|Submitted By: Matthew Popovich / American Society of Anesthesiologists|
|Data Element Information|
|Use Case Description(s)|
|Use Case Description||Level 2 - Features of airway management are commonly used by anesthesiologists to understand patient needs and potential complications that patients may encounter when anesthesia is administered or tracheal intubation is required. Outside of the operating room, airway management is used in emergency departments, critical care units, and in non-operating room anesthetizing locations where the delivery of anesthesia or tracheal intubation is a possibility.
The collection of airway management information in Health System A may occur as a combination of the following: a procedure note, an element of the anesthesia record, as part of respiratory therapy documentation. Often, when a patient is cared for in Health System B for anesthesia, prior anesthesia records are requested specifically, in part, to ensure prior airway management was not difficult.
The critical use case that strongly supports the adoption into the USCDI is the difficult airway. For a variety of reasons, patients who have experienced difficult airway management in the past may not be aware of those difficulties, and it would be unreasonable to assume most patients would have enough baseline understanding of medical terminology to pass along the key elements of airway management that led to successful tracheal intubation. Knowledge of prior difficult airway management may lead to different care decisions by providers in the emergency room, intensive care unit, or operating room and mitigate risks to patient harm. This has been documented in the literature and citations can be provided.
|Estimate the breadth of applicability of the use case(s) for this data element||Level 2 – elements pertain to most or all patients, providers or requestors.
Any patient that has undergone prior surgery, anesthesia, or has had prior airway management in the emergency department or intensive care unit.
Anesthesiologists, Certified Anesthesiologist Assistants, Certified Registered Nurse Anesthetists, Emergency Medicine Physicians, Critical Care Physicians, Surgeons, Respiratory Therapists
|Use Case Description||Airway management includes a number of assessments, including whether the patient is at risk for, or has previously demonstrated, a difficult airway. Because “difficult airway” is subjective to the physician or clinician attempting to intubate the patient, a general element of airway management is more important for information exchange between physicians, clinicians, and other members of the patient’s care team.
We recommend that airway management include: Difficult tracheal intubation, Difficult facemask or supraglottic airway ventilation, Difficult supraglottic airway placement, difficult larynogoscopy, failed intubation, Mallampati score, Video intubation, intubation techniques, anesthesia type, direct laryngoscopy Cormack-Lehane grade. Because of the potential subjectivity associated with difficult airway designation, a simpler approach would be simply to include any airway management previously performed rather than attempting to isolate those cases in which “difficulty” was experienced.
|Estimate the breadth of applicability of the use case(s) for this data element||Anesthesiologists, Certified Anesthesiologist Assistants, Certified Registered Nurse Anesthetists, Emergency Medicine Physicians, Critical Care Physicians.
ASA does not track the total number of operating room cases where an airway was assessed. Likewise, we cannot provide a specific number of cases where Anesthesiologists, Certified Anesthesiologist Assistants, Certified Registered Nurse Anesthetists, Emergency Medicine Physicians, Critical Care Physicians would access airway management data or complete documentation related to airway management.
|Maturity of Use and Technical Specifications for Data Element|
|Applicable Standard(s)||Difficult tracheal intubation:
Difficult mask ventilation:
Video intubation: (glidescope)
Difficult supraglottic airway ventilation
The Pre-Procedure Anesthesiology Domain Analysis Model and Implementation Guide contains technical specifications relevant to airway management and difficult airway; the Intraprocedure Anesthesia Domain Analysis Model has been published as well and an Implementation Guide is forthcoming.
|Current Use||Extensively used in production environments|
Level 1 – Most, if not all Anesthesia Information Management Systems (AIMS) and Electronic Health Records allow physicians and other clinicians to assess and document a patient’s airway. We believe that adding airway management elements will foster greater standardization in data elements between physicians and other clinicians.
We note that both the Anesthesiology Preprocedural and Intraprocedural Domain Analysis Models (and Implementation Guides for Preprocedural) have been published by HL7 (in 2013 and 2020, respectively), but neither has (to our knowledge) achieved implementation by EHR systems to date. Therefore, each EHR system approaches documentation to airway management in what would be considered to be an unstructured or less constrained use.
At the present time, airway management is not specifically shared or exchanged using structured terminology. However, elements of airway management may be shared between EHR/HIT system. Many EHR/HIT users have a process to update a patient’s history of difficult airway. This information can also be shared as a problem list or text comment within an “anesthesia complication” data element.
In addition, as previously noted, the Preprocedural and Intraprocedural Domain Analysis Models and a Preprocedural Implementation Guide for Anesthesia have been published by HL7, but they have not yet achieved implementation by EHR systems to date. Inclusion of this element in USCDI may drive EHR systems to develop these IGs in order to meet the requirements for interoperable exchange of this and other data elements covered by these IGs.
|Extent of exchange||N/A|
|Restrictions on Standardization (e.g. proprietary code)||Airway management includes both an assessment of the patient’s airway as well as difficulties that a physician or other clinician may have when intubating the patient. We believe there are different interpretations of “difficult airway” as one physician and/or clinician may have difficulty in intubating a patient while another physician or clinician may have little problem in intubating the same patient. At the same time, we believe that information can be shared that indicates an “easy airway” (i.e., the opposite of a “difficult airway” scenario). Conveying that information among physicians and other clinicians is important but may not be fully communicated between providers.
For example, the Cormack-Lehane (CL) grading is defined as best view of the glottis during direct laryngoscopy but is, in our experience and to our knowledge, universally documented to indicate the view with any/all equipment, including video-assisted or optically-assisted intubation devices (Glidescope, C-MAC, AirTraq, to name a few examples.) When a physician or clinician views that information, they would make their own assessment as to how the grade was assigned based upon the equipment used and make a determination of the equipment they may need to appropriately intubate the patient.
|Restrictions on Use (e.g. licensing, user fees)||We are unaware of any restrictions on the use of this data element.|
|Privacy and Security Concerns||None|
|Estimate of Overall Burden||How hard is it to access and provide the data? Is it only available in an outside system, such as a lab reporting system? The data element may reside within a separate anesthesia information management system, electronic health record, or an enterprise system.
Does it need to be calculated by the patient or provider, or can it be automatically retrieved or calculated by the system in a production environment? Elements of airway management are assessed by each individual provider. There is no electronic means to assess a patient’s airway or otherwise calculate risk.
Does it require significant time on the part of patient or provider to access or record or does it require an interruption in normal workflow to capture? Assessing a patient’s airway is part of routine workflows and the inclusion of this data element would not significantly alter a physician’s or other clinician’s workflow.
Does it require significant developer time to implement in EHR systems? We do not expect that implementation would cost significant developer time. The burden to implementation is low so long as the systems responsible for interoperating with this information are systems in which the provider routinely documents their care. We recognize that some ambulatory surgery centers may still have anesthesia records on paper even though other documents may be stored in an EHR. In those cases, documentation would not be feasibly collected for interoperability purposes.
|Other Implementation Challenges||We do not see any other significant challenges to implementation.|
Narrative patient data relevant to the context identified by note types.
Patient history and assessments performed by healthcare providers which are used to identify airway management techniques used and potential complications. These elements are important for any patients undergoing airway management, whether in the emergency department, in the intensive care unit, or in the operating room for elective or emergent surgical procedures with anesthesia.