Airway Alert Bracelets: Enhancing Safety in the COVID-19 Era : Anesthesia & Analgesia

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Airway Alert Bracelets: Enhancing Safety in the COVID-19 Era

Matthews, Laura J. MB BS, FRCA; O'Connor, Michael MB BS, FRCA; Chaggar, Rajinder Singh MB BS, FRCA; Vaughan, David MB BS, FRCA

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Anesthesia & Analgesia 131(5):p e237-e238, November 2020. | DOI: 10.1213/ANE.0000000000005165

To the Editor

At our hospital, we have a high number of patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) requiring intubation. At the peak of the crisis, we were intubating almost 1 patient per hour. To manage these patients efficiently, teams of anesthetists intubate the patients where they are, most often in the Emergency Department, and then transfer them to the intensive care unit (ICU). Our records are electronic, but because of pressures of the current crisis, handover and documentation may not be as comprehensive or immediately accessible as usual.

We are concerned that potential key information about patients with difficult airways can be missed. As mentioned in a recent letter to this publication by Berkow and Kanowitz,1 patients treated for coronavirus disease (COVID) on the ICU are at a higher risk than normal for accidental extubation and therefore requiring emergency reintubation. This is due to a multitude of factors, including higher nursing ratios and that many of our patients require regular proning—a procedure where there is significant risk of accidental extubation.2 For logistical reasons, patients are frequently moved, and a substantial number of our patients are transferred to other units for ongoing care. These actions make conventional “signs above the bed” unreliable as sole indicators of a difficult airway. Emergency reintubation is usually a time critical procedure, often not allowing for a thorough review of the patient’s notes.

We have designed a medical alert bracelet, similar to a hospital name band, that is placed on any patient where nonstandard equipment (anything other than iView video laryngoscope [Intersurgical, Wokingham, England] plus bougie) was needed to secure the airway or where the person intubating experienced difficulty (Figure). The bracelets are stocked in our intubation bags and placed on the patient immediately after intubation if difficulty is encountered. They then remain on the patient’s wrist for the duration of their ICU stay and provide a visual alert of their difficult airway, regardless of the bed space or even hospital if they are transferred for ongoing care. The presence of this bracelet on a patient prompts a review of the electronic intubation notes before undertaking any procedure where the airway could be “at risk,” and appropriate measures to be put in place—for example, a senior anesthetist with the relevant equipment present when airway alert patients are proned or deproned. In the event of an airway emergency, such as accidental extubation, the presence of the bracelet would immediately highlight the need for the rapid attendance of the most senior skilled airway physician with appropriate equipment for managing a difficult airway. With the high numbers of tracheostomies performed to aid ventilatory weaning we have also devised similar bracelets for patients with new tracheostomies, detailing the type of tracheostomy and date performed.

Disposable single use alert bracelets for patients with difficult to manage airways and new tracheostomies.

These alert bracelets have been well received within the department and are a simple way to enhance the safe care of intubated patients where standard safety measures may not be possible or reliable. While we are aware of medical alert bracelets being used to indicate patients with chronic medical conditions in the community,3 we are not aware of their use in the acute setting to maintain safety in a pressured environment.

Laura J. Matthews, MB BS, FRCA
Department of Anaesthesia and Intensive Care
Anaesthetic SpR, Northwick Park Hospital
London, United Kingdom
[email protected]
MichaelO'Connor, MB BS, FRCA
Rajinder Singh Chaggar, MB BS, FRCA
David Vaughan, MB BS, FRCA
Department of Anaesthesia and Intensive Care
Northwick Park Hospital
London, United Kingdom


1. Berkow L, Kanowitz A. COVID-19 putting patients at risk of unplanned extubation and airway providers at increased risk of contamination. Anesth Analg. 2020;131:e41–e43.
2. Matos RI, Chung KK, Benjamin J. DoD COVID-19 practice management guide; clinical management of COVID-19.Published March 23, 2020. Available at:≥technical-documents≥2020/03/24. Accessed March 24, 2020.
3. MedicAlert. MedicAlert bracelets. Soulbury, Buckinghamshire, UK.Available at: Accessed August 8, 2020.
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