Patients who have undergone tracheotomy or laryngectomy have a risk of acute respiratory obstruction due to such common occurrences such as mucous plugging and tube displacement. After tracheotomy, the rate of serious complication is reported at 2.7% for tube obstruction and 1.5% for tube displacement [4
]. A recent study reviewing 1130 tracheotomies found a death rate of 0.35%, which was most often caused by hemorrhage or tube displacement [5
]. In a review of 183 laryngectomy patients, there was a 7% chance of airway complications, mostly thick mucous plugging associated with lack of humidification [6
]. However, little data is reported on the exact nature and sequence of events that result in serious morbidity and mortality in this patient group.
Airway emergencies are characterized by hypoxia or anoxia that can produce irreversible brain damage in a matter of minutes. Subspecialists, such as otolaryngologist-head and neck surgeons, routinely perform alterations to the upper airway that may not be immediately obvious to other medical and surgical providers who are often the primary responders of a typical code team. For instance, at the time of tracheotomy, a Bjork flap may be created or “stay sutures” may be placed in the upper and lower rings of the trachea to facilitate retraction of the rings for reinsertion of a dislodged tracheotomy tube. However, if primary responders do not know how to use “stay sutures,” these potential life-saving interventions are of little value. In addition, a laryngectomy tracheal stoma may be mistaken for a tracheotomy site. In this situation, oral ventilation or intubation may be attempted. Thus, it is important for medical, nursing, and respiratory therapy colleagues to comprehend key points of airway anatomy in these patients to avoid significant morbidity.
As a result of our hospital quality assurance process, we identified a potential knowledge deficit among typical primary responders in the code team. This study represents an attempt to accrue pilot data to characterize the baseline knowledge of caregivers at a tertiary care hospital and present our attempted solution to improve communication among providers.
During quality assurance review of events in prior Code Blue events involving laryngectomy patients at our institution, two important factors were identified that could impact patient outcomes: first, a lack of understanding of subspecialty alteration of the airway by other health care providers, and second, difficulty communicating this knowledge in a timely fashion due to the inherent limitations imposed in a Code Blue event. Our initial hospital staff survey identified specific knowledge gaps of airway anatomy, most notably among medical internists. Having identified a potential patient safety concern, our institution tasked a multidisciplinary committee to develop recommendations for improving the acute management of emergent airway situations in patients with altered airways. Loss of the airway can rapidly result in patient demise, and there is not always time for a knowledgeable airway specialist (i.e., head and neck surgeon) to respond. Thus, a pilot program was initiated to identify all surgically altered airways in the hospital and determine their airway status (i.e., tracheotomy, laryngectomy, or other high-risk airways such as patients who might be very difficult to orally intubate). These identified patients would have an Emergency Airway Access form posted at the bedside at all times (). Since it was determined that a respiratory therapist is reliably present at every code, we focused particular attention to training this group of caregivers regarding the form, with the expectation that they could communicate any significant or unusual airway anatomy to the other caregivers at the code.
Our data reveals that the majority of caregivers appreciate the danger of blind reinsertion in “fresh” tracheotomies (). However, this knowledge does not always translate into clinical application. For instance, reveals that even though the majority of caregivers appreciate the danger of creating a false tract through blind reinsertion of the tracheotomy tube, less than half of medical internists knew to discontinue the futile ventilation and to deflate the tracheotomy cuff for oral ventilation. In addition, nearly half of respondents and 77% of medical internists did not know how to use “stay sutures” in a new tracheotomy wound in the event of accidental tube dislodgement (). Given that medical internists are frequently in charge of Code Blue teams in these emergency settings, these findings are especially concerning.
Postintervention surveys showed overall improvement in knowledge regarding basic airway anatomy in patients after tracheotomy and laryngectomy. While the improvement in knowledge is gratifying, one could argue that close to 100% knowledge of airway anatomy should be expected among caregivers who may be called in an emergency to manage these patients. Regarding appropriate management of common emergency airway scenarios with laryngectomy and tracheotomy patients, the overall results did not improve after implementation of the bedside airway form. These findings suggest additional training regarding appropriate management of common emergency airway scenarios that occur with laryngectomy and tracheotomy patients may be needed in order to prevent future morbidity and mortality.
4.1. Study Limitations
This study presents pilot data assessing the knowledge base of caregivers involved in Code Blue settings and introduces the concept of the EAA form. The form was not meant to replace provider knowledge but was developed to help standardize terminology and improve communication efficiently in the rushed Code Blue setting. There are several limitations to our study. Unfortunately, at a teaching hospital, there is a significant amount of turnover of residents, nurses, and attending physicians. Thus, the data does not represent the same respondents pre- and postintervention. Statistical analysis in this setting is very weak due to the poorly controlled nature of the study, and we cannot conclude that the improvement in responses is due to the EAA form. However, the descriptive data does clearly identify a persistent knowledge gap among many providers in this setting.
Despite the study's limitations, it nonetheless suggests the need for more education regarding appropriate emergent airway management of patients with altered airways as well as the need for more focused instruction regarding how the bedside airway form can be useful to assist critical clinical decision-making, especially by physicians who may be part of the code team. Improvements in tests of knowledge are only indirect measures of quality improvement. A true test of efficacy of the EAA would be to demonstrate a reduced mortality of airway events; however, given the rarity of these events, there is insufficient data to analyze at one institution.