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.
Text Size: A A A
Published online

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.

Figures in this Article

Sign In to Access Full Content

Don't have Access?

Register and get free email Table of Contents alerts, saved searches, PowerPoint downloads, CME quizzes, and more

Subscribe for full-text access to content from 1998 forward and a host of useful features

Activate your current subscription (AMA members and current subscribers)

Purchase Online Access to this article for 24 hours


Place holder to copy figure label and caption
Figure 1.
Connecticut Airway Risk Evaluation (CARE) Group 1 Airway

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

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.
Connecticut Airway Risk Evaluation (CARE) Group 2 Airway

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

Graphic Jump Location
Place holder to copy figure label and caption
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.

Graphic Jump Location




Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).
Submit a Comment


Some tools below are only available to our subscribers or users with an online account.

Sign In to Access Full Content

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Topics

Users' Guides to the Medical Literature
Clinical Resolution

Users' Guides to the Medical Literature
Clinical Scenario