To the Editor:
Clinicians frequently have problems obtaining important information about a patient’s previous medical care. In the practice of anesthesia, particularly vital information concerns the management of the patient’s airway, especially if there has been past difficulty. Such information is often unavailable when needed. According to the American Society of Anesthesiologists closed claims project database, difficult tracheal intubation is the second most frequent primary event leading to anesthesia malpractice claims.1 We present a relatively simple method to facilitate interprovider communication of the details of an individual patient’s past airway management.
A history of previous difficult tracheal intubation offers clinically suggestive evidence that difficulty may recur and it is the single most important predictor of subsequent difficult laryngoscopy.2,3 The patient, even if aware of previous difficulty, may not be able to communicate this or to recall specific details. Systems to transmit airway information that have been tried include verbal or written reports given to the patient, notes entered in the medical chart, communication with the patient’s surgeon and the primary care physician, and notification bracelets.2 Enrollment in the Medic Alert Emergency Identification Program4 or registration in a local or national database for patients with difficult airways are additional approaches for dissemination of critical information.5
This information may not be available outside of the institution in which it was generated, and bracelets, although pointing to difficult tracheal intubation, cannot transmit the details of airway management. We propose an alternative solution.
Our criteria are that the information should be accessible from the patient at all times, that it contains the details of airway management important to subsequent providers, and that it not be dependent on a particular technology. To this end, we have created a wallet-sized card with checkboxes to detail airway management, which is then laminated to provide longevity. The front and back of the card are illustrated in Figure 1. The card was created in PowerPoint 2008 for Mac, version 12.1.1, Microsoft Corp., Seattle, WA.
Once completed, the card is laminated with a pouch laminator (GBC Heatseal™ H110, ACCO brands, Lincolnshire, IL) for protection. The card is given to the patient or next of kin before discharge from the postanesthesia care unit. At the same time, the patient is formally notified about the difficulty with airway management and instructed to carry the card at all times, e.g., in the wallet. The patients are also specifically instructed to show the card to subsequent anesthesia providers.
These cards can be created locally with several different software applications and printing costs are minimal. Laminating devices are inexpensive and we deployed this system at three different sites for less than $400. Until the availability of electronic national health records or “smart” cards with magnetically stored information, the system we describe provides a simple and easily implemented way to transmit vital airway management data between providers.
Joerg C. Schaeuble, MD
James E. Caldwell, MB ChB
Department of Anesthesia and Perioperative Care
University of California, San Francisco
San Francisco, California
1. Miller C. Management of the difficult intubation in closed malpractice claims. ASA Newsl 2000;64(6):13–16, 19
2. Practice guidelines for management of the difficult airway. An updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2003;98:1269–77
3. El-Ganzouri A, McCarthy R, Tuman K, Tanck E, Ivankovich A. Preoperative airway assessment: predictive value of a multivariate risk index. Anesth Analg 1996;82:1197–204
4. Atkins R. Simple method of tracking patients with difficult or failed trachea intubation. Anesthesiology 1995;83:1373–5
5. Mellado P, Thunedborg L, Swiatek F, Kristensen M. Anaesthesiological airway management in Denmark: assessment, equipment and documentation. Acta Anaesthesiol Scand 2004;48:350–4