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.

Effect of distractions on operative performance and ability to multitask--a case for deliberate practice.

OBJECTIVES/HYPOTHESIS: To measure the effect of distractions on the operative performance and analyze if practice and experience are the factors that can help to overcome the distractions. STUDY DESIGN: Prospective observational study. METHODS: Ten postgraduate year (PGY) 2-6 residents and two faculty members from Johns Hopkins' otolaryngology department were recruited and asked to deepen the dissection at the sinodural angle on the Voxel-man mastoidectomy simulator. They were asked to perform the task under four conditions: 1) no distractors, 2) differentiation and counting of a specific alarm sound among different sounds played in the background while performing the surgical task, 3) simultaneous performance of simple arithmetic task of moderate difficulty, and 4) simultaneous performance of the task with both sets of distractors combined. RESULTS: Time taken for the task (P = .02) and error scores (P = .002) increased under the third and fourth conditions. The ability to multitask and response to surgical and cognitive tasks improved with increasing level of experience of the participants. CONCLUSIONS: Distractions lead to impaired dexterity and an increase in the incidence of errors. However, experience and deliberate practice can help achieve the ability to multitask without compromising the operative performance.