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Original Investigation |

Development of the Connecticut Airway Risk Evaluation (CARE) System to Improve Handoff Communication in Pediatric Patients With Tracheotomy

Amy Lawrason Hughes, MD1; Nicole Murray, MD2; Tulio A. Valdez, MD2; Raeanne Kelly, BSN, RN, CPN2; Katherine Kavanagh, MD2
[+] Author Affiliations
1Division of Otolaryngology, University of Connecticut, Farmington
2Division of Otolaryngology, Connecticut Children’s Medical Center, Hartford
JAMA Otolaryngol Head Neck Surg. 2014;140(1):29-33. doi:10.1001/jamaoto.2013.5550.
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Importance  National attention has focused on the importance of handoffs in medicine. Our practice during airway patient handoffs is to communicate a patient-specific emergency plan for airway reestablishment; patients who are not intubatable by standard means are at higher risk for failure. There is currently no standard classification system describing airway risk in tracheotomized patients.

Objective  To introduce and assess the interrater reliability of a simple airway risk classification system, the Connecticut Airway Risk Evaluation (CARE) system.

Design, Setting, Participants  We created a novel classification system, the CARE system, based on ease of intubation and the need for ventilation: group 1, easily intubatable; group 2, intubatable with special equipment and/or maneuvers; group 3, not intubatable. A “v” was appended to any group number to indicate the need for mechanical ventilation. We performed a retrospective medical chart review of patients aged 0 to 18 years who were undergoing tracheotomy at our tertiary care pediatric hospital between January 2000 and April 2011.

Interventions  Each patient’s medical history, including airway disease and means of intubation, was reviewed by 4 raters. Patient airways were separately rated as CARE groups 1, 2, or 3, each group with or without a v appended, as appropriate, based on the available information.

Main Outcomes and Measures  After the patients were assigned to an airway group by each of the 4 raters, the interrater reliability was calculated to determine the ease of use of the rating system.

Results  We identified complete data for 155 of 169 patients (92%), resulting in a total of 620 ratings. Based on the patient’s ease of intubation, raters categorized tracheotomized patients into group 1 (70%, 432 of 620); group 2 (25%, 157 of 620); or group 3 (5%, 29 of 620), each with a v appended if appropriate. The interrater reliability was κ = 0.95.

Conclusions and Relevance  We propose an airway risk classification system for tracheotomized patients, CARE, that has high interrater reliability and is easy to use and interpret. As medical providers and national organizations place more focus on improvements in interprovider communication, the creation of an airway handoff tool is integral to improving patient safety and airway management strategies following tracheotomy complications.

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Figure 1.
Connecticut Airway Risk Evaluation (CARE) Group 1 Airway

A, Direct laryngoscopy demonstrating a normal larynx. B, Bronchoscopy demonstrating a normal-appearing subglottis.

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Figure 2.
Connecticut Airway Risk Evaluation (CARE) Group 2 Airway

A, Direct laryngoscopy with exposure of the larynx. B, Bronchoscopy demonstrating a subglottic stenosis.

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Figure 3.
Connecticut Airway Risk Evaluation (CARE) Group 3 Airway

Direct laryngoscopy demonstrating 99% glottic and subglottic stenosis in a patient who has a tracheotomy tube and is not intubatable from above.

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