Operations and outcomes of a Hospital-wide Emergency Airway Response Team (HEART) in a quaternary academic children’s hospital.

Edition: September-October 2021

Venkatachalam SJ, Garcia-Marcinkiewicz A, Giordano R, et al. Paediatr Anaesth. 2021;31(10):1105-1112. doi:10.1111/pan.14249

Background

This article looks at the outcome of emergency airway interventions and incidence of airway complications before and after the creation of a formal hospital emergency airway response team (HEART) in a specialist paediatric hospital.

Design

Retrospective cohort study. Single site. Study period January 2017 to December 2019

HEART: Multidisciplinary team (anesthesiology, ICU physicians, otorhinolaryngology surgeons, respiratory therapists & nurses) established in 2014.

The team was accompanied by a clinical pathway containing guidance on suitable triggers, airway management etc based upon by whom and where the child was being managed as well as their clinical condition.

Primary outcome: Adverse Airway Outcomes (AAO) – either oxygen desaturations (SpO2 <80%) or adverse tracheal intubation-associated events (TIAE) e.g., cardiac arrest, aspiration, oesophageal intubation, trauma etc.

Secondary outcomes: individual components of AAOs and process metrics including number of advanced airway insertion attempts and successful advanced airway placement.

Outcomes measured before and after arrival of HEART to patient.

Results

  • 96 (91 children) HEART activations: NICU 36; PICU/CICU 35; ED 14; Wards 11
  • Median age 7 months
  • “Airway anomalies” 62%
  • New (< 7 days) tracheostomy 9%. Mature tracheostomy 5%
  • Night-time (1900-0700) 46%
  • Median time to arrival 5mins

Advanced airway management:

Before HEART arrival

    • Intubation needed: 42 (84%) à 21 (50%) successful
    • Resiting tracheostomy: 3 (6%)à 2 successful.
    • Supraglottic airway (SGA): 5 (10%) à all successful.
    • Advanced airway management = overall 56% success rate


After HEART arrival

    • Total 56 (58%) needed advanced airway management.
    • 22 (23%) required no intervention (successfully managed before arrival).
    • Intubation needed: 46 (82%) à 43 (94%) successful
    • Resiting tracheostomy: 6 (11%) à all successful.
    • SGA: 4 (7%) à all successful.
    • 3 (6%) unsuccessful intubations all rescued with either SGA or bag mask ventilation until airway secured in theatre.

The HEART team were also more likely to successfully intubate at first attempt (pre-HEART 44/42 (26%) vs. post 33/46 (72%) p<0.001) and on average required fewer attempts to successfully intubate (pre-HEART 3 vs. post 1, p<0.001). ≥3 attempts more common before HEART arrival (pre-HEART 14/42 (33%) vs. post 9/46 (20%), p=0.15).

Adverse Airway Outcomes (AAO):

  • pre-HEART 56/96 (58%) vs. post 28/96(29%) absolute risk (AR) difference 29% (16-41%), p<0.001.

O2 desaturations:

  • pre-HEART 46/96 (48%) vs. post 24/96 (25%) AR difference 23% (11-35%), p=0.02.

Adverse TIAE:

  • pre-HEART 18/96 (19%) vs. post 7/96 (7%) AR difference 11% (2-21%), p<0.001.


Comments

Emergency care by the HEART team was associated with significant improvements in airway care as judged by successful airway interventions and reduced associated complications.

The HEART team and guidelines system has been established since 2014 so there was no “learning curve” for practice during the study period. In addition, experienced team members are on site, thus minimising delay in response and delivery of skilled care. This may not be the case in every hospital and so caution should be exercised when hoping to directly and immediately translate such significant benefits to a different hospital when establishing a similar system.

Reviewed by H. Hack

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