When anesthesiologists manage airways in a remote setting, there is an added degree of complexity due to unfamiliar surroundings. A closed claims analysis of airway cases outside of the OR from 2000-2017 (conducted by our team using data from the Anesthesia Quality Institute) found that the two highest-risk locations for airway events were the intensive care unit (ICU) (46%) and emergency department (ED) (34%), consistent with past literature (Br J Anaesth 2011;106:632-42). The primary damaging event in these claims was attributed to difficult intubation (28%), esophageal intubation (28%), inadvertent extubation (16%), patient condition (16%), other airway device (8%), and other equipment (4%). Past studies have demonstrated that remote airway management poses high risks. Bowles et al. found that not only did 39% of patients in their investigation suffer an adverse event, but adequate equipment was often not available for practitioners (Br J Anaesth 2011;107:687-92). Russotto et al. reported that the most common adverse events include cardiovascular instability (43%), severe hypoxemia (9%), and cardiac arrest (3%) (Eur J Anaesthesiol 2022;39:463-72).

Airway management outside the OR may be needed in the trauma ward or ICU, or during cardiopulmonary arrest. Anesthesiologists may also be expected to serve as backup to other services that intubate patients. Delineation of responsibility may vary widely between institutions, and in some hospitals the anesthesia team may only be called for backup or difficult airways. In some institutions, a certified registered nurse anesthetist (CRNA) and/or resident might be responsible for floor intubations, with an attending anesthesiologist being either present or immediately available. Regardless of the potential variations, it is important for anesthesiologists to understand their responsibilities in a particular practice and potential patient safety hazards that may be present.

Figure 1 categorizes several important factors that may impact the safe management of airways outside the OR. The first category is the decision-making regarding patient management, including placement of an endotracheal tube. Does the primary service determine if a patient should be intubated or does this responsibility rest with a consulting service? Who orders the ventilator settings and sedation? Is the intubation truly “emergent” (e.g., the patient is decompensating) or “urgent” (pending respiratory failure)?

Figure 1: Potential safety concerns regarding airway management outside of the OR, by category, with sample considerations in each category.

Figure 1: Potential safety concerns regarding airway management outside of the OR, by category, with sample considerations in each category.

Close modal

In addition, equipment and resource availability is critically important. Does the anesthesia team have access to advanced airway equipment such as videolaryngoscopes? Does the anesthesia team bring necessary equipment with them? Does the respiratory therapist bring a ventilator bedside? Is adequate suction available? Can the patient be repositioned to improve intubation success? Does the patient need an awake fiberoptic intubation that requires relocation of the patient to the OR?

The next important category is backup personnel. Often, when a clinician struggles with an airway in the OR, colleagues are available for rapid consultation and assistance. The anesthesiologist may not be afforded such luxury in remote locations. Anesthesiologists should also consider the availability of clinicians to perform a tracheostomy following failure of airway management.

Follow-up of care is also an important consideration for the anesthesiologist after successful airway management; this may involve leading resuscitation and/or ordering further diagnostic testing. Consideration should be given to response times for airway emergencies far from the OR. If the children's hospital, for example, is in an adjacent building, would it be more prudent to assign a group of clinicians who are geographically closer to manage airway emergencies there? Similarly, if specialized teams (such as pediatric anesthesiologists) are on home call, what is a reasonable expected response time for emergent pediatric airway management?

Finally, should anesthesiologists be backup airway managers, standing by to assist airways primarily managed by another service? For example, should anesthesiologists respond to airway emergencies in the trauma bay initially managed by emergency department personnel, called in to help if the primary attempts fail? Repeated intubation attempts may result in bloody and edematous airways. Further complicating matters, attending anesthesiologists may be asked to supervise residents or other providers whose skill levels may be difficult to ascertain.

What can be done to minimize the patient safety risk presented by airway management outside of the OR? Ensuring adequate teamwork via improved communication, adequate training, and use of a checklist have been shown to be effective (BMJ Open Qual 2021;10:e001448; Chest 2005;127:1397-412). We propose the following to help facilitate the safety of non-OR intubations (Figure 2):

  1. Planning: Planning should be performed by leadership prior to the initiation of airway management services, ensuring clear role delineations and expectations during and after the intubation. There should be guidance for which airway emergencies anesthesia personnel must respond to and in what locations. A reasonable response time should be established. Management of airway equipment should also be clearly delineated.

  2. Clinical decision-making: Upon arrival to the airway emergency, the anesthesiology team (along with the clinical team) should assess whether the airway is truly emergent or if there is time for additional safety checks and assessments (Ann Med Surg 2022;80:104284). Decision-making to move the patient to the OR for a difficult airway must also occur. Airway plans and backup airway plans should be made efficaciously.

  3. Checklists: Checklists are used in health care to avoid missed information and improve patient safety. In the stressful, nonroutine situation of non-OR intubations, we propose the use of a quick checklist prior to intubation. Depending on the time available, we propose the “Urgent” versus “Emergent” pathway. Just as in the OR before inducing a patient, the clinician should plan appropriately. Resources can be made available, including medications and advanced airway equipment. Staff should be assigned as needed to respond to airway emergencies, and residents/CRNAs/certified anesthesiologist assistants should have backup immediately available. Airway intubations during emergencies offer challenges such as unfamiliar surroundings, lack of accessible equipment, and critically ill patients.

Figure 2: An algorithm for the management of airway emergencies outside of the OR, including advance planning, clinical decision-making, and procedural checklist.

Figure 2: An algorithm for the management of airway emergencies outside of the OR, including advance planning, clinical decision-making, and procedural checklist.

Close modal

A structured approach with careful planning is necessary to successfully navigate the challenges associated with airway management outside of the OR. Limited data show that difficult airways and esophageal intubations lead to the most frequent complications that then lead to closed claims. The algorithm presented may assist with decision-making regarding these complex clinical scenarios.

George Tewfik, MD, MBA, FASA, ASA Committee on Patient Safety and Education, ASA Committee on Quality Management and Departmental Administration, Associate Professor of Anesthesiology, and Director of Quality Assurance, Rutgers New Jersey Medical School, Newark, New Jersey.

George Tewfik, MD, MBA, FASA, ASA Committee on Patient Safety and Education, ASA Committee on Quality Management and Departmental Administration, Associate Professor of Anesthesiology, and Director of Quality Assurance, Rutgers New Jersey Medical School, Newark, New Jersey.

Close modal

Karolina Brook, MD, FASA, ASA Committee on Patient Safety and Education, Assistant Professor of Anesthesiology, Boston University Aram V. Chobanian & Edward Avedisian School of Medicine, and Director, Quality and Safety, Department of Anesthesiology, Boston Medical Center, Boston, Massachusetts.

Karolina Brook, MD, FASA, ASA Committee on Patient Safety and Education, Assistant Professor of Anesthesiology, Boston University Aram V. Chobanian & Edward Avedisian School of Medicine, and Director, Quality and Safety, Department of Anesthesiology, Boston Medical Center, Boston, Massachusetts.

Close modal

Linda Laham, MD, PGY-4 Anesthesiology Resident, Rutgers New Jersey Medical School, Newark, New Jersey.

Linda Laham, MD, PGY-4 Anesthesiology Resident, Rutgers New Jersey Medical School, Newark, New Jersey.

Close modal