safe management of airways with acceptable outcomes. Our model consisted of defining airway care as either urgent or emergent based on whether the patient was expected to require endotracheal intubation within 30 minutes. Prior experience indicated that the majority of intubations actually occurred in patients who exhibited signs of progressive deterioration over a period of longer than 30 minutes and that anesthesia personnel could be paged to the medical center to participate in airway care. Further, we had observed that the more complex airway problems (requiring MD involvement) were in patients who were deteriorating but had not yet arrested. By contrast, after cardiac arrest, there is less of a need for considering the complexities of sedation, muscle relaxation, or hemodynamic instability. We established a certification program in airway management for respiratory therapists. Training included practice with mannikins, one-on -one teaching, lecture, written materials, and OR sessions with a minimum of 10 days in the OR, and included use of the Macintosh and Miller blades and Eschmann stylets. Our results over the first year included 107 total out-of-OR intubations, 52 for arrest and 55 for other airway problems. Of the non-code cases, 49 of 55 had an anesthesiologist present. An anesthesiologist supervised 27 of 52 cardiac arrest intubations. Of the 76 supervised intubations (supervised either because of daytime hours or because they were urgent rather than emergent), all were successfully intubated. Anesthesiologists were not initially present for 31 intubations and of these, 2 were never intubated and both patients died. Two patients were intubated by a surgeon who was present after an initial attempt by a RT was not successful, and one patient was supported with a bag and mask after initial unsuccessful attempts by RT and a thoracic surgeon at which time anesthesia arrived and intubated the patient. This resulted in 26 successful unsupervised intubations by RT. The unsuccessful intubations were in patients with difficult airways, one had massive facial swelling and the other was in a halo following transoral cervical spine surgery. Neither patient had been expected to survive, and the anesthesiologist was also unable to intubate either patient. Our model resulted in 105 of 107 patients intubated successfully. The 2% failure rate is well within reported rates for out-of-OR intubations. Thus, the two level response model is safe, yields acceptable outcomes, and allows a physician to be present for the non-arrest patients who often are unstable and have complicating factors. Our model was also cost effective in that it has resulted in an estimated savings of $150,000 to the Medical Center since anesthesia personnel are not required to be in the Medical Center 24 hours a day.