Difficult Intubation Alert Is Associated With a Reduced Incidence of Difficult Intubation

Introduction: Difficult or failed intubation significantly increases the risk of morbidity and mortality. Documentation of a prior difficult or failed tracheal intubation is a strong predictor of future difficult intubation.

Methods: We undertook a quality improvement project to create a redesigned difficult intubation alert with increased visibility in our electronic health record. We sought to determine whether this redesigned alert would be associated with a reduced incidence of difficult intubations. After reviewing many intubation procedure notes, we chose the following criteria to define a predicted future difficult intubation: requiring an awake technique, ease of intubation procedure charted as "difficult" or "unable", procedure requiring flexible bronchoscopy, a procedure requiring three or more attempts, and intubation with a grade three or four view during laryngoscopy. Patients meeting one or more of the above criteria were included in our study. An intervention was implemented which consisted of the introduction of a new difficult intubation alert that could easily be applied to a patient's chart by anyone on the anesthesia team. Further, if the anesthesia clinician filling out the intubation procedure note charted an intubation procedure as "difficult" or "unable", they were prompted by a pop-up asking if difficult intubation should be added to the patient's problem list. If yes was clicked, the electronic alert was activated, and a large red banner appeared. Outcomes included the number of patients who had the difficult intubation label in the pre-intervention period, the number of patients who had the new difficult intubation alert in the post-intervention period, the number of records with ease of intubation procedure charted as "difficult" or "unable", the number of records requiring three or more attempts at intubation, and the number of records with grade three or four view charted at intubation.

Results: There was an expected increase in the application of the difficult intubation alert from 9% of patients with a difficult intubation label in the pre-intervention period to 38% with the redesigned alert in the post-intervention period which was statistically significant (p<0.001). In the 21 months prior to the introduction of the alert, our screening process identified 988 records as predicted difficult intubations. Of these, 672 (68%) were charted by the intubating clinician as actual difficult intubations with 32% not being recorded as difficult. During the 20 months after the end of the interim period, the screening process identified 976 predicted difficult intubations with intubating anesthesia clinicians charting 416 (42%) of them as actual difficult intubations and 58% found not to be difficult. This reduction in monthly median percent of actual difficult intubations was statistically significant (p<0.001).

Conclusions: The introduction of a difficult intubation alert at our institution was associated with a reduced incidence of difficult intubation.