Organizational Factors
Garrett S. Pacheco
Michael J. Lauria
Peter G. Brindley
“By failing to prepare, you are preparing to fail.”
—Benjamin Franklin, 1706-1790
“Who is in charge of the clattering train?
The axels creak, and the couplings strain.
For the pace is hot, and the points are near,
And sleep hath deadened the driver’s ear;
And signals flash through the night in vain.
Death is in charge of the clattering train!”
—Edwin James Milliken, 1890
INTRODUCTION
When humans and their systems exceed their limits, disaster follows: it is just a matter of time or volume. Over a century ago, Milliken’s poem was relevant when a train crashed due to poor working conditions. Half a century on, it was repurposed by Winston Churchill to explain the cultural failings that led to World War II. Fast forward, another 50 years and it remains relevant for modern organizations and even airway disasters. This poem will continue to be relatable until we humbly accept that systems “produce the results they were designed to,” and that “safety really is no accident.”
Chapter 39, ‘Human factors’ introduced the importance of human factors (HFs), and offered practical insights at the individual and team levels. This chapter continues that journey by addressing the macro, namely the environment and the organization. Like many things in medicine, major improvements come from leveraging every minor improvement, and at every level. Patient safety and practitioner resilience is a deliberate and endless commitment from bedside to boardroom. It happens when we put patient welfare at the center of all we do, share responsibility, and commit to continuous iterative improvement.
Returning to the poem, it is easy to compare a pressured intubation to a clattering train, with people in peril and workers straining to prevent death. After all, despite all of our technologic advances, it can still be unclear who is in charge. Moreover, “red flags” can still go unnoticed, and technology can falsely reassure. What is less readily apparent is that behind the frontlines, others are expected to create and maintain those systems. In other words, even a clattering train needs fail safes, redundancies, and standard operating systems.
Systems need to be made deliberately resilient and reliable because individuals and teams won’t always be. Often, organizational change is a longer-term project, but it is informed by similar human factors ideals, namely nontechnical expertise. Moreover, because health care is increasingly delivered within networks, we should leverage every opportunity to streamline how we manage airways across organizations. Get this right and we protect patients and engage professionals. Get it wrong and we imperil patients and burnout professionals.
CLINICAL PRACTICES GUIDELINES
Clinical practices guidelines (CPGs) can offer a common framework, a common language, and a predictable roadmap for every team member. Done right, CPGs provide the boat, the oars, and the finish line, and the result is that we all row in the same direction. This common framework and understanding of how to address airway problems means practitioners have a shared mental model (SMM). CPGs facilitate SMMs, and hence allow teams to perform better in high-stress,
time-sensitive, environments.1 In psychological language, we achieve overlapping cognitive representations. In plain language, we are on the same page and know what needs to happen, how it needs to happen, and when. CPGs allow a sequence for quick, implicit action, and less need for debate. Increased clarity of purpose also means that team members are better able to anticipate others’ needs.2,3 Not surprisingly, having clear SMMs and CPGs is a key strategy in maximizing patient safety.4
time-sensitive, environments.1 In psychological language, we achieve overlapping cognitive representations. In plain language, we are on the same page and know what needs to happen, how it needs to happen, and when. CPGs allow a sequence for quick, implicit action, and less need for debate. Increased clarity of purpose also means that team members are better able to anticipate others’ needs.2,3 Not surprisingly, having clear SMMs and CPGs is a key strategy in maximizing patient safety.4
CPGs offer familiarity, which is also important given high staff turnover and increasingly large intensive care units (ICUs). As outlined in the previous human factors chapter, this should not replace thinking and should not prevent matching the right airway strategy to the right patient. Regardless, structure can eliminate the need to start from scratch each time. It removes the need to repeatedly explain the fundamentals of airway management such as “Why flush rate oxygen?” “Why prepare norepinephrine for a normotensive patient?” “Why does the airway cart need to be within eyesight?” CPGs also subdivide the process into manageable chunks. In regards to airway management for the critically ill, we suggest four key steps: preoxygenation, hemodynamic optimization, equipment, and extubation (Table 40.1).
TABLE 40.1 Key Steps to Airway Management for the Critically Ill | ||||||||
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DRUG ORGANIZATION
There is no single universal airway drug. Accordingly, we need to ensure practitioners have all they need, but not so much that they become overwhelmed. Much like CPGs, having standardized drug boxes can decrease stress, decrease delays, and free up cognitive space for other decisions. These drug boxes should be prepackaged and located near where airway management occurs, which usually means the ED/ICU drug dispensary (e.g., Pyxis). They should include induction agents (etomidate, ketamine, fentanyl), neuromuscular blocking agents (succinylcholine, rocuronium), plus phenylephrine, or another vasoactive agent that can be administered to treat peri-intubation hypotension (e.g., epinephrine or norepinephrine). In addition, “awake tracheal intubation” kits
should include 4% aqueous lidocaine, an atomizer to assist with topicalization, plus 5% lidocaine ointment, a tongue depressor, glycopyrrolate, as well as ketamine, and dexmedetomidine.
should include 4% aqueous lidocaine, an atomizer to assist with topicalization, plus 5% lidocaine ointment, a tongue depressor, glycopyrrolate, as well as ketamine, and dexmedetomidine.
AIRWAY CARTS
Intubation teams need their equipment readily available and rationally arranged. Most airways will be routine and hence standard equipment should be front and center. However, despite appropriate airway planning, airways can still be difficult, and this difficulty can be unanticipated.5 This means that rescue devices (and rescue drugs) need to be in obvious places and easy to deploy. In the past, “difficult airway carts” were reserved for select patients: in other words: “do you really think you will need the difficult airway cart nearby, doctor?” This sort of thinking misses the point: all airways can be difficult and our difficult airway prediction tools are imperfect. In short, always be prepared for difficulty by having the airway kit nearby.
These “difficult airway carts” are actually misnamed. A better term would be “comprehensive airway carts,” thereby emphasizing that all critically ill patients could have a difficult airway. Airway teams should have everything they might need in one place, and, just as importantly, should only need to familiarize themselves with one hospital-wide cart. Once again, the idea that you only locate the difficult airway cart once you are already experiencing difficulty is counterintuitive. Hyperbole aside, this type of thinking is why “failing to prepare is like preparing to fail” and why it is better to avoid difficulty rather than presuming that you can always get out of trouble. Comprehensive airway carts should be within eyesight for every intubation, and every ED and ICU should have their own cart. An airway cart should contain items listed in Table 40.2.
TABLE 40.2 Comprehensive Airway Cart Suggested Contents | |||||||||||
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While the airway cart should contain all necessary implements, it should not contain every possible device. It should be limited to a range of strategically chosen equipment because this maintains cognitive bandwidth and minimizes delays.6 An overabundance of equipment options leads to what psychologist Barry Schwatz calls, “the paradox of choice.”7 Access to every airway device is likely to increase cognitive load, thereby prolonging response time. In fact, in stressful circumstances individuals can become completely overwhelmed by choice that they experience “analysis paralysis”: no choice is made and no action is taken.8 When it comes to difficult airway equipment, less is more.9
We should avoid duplication. In other words, select one device if two perform essentially the same function. We should also prioritize equipment that addresses an especially perilous situation (e.g., the cric kit, for the “cannot intubate, cannot oxygenate” [CICO] situation, must be easy to find). Determining what is truly essential means asking practitioners beforehand and practicing afterward. This is because many of us have beloved pieces of equipment and idiosyncratic practices. We need to find the balance between allowing diverse inputs and achieving a single output: a safely intubated patient.
We do not want practitioners to feel underequipped, nor insufficiently listened to. They should understand that limiting equipment reduces clutter and makes each piece more visible. In so doing, a well-organized cart prompts practitioners to access and deploy the equipment quickly. We do not want anyone rummaging through a crowded cart while the patient deteriorates and the team becomes frazzled. Standardization also decreases choice fatigue: the deterioration in the quality of successive decisions if we feel drawn to trial every option; however inappropriate.10 Airway carts that are logically organized can also mitigate situations like those reported by Schnittker and colleagues. They found that not having equipment visible meant clinicians failed to even think about certain devices as potential rescue options.11
Color coding, including brightly colored drawers, facilitates visual recognition, faster access, and more logical organization.12 It should also reduce errors in terms of equipment retrieval.13 We should also use colors that correspond to familiar social constructs; for example, red indicates “emergency,” “warning,” or “stop.” Accordingly, we recommend that the emergency front-of-neck access (eFONA) equipment be in a red drawer.14,15,16
Airway carts should be organized in a way that logically follows the difficult airway algorithm.17 For example, drawer one often has intubation equipment; drawer two rescue oxygenation via supraglottic airway device; drawer three might have equipment and adjuncts for flexible endoscopic intubation; drawer four facilitates facemask ventilation, and drawer five has equipment for eFONA.10,17 Labeling should be large, clear, and consistent. Memory/cognitive aids and algorithms should be clearly visible.10
Limiting the range of equipment also reduces the number of techniques the airway team members must learn and practice. In doing so, airway carts are not just a place to store equipment; they are a strategy to increase competency, efficiency, and cohesion. We must practice regularly, with the very same equipment that we use, and ideally in the same teams.
As outlined, stress and unfamiliarity can impair decision making, worsen situational awareness, and increase task fixation.18 In other words, if an airway disaster progresses, it is not just the patient who is in peril, teamwork is too. The need to leverage every cumulative advantage brings us to the importance of airway preparation and communication.
PREPARING FOR THE DIFFICULT AIRWAY, AND COMMUNICATING THIS TO OTHERS
The Fourth National Audit Project (NAP4) scrutinized over 300 hospitals. It found that a quarter of airway-related adverse events resulted in brain damage and death.19 When random cases were further dissected, all were found to have some aspect of poor planning and/or communication.19,20 For example, half of the major airway complications identified in NAP4 were in patients anticipated to have a difficult airway, and many had had a previous airway issue. A history of airway difficulty is a very useful, albeit imperfect, predictor of higher risk for both intubation failure and peri-intubation cardiac arrest.21 Which brings us to the woeful state of airway documentation.
Fortunately, a number of NAP4 patients who experienced an adverse event had medical documentation identifying them as a high-risk airway. Unfortunately, only a third of patients had been informed about their difficult airway, either verbally or in writing.22 In other words, it is important to devote time to a brief preemptive airway history, and a targeted examination, but also to document and share the particulars. This should be obvious, but it does not help the patient if they are not told, and does not help the intubator if they do not know. It also does not really help the future intubator if all they know is that there was “nonspecific difficulty.” We need more documentation, more specific documentation, and it needs to be shared.
Strategies include adding “difficult airway” to a patient’s problem list; having patients wear a medic alert bracelet, and having a large sign over the bed. Again, though, each of those warnings needs to include specifics that is, were the difficulties with laryngoscopy; facemask ventilation; supraglottic airway ventilation, or eFONA?23 The signs can also recommend a care plan. For example, an airway expert might suggest “awake tracheal intubation” for the patient with an airway malignancy. This would be especially helpful if there was accompanying documentation outlining the difficulty with facemask ventilation, laryngoscopy, and supraglottic airway ventilation.
In addition to signs for patients with difficult airways, specific alerts are recommended for specific situations. For example, the National Tracheostomy Project has already developed signs for the bedside of patients with fresh tracheostomies and laryngectomies. These save having to fish through the chart. They also outline why the tracheostomy was performed, how it was performed (surgical or percutaneous), when it was performed (so that clinicians know stomal maturity), if there are any sutures in place (and what these do), and if there is any difficulty with the upper airway (and how this was managed).24
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