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Time for Hospital-Wide Standardization of Team-Based Airway Management Safety

Drew Fuller, MD, MPH, FACEP, RRT
Kenneth P. Rothfield, MD, MBA, CPE, CPPS

Drew Fuller_2017Kenneth P. Rothfield_2017Currently, most hospitals lack standardization of airway management among individual providers, teams, units or facilities. The techniques and technology employed to manage airway emergencies vary significantly depending on the provider, as well as the physical location (unit) of the patient in the facility.

Institutions have typically relied on the individual skillset of the intubating clinician with few assurances that high reliability system safety processes were in place and utilized. Specifically, few hospitals collect data on emergency airway management or have key operational safeguards hardwired such as failed airway pathways, uniform availability of comprehensive equipment, quality assurance processes for critical practices and team-based training. In the US alone, the cost of preventable patient harm in the setting of emergency airway management is estimated to be in excess of one billion dollars annually.

As a specialty, anesthesiology has taken a progressive approach to patient safety. In addition to an early recognition of the pivotal role of human factors in preventable patient harm, anesthesiologists in the OR setting have developed and implemented standardized pathways and systems for dealing with difficult or failed airways. Other specialties are beginning to embrace this degree of standardization. However, emergency departments and ICUs in the US have, for the most part, remained unstandardized. These critical areas experience a high number of difficult airways. Data from the UK has shown the incidence of failed airways can be as high as 1 in 50 in the ED and ICU settings and the occurrence of death or brain damage have been reported to be 38 fold (ED) to 58 fold (ICU) higher than in OR settings.1

We propose that standardized high-reliability safety and performance processes should be in place throughout all hospitals for airway management in the ED, ICU, and other intubation settings. In addition, we support team-based models that unify physician (anesthesiology, emergency medicine, intensive care and hospital medicine), nursing and respiratory therapy collaboration in the implementation and advancement of institutional-wide practices and resources.

We are partnering with organizations such as the Patient Safety Movement Foundation (PSMF) and professional organizations to drive the establishment of institutional standardization and hardwired safeguards. The PSMF has published an “Actionable Patient Safety Solution” focused on airway management.

The Safer Airway model is one example for practical system integration of airway management safeguards. The Safer Airway guide provides an integrated set of validated best practices and resources for a comprehensive and coordinated approach for strengthening intubation safety in hospitals regardless of size or location. Information on the guide and customizable resources are available at

It is time to move beyond system practices that rely heavily on individual ability and even heroism as the primary mode for avoiding adverse events from a difficult or failed airway. Anesthesiology, emergency medicine, critical care, hospital medicine, nursing, respiratory care and risk management should collaborate to further advance tools, resources and programs that will help all hospitals implement practical system-wide safety practices and safeguards for airway management.

Author’s note: This article first appeared in the Summer 2016 edition of the Society of Airway Management’s Airway Gazette and is reproduced for ACEP QIPS with permission.2 In response to this piece and a presentation on “Safer Airway” at the annual meeting, SAM has formed a special committee on system-wide airway management safety. To learn more about Society of Airway Management (SAM), the 20th annual meeting (Sept 14-17, Newport News, CA) or membership, please check out:


  1. Cook TM, MacDougall-Davis SR. Complications and failure of airway management. Br J Anaesth. 2012;109(S1):i68-i85.
  2. Fuller D, Rothfield K. Time for Hospital-Wide Standardization of Team-Based Airway Management Safety, The Airway Gazette. 2016;21(2)11.

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