Increasing Effectiveness of the Surgical Airway Response System: Introduction of the Otolaryngology Airway Pager, Quality Improvement Project of the PGY-2 Class
Introduction:
The need for an Otolaryngology airway pager is based on several external and internal factors. The current communication pathway for emergent airways at our institution is well established but often misinterpreted. The protocol is outlined in Figure 1. The priority to reach out to other departments is based on their availability of an attending in house overnight. Furthermore, there is often a delay in contacting the Otolaryngology department. Our service has multiple pagers to accommodate for each of our inpatient teams, which can be confusing for other services. One of the driving events for this project was an incident at JHN where a tracheostomy tube became dislodged. There were several attempts to contact our team through the wrong pager and by the time we were notified the patient had expired. In addition our personal cell phones are commonly used as the primary means of contact for urgent situations. On several occasions the wrong person has been called in the middle of the night or the on-call resident is contacted while they are in the operating room during the day, resulting in a slower response time. From the perspective of the Otolaryngology Department at times we receive multiple pages and answer in the order that the pages were received, not in order of acuity as this is unknown. A dedicated airway pager will help us prioritize our decisions most safely.https://jdc.jefferson.edu/patientsafetyposters/1067/thumbnail.jp
