The issue of comprehension of airway anatomy amongst various providers was identified during multidisciplinary quality assurance reviews of Code Blue events at our institution after difficulties arose in the management of two patients with laryngectomies within a 12-month period. In one patient who suffered a cardiopulmonary arrest after total laryngectomy, oral intubation was the initial approach taken by the resuscitation team. During this review it became apparent that there was a lack of understanding of airway anatomy amongst many inpatient caregivers of these patients. Furthermore, communication between the airway experts (otolaryngologist-head and neck surgeons) and primary Code Blue responders (nurses, medical internists, anesthesiologists, general surgeons, and respiratory therapists) is limited by nonstandardized terminology, the rushed pace, and inherent confusion of these events.

Because of the occurrence of these cases, a multidisciplinary team including faculty from the University of California, San Francisco Departments of Otolaryngology-Head and Neck Surgery; Anesthesia and Perioperative Care; and managers of the Departments of Nursing, Respiratory Care Services, and the UCSF Medical Center Performance Improvement staff initiated a quality improvement project designed to improve emergency airway management in patients who have previously undergone surgical alteration of their upper airway, typically tracheotomy or laryngectomy.

The multidisciplinary team created a survey to assess the hospital staff's knowledge of emergency airway access in patients with surgically altered airways (tracheotomy or laryngectomy). After analysis of survey results and review of Code Blue records, a pilot program was introduced to improve knowledge of emergency airway management of these patients amongst inpatient caregivers. The program consisted of instructional lectures to relevant caregivers (anesthesiologists, general surgeons, internal medicine physicians, nurses, and respiratory therapists) and introduction of a bedside form to identify the altered airway. Since the difference between a tracheotomy and laryngectomy may not immediately be obvious to emergency responders, the bedside Emergency Airway Access form was developed to improve awareness and facilitate communication during emergency situations.

Figure 4 demonstrates that preintervention, 37% of medical internists and 19% overall, did not understand that laryngectomy patients no longer have an oral or nasal airway. There was an overall improvement of laryngectomy airway anatomy knowledge in the intervening 24 months. There was also an overall improvement in the understanding that tracheotomy patients can be ventilated orally if the tracheotomy tube is cuffless or deflated (Figure 5). Figure 6 confirms that the majority of caregivers appreciate the danger of blind tube reinsertion in “fresh” tracheotomies. Figure 7 reveals that less than half of caregivers knew to discontinue the futile ventilation of a dislodged or plugged tracheotomy tube and to deflate the tracheotomy cuff for oral ventilation. In addition, nearly half of respondents did not know the purpose of “stay sutures” in a new tracheotomy wound in the event of accidental tube dislodgement (Figure 8).

The results of the pre- and postintervention surveys were compared and analyzed for statistically significant changes. No statistically significant differences (P > .05) could be appreciated using the Mantel-Haenszel Chi squared test.

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 (Figure 1). 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 (Figure 6). However, this knowledge does not always translate into clinical application. For instance, Figure 7 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 (Figure 8). 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.