A best practice advisory (BPA) can improve difficult airway documentation in electronic health records (EHRs) of patients at risk for difficult intubation, with optional alerts being the best mode of encouraging documentation. These study findings were presented at the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) 2022 Annual Meeting and OTO Experience, held in Philadelphia, Pennsylvania, September 10 to 14, 2022.

The EHR currently has a flagging system to identify patients at risk for difficult intubation. Risk factors for these patients are usually identified in the outpatient setting. To increase earlier documentation and use of the difficult airway EHR flag, researchers performed a structured analysis to assess the current identification system and develop an intervention using the BPA mechanism.

In this approach, the BPA was triggered by ICD-10 diagnoses commonly associated with patients with existing flags. Researchers tested 3 types of BPA alerts, forced acknowledgment interruptive alerts (forced alerts), optional acknowledgment interruptive alerts (optional alerts), and passive BPA header alerts (passive headers). Over a 5-month period the researchers recorded the number of times the BPA fired, the triggering diagnosis, the rate of flag placement, and provider feedback.


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Overall, 16 ICD-10 codes were used to trigger a BPA alert. These were related to head and neck cancer/radiation, airway stenosis, tracheostomy dependence and craniofacial abnormalities. During the 5-month research period, there were 4594 BPA fires, resulting in 350 flag placements. An analysis of flag placement by alert type found the rates of flag placement for forced alerts, optional alerts, and passive headers were 61.4%, 12.2% and 0.1%, respectively (odds ratio 0.09, 95% CI 0.06-0.12 for optional alerts; and OR 0.0008, 95% CI 0.0002-0.0023 for passive headers vs forced alerts).

Researchers concluded that BPA improves difficult airway documentation, but the utility depends on alert type. They further noted that “Benefits of early flag placement must be weighed against provider alert fatigue. [Optional alerts] may optimally encourage early documentation of difficult airways in the outpatient setting whilst minimizing this fatigue.”

Reference

Spielbauer KK, Peddireddy NS, Dermody SM, Prince MEP, Terrell JE, Morrison RJ. Increasing early documentation of difficult airways: a quality improvement initiative. Otolaryngol Head Neck Surg. 2022;167(1 suppl):P110.