Difficult airway response team: a novel quality improvement program for managing hospital-wide airway emergencies.

BACKGROUND: Difficult airway cases can quickly become emergencies, increasing the risk of life-threatening complications or death. Emergency airway management outside the operating room is particularly challenging. METHODS: We developed a quality improvement program-the Difficult Airway Response Team (DART)-to improve emergency airway management outside the operating room. DART was implemented by a team of anesthesiologists, otolaryngologists, trauma surgeons, emergency medicine physicians, and risk managers in 2005 at The Johns Hopkins Hospital in Baltimore, Maryland. The DART program had 3 core components: operations, safety, and education. The operations component focused on developing a multidisciplinary difficult airway response team, standardizing the emergency response process, and deploying difficult airway equipment carts throughout the hospital. The safety component focused on real-time monitoring of DART activations and learning from past DART events to continuously improve system-level performance. This objective entailed monitoring the paging system, reporting difficult airway events and DART activations to a Web-based registry, and using in situ simulations to identify and mitigate defects in the emergency airway management process. The educational component included development of a multispecialty difficult airway curriculum encompassing case-based lectures, simulation, and team building/communication to ensure consistency of care. Educational materials were also developed for non-DART staff and patients to inform them about the needs of patients with difficult airways and ensure continuity of care with other providers after discharge. RESULTS: Between July 2008 and June 2013, DART managed 360 adult difficult airway events comprising 8% of all code activations. Predisposing patient factors included body mass index >40, history of head and neck tumor, prior difficult intubation, cervical spine injury, airway edema, airway bleeding, and previous or current tracheostomy. Twenty-three patients (6%) required emergent surgical airways. Sixty-two patients (17%) were stabilized and transported to the operating room for definitive airway management. There were no airway management-related deaths, sentinel events, or malpractice claims in adult patients managed by DART. Five in situ simulations conducted in the first program year improved DART's teamwork, communication, and response times and increased the functionality of the difficult airway carts. Over the 5-year period, we conducted 18 airway courses, through which >200 providers were trained. CONCLUSIONS: DART is a comprehensive program for improving difficult airway management. Future studies will examine the comparative effectiveness of the DART program and evaluate how DART has impacted patient outcomes, operational efficiency, and costs of care.

Age-Related Imbalance Is Associated With Slower Walking Speed: An Analysis From the National Health and Nutrition Examination Survey.

BACKGROUND AND PURPOSE: Walking speed is an important dimension of gait function and is known to decline with age. Gait function is a process of dynamic balance and motor control that relies on multiple sensory inputs (eg, visual, proprioceptive, and vestibular) and motor outputs. These sensory and motor physiologic systems also play a role in static postural control, which has been shown to decline with age. In this study, we evaluated whether imbalance that occurs as part of healthy aging is associated with slower walking speed in a nationally representative sample of older adults. METHODS: We performed a cross-sectional analysis of the previously collected 1999 to 2002 National Health and Nutrition Examination Survey (NHANES) data to evaluate whether age-related imbalance is associated with slower walking speed in older adults aged 50 to 85 years (n = 2116). Balance was assessed on a pass/fail basis during a challenging postural task-condition 4 of the modified Romberg Test-and walking speed was determined using a 20-ft (6.10 m) timed walk. Multivariable linear regression was used to evaluate the association between imbalance and walking speed, adjusting for demographic and health-related covariates. A structural equation model was developed to estimate the extent to which imbalance mediates the association between age and slower walking speed. RESULTS: In the unadjusted regression model, inability to perform the NHANES balance task was significantly associated with 0.10 m/s slower walking speed (95% confidence interval: -0.13 to -0.07; P < .01). In the multivariable regression analysis, inability to perform the balance task was significantly associated with 0.06 m/s slower walking speed (95% confidence interval: -0.09 to -0.03; P < .01), an effect size equivalent to 12 years of age. The structural equation model estimated that age-related imbalance mediates 12.2% of the association between age and slower walking speed in older adults. CONCLUSIONS: In a nationally representative sample, age-related balance limitation was associated with slower walking speed. Balance impairment may lead to walking speed declines. In addition, reduced static postural control and dynamic walking speed that occur with aging may share common etiologic origins, including the decline in visual, proprioceptive, and vestibular sensory and motor functions.

Perioperative continuous cerebrospinal fluid pressure monitoring in patients with spontaneous cerebrospinal fluid leaks.

BACKGROUND: Elevated intracranial pressure (ICP) is an inciting factor for cerebrospinal fluid (CSF) leaks and can be measured by CSF pressure (CSFP) monitoring. Current CSFP literature is limited to the assessments of opening pressure. This study reinvestigates a previously discussed monitoring approach that evaluates continuous CSFP parameters, physiologic measurements, and treatment outcomes in patients undergoing endoscopic repair of spontaneous CSF leaks. METHODS: Retrospective review of patients undergoing endoscopic endonasal repair of spontaneous CSF leaks. All participants had a lumbar catheter placed for 24-hour continuous preoperative pressure monitoring, and 24 hours of continuous monitoring starting 48 hours after repair. In addition to patient characteristics, mean and peak CSFP, pulse waveform amplitudes (PWAs), and related parameters were calculated. RESULTS: Twenty-five patients underwent monitoring between 2004 and 2013, with a mean follow-up of 526 days. The mean age was 49.2 years, the mean body mass index (BMI) 38.5, and 8 of 25 (32%) had obstructive sleep apnea. Although mean CSFP and PWA decreased after the repair, mean peak CSFP increased by 1.56 cmH2O (1.15 mmHg). Six patients (24%) had elevation in their CSFP >25 cmH2O (18.4 mmHg) for a minimum of 4% of the recording time. Based on their continuous pressure monitoring data, 9 patients (36%) underwent treatment for high ICP, either with acetazolamide or a ventricular shunt. There were no CSF leak recurrences. CONCLUSION: Continuous perioperative CSFP monitoring provides valuable insight into multiple physiologic parameters. Systematic continuous CSFP monitoring can identify individuals in need of ICP-lowering therapy, possibly improving the outcomes in CSF leak repair surgeries.