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Use Your SMARTs (Some Kind of Multidisciplinary Airway Response Team) for Emergent Airway Management Outside the Operating Room

Joffe, Aaron M. DO

doi: 10.1213/ANE.0000000000000723
Editorials: Editorial

From the Department of Anesthesiology and Pain Medicine, University of Washington, Harborview Medical Center, Seattle, Washington.

Accepted for publication January 15, 2015.

Funding: None.

The author declares no conflicts of interest.

Reprints will not be available from the author.

Address correspondence to Aaron M. Joffe, DO, Department of Anesthesiology and Pain Medicine, University of Washington, Harborview Medical Center, 325 Ninth Ave., Box 359724, Seattle, WA 98104. Address e-mail to

“Whoo-hoo-hoo, look who knows so much. It just so happens that your friend here is only MOSTLY dead. There’s a big difference between mostly dead and all dead. Mostly dead is slightly alive. With all dead, well, with all dead there’s usually only one thing you can do.”

Miracle Max (Billy Crystal), The Princess Bride 20th Century Fox, 1987

Performing high-quality advanced cardiac life support for in-hospital cardiac arrest requires a large and diverse team of responders. Notified via a universal paging system, the resuscitation team generally includes a designated leader, airway managers, bedside nurses for drug administration and phlebotomy, pharmacists to prepare and distribute medications, several individuals to perform chest compressions, and a data recorder. In recognizing this complexity, the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care make specific recommendations for teamwork and leadership training.1 Such training enhances emergency management by improving communication, increasing guideline adherence, and reducing medical errors.2 In sum, when a patient is “all dead,” a massive, well-coordinated, resource-intensive response is our best chance to reverse the condition and make them “alive.”

Paradoxically, current literature has paid little attention to a coordinated response for when the patient is “mostly dead.” Such is the case with impending respiratory failure requiring intubation where hypoxia and/or hypercapnia will lead to full cardiopulmonary arrest. Most anesthesiologists agree that emergency airway management outside the operating room (OR) is more difficult than during induction of routine endotracheal anesthesia.3–7 Airway-attributable morbidity such as hypoxemia, hypotension, esophageal intubation, and aspiration is high,3–6 and hypoxemia-driven cardiac arrest during emergency tracheal intubation occurs in as many as 3% of patients.7 Moreover, airway-attributable morbidity can cause lasting harm. In the most recent American Society of Anesthesiologists Closed Claims Project, out-of-OR airway management claims universally resulted in death.8 Of the 184 reported airway events in the Fourth National Audit Project by the United Kingdom’s Royal College of Anaesthetists, nearly 20% occurred in either the intensive care unit or the emergency department and almost two-thirds directly resulted in death or permanent neurologic injury.9

In this issue of Anesthesia & Analgesia, Mark and colleagues10 from Johns Hopkins describe the genesis and implementation of a Difficult Airway Response Team (DART) to improve the quality of emergency airway management outside the OR. Only one other study has described such an approach. In a 600-bed trauma center, Long and colleagues11 used a R3P3, “Right People, Right Parts, and Right Place,” methodology to create policies for optimizing difficult airway management. These policies addressed identification of the difficult airway, creation and implementation of a DART (called the “alpha team”), and education of the hospital staff regarding the process changes. However, the level of detail in the report by Long et al.11 was insufficient to enable the reader to develop their own DART.

The greatest contribution of Mark and colleagues10 is to describe in detail their preimplementation out-of-OR emergent airway management model: how the hospital recognized the need for the DART, who developed it, detailed specifics of its operation, and how DART performance was monitored. The authors additionally provide a thorough description of how the staff was educated, including in situ simulation and written DART case examples. The amount of detail and degree of thought invested in the DART described by Mark et al.10 are impressive.

But, should every institution create a DART? As the authors acknowledge, generalizing their program to other institutions may not be straightforward. Before instituting the DART program, emergent airways at Johns Hopkins were managed by a more traditional code team, which included a senior anesthesiology trainee. Equipment was noncentralized. Basic airway equipment was contained in the code cart, while more specialized airway equipment such as extraglottic airways, bougies, and airway-related medications were carried in a backpack by the anesthesiology trainee. Attending anesthesiologists, surgeons, and more advanced equipment were available but required additional phone/pager communication and precious time to mobilize. Insofar as 65% of all airways managed by the DART were secured using direct laryngoscopy, an Eschmann gum elastic bougie, or a video laryngoscope (all available before a DART call); perhaps the greatest benefit of the DART was simply to systematize the arrival of multiple experienced personnel. Indeed, 2 prior studies have reported that supervision of trainees by an attending anesthesiologist lowers the chance of airway-related complications.4,12

Intubation procedures and airway consults will generate billing. However, DART-related revenue is likely to be modest at best. In King County, Washington, where my institution is located, 2014 Medicare payment for an anesthesia consult (CPT 99233) and emergent intubation (CPT 31500) are $109.10 and $115.61, respectively.a Thus, each DART activation could generate approximately $226. If all emergent intubations performed at my institution (average 900/year) generated the same $226, the yearly revenue could be in excess of $200,000. Without lowering the yearly operating costs as reported by Mark et al.,10 an operating shortfall of nearly $300,000 remains. Of course, a DART system for an institution the size of Johns Hopkins might cost more than an institution with fewer beds. However, many of the over 5000 registered hospitals in the United Statesb may balk at the monetary investment. To further complicate the cost-benefit analysis, difficult airway events outside the OR are low-frequency high-morbidity events. According to the American Society of Anesthesiologists Closed Claims Project, the median payment for a difficult airway claim originating in a location outside the OR in 1999 dollars was $49,050 to 2,010,000,8 which translates into $70,000 to 2,835,000 in 2014 dollars.c

Furthermore, little is known about the baseline variability in out-of-OR airway management systems in the majority of United States hospitals. Designated airway managers may have backgrounds in anesthesiology, emergency medicine, internal medicine, or respiratory therapy. Airway managers may or may not be part of a response team. Medications and equipment may be centralized or the responsibility of a single individual. Surgical airway access at the bedside or via rapid transfer to an OR may not be systematized. It is also doubtful that quality metrics surrounding these events are rigorously recorded.

Some general DART principles are clear from Mark et al.10 Institutions, no matter their size, should identify airway experts who will comprise a DART and be available 24/7. The primary training of the experts will depend on the available manpower. The team should also consist of other individuals with prespecified jobs, such as equipment delivery and setup, medication preparation and administration, and event recording. A standardized and universal notification (notify) system must be in place so that all team members can be made aware of an event. Two members of the response team should be experienced in airway management (duplicate). All equipment and medications needed for airway management should be available at the bedside (supply), ideally from centralized sources like an airway cart or Pyxis MedStation® (CareFusion Corporation, San Diego, CA), and prepared at the request of the airway managers to minimize distraction from their primary task. At my institution, convincing managers of this need is the most difficult aspect of emergent out-of-OR management. However, the reader should consider that in no other in-hospital emergency situation are the proceduralists primarily responsible for the equipment to be used and medications administered, as are clinicians who manage emergent airways. For example, when chest thoracotomy is required, the surgeon is not expected to arrive with a backpack with a variety of chest tubes and scalpels. Rather, designated procedure carts are stocked to specification and regularly checked to assure that needed equipment is available. Emergent airway management, like any other life-saving critical care procedure, should be no different. An airway management model that includes a single operator arriving to the bedside with a bag of equipment and drugs is historic at best and distracting and dangerous at its worst. Where centralization of resources is not possible, areas from which these resources are obtained should be included in the universal notification system to avoid delays associated with extra phone/pager communications. Given the variation in whom will constitute the DART and what resources and equipment they will use, all teams must be trained in the system under which they are operating (educate). Such training should include a standard protocol for contacting the OR and potentially transferring the patient for surgical airway. As with any other form of standardized advanced resuscitation training, competence should be required for inclusion and continuing participation. Simulation, workshops, Web-based learning modules, and tracking numbers of procedures are examples of ways to develop competence and maximize DART performance. Lastly, events should be recorded in real time so that they can be used to debrief team members after an activation and to define areas for improvement. An additional area of focus would be early detection of patients at greatest risk for a difficult airway before they need intubation. Risk factors for difficult intubation could be noted upon hospital admission. This information could be added to the patient record via electronic notification. Manual bedside signage or wristbands could be placed, and/or members of the DART could be notified once a particular predicted difficulty threshold is reached.

In the end, emergency airways should be performed by using Some Kind of Multidisciplinary Airway Response Team (SMARTs). To do so, the same systems-based, team-centered approach, which has been the foundation of modern advanced cardiac life support care, must be applied to situations where patients are still slightly alive to avoid the situation where they are all dead.

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Name: Aaron M. Joffe, DO.

Contribution: This author prepared the manuscript.

Attestation: Aaron M. Joffe approved the final manuscript and is the archival author.

This manuscript was handled by: Avery Tung, MD.

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a American Medical Association Code Manager®. Available at: Accessed December 29, 2014.
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b Fast Facts on US Hospitals. Available at: Accessed January 4, 2015.
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c US Inflation Calculator. Available at: Accessed January 4, 2015.
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