This set of Actionable Patient Safety Solutions (APSS) promotes airway safety and gives broad recommendations for urgent and emergent airway management in settings both inside and outside of the operating room including pre-hospital emergency medical services (EMS), emergency departments (ED), intensive care units (ICU), general medical/surgical units, procedural areas and outpatient settings.
Centers for Medicare and Medicaid Services (CMS) has identified Airway Safety as a priority area for Round 2 of the Hospital Engagement Networks (HENs) due to the high risk and significant impact of airway related injuries and deaths. Several United States and European organizations have provided focused evidence based clinical recommendations to their specialty membership and general audiences. There have been few calls for specific standards outside of the operating room (OR).  We strongly promote that this needs to change.
This Airway Safety APSS serves to highlight key need areas for best practice development and implementation, as well as promote evolving programs that introduce a new level of practice and comprehensive airway safety engagement.
Finally, this Airway Safety APPS serves as a launching point calling for a multi-disciplinary Global Airway Safety (GAS) Collaborative to support further development, assessment, implementation, and promotion of clear actionable solutions for strengthening airway safety awareness, education, management, research and policy.

Threats and Vulnerability

Delayed, missed or lost airways can result in death or catastrophic injuries that are almost always preventable. In particular, endotracheal intubation via direct laryngoscopy is a skill intensive, physically challenging, single operator technique, which has an unacceptable rate of failure, even in the hands of airway specialists. Unrecognized esophageal intubation, multiple failed attempts at securing the airway, aspiration of gastric contents, airway injury, dental trauma, hypoxemia and brain injury are tragically all too common. 
The wide variation of techniques and technology for airway management is a key contributing factor to patient outcomes.  Although the goals of airway management are essentially uniform, clinical approaches depend heavily on provider specialty and physical locale in healthcare settings, without standardization of best practices. For example, video laryngoscopy (VL) equipment is not reliably available in all areas, despite a wealth of scientific evidence that demonstrate its clinical superiority over direct laryngoscopy in a variety of clinical settings. The incidence of failed airways can be as high as 1 in 50 in the ED and ICU settings and the occurrence of death or brain damage have been reported to be 38 fold (ED) to 58 fold (ICU) higher than in OR settings.\cite{Cook_2012} Adverse events from airway management failure may be even higher in non ED/ICU hospital settings. Incidences of inadvertent airway extubation are also serious threats that can lead to death or severe disability.
Missed airways in the EMS setting have been reported to be as high as 52%.\cite{Hubble_2010} Although airway management can be successfully performed by paramedics in the field (success rates as high as 97.7%), variations in training, techniques, and technology result in many systems with less than optimal provider competence and inadequate intubation success rates (47.6%). The approach to airway management in the EMS setting has undergone a dramatic transformation since the advent of video laryngoscopy.\cite{Chemsian_2014} Video laryngoscopy improves laryngeal view and results in high rates of endotracheal intubation (ETI) success, both during first pass attempts and after difficult or failed direct laryngoscopy in the hospital setting.\cite{Silverberg_2015,Aziz_2011} However, due to the high cost of video laryngoscope equipment, EMS has not widely adopted VL and therefore the ETI success rates in the field remain low. 
Studies indicate that unrecognized esophageal intubation in prehospital settings is as high as 25%.\cite{Katz_2001} With the outcome of an unrecognized esophageal intubation frequently being death, and with the availability of capnography which allows for easy recognition of malpositioned placement of the endotracheal tube, any unrecognized episode of esophageal intubation is avoidable. Yet some EMS agencies have not adopted waveform capnography and unrecognized esophageal intubations still occur.
Unplanned extubation, both in the field and in the hospital, is an avoidable, costly problem. Unplanned extubation occurs in over 7% of patients undergoing mechanical ventilation in the Intensive Care Unit and the complications of unplanned extubations result in over $4 Billion in healthcare costs.\cite{da_Silva_2012} Although the incidence is likely higher in EMS settings due to the difficulties of transporting critically ill patients in a chaotic environment, unplanned extubation is not tracked in most EMS data systems. Similarly, most hospitals do not track unplanned extubations and therefore the 7% incidence may be an underestimate.
Because of underreporting, the true incidence of airway management related injuries is unknown. What is clear, however, is that the healthcare industry must transition away from viewing airway management related injuries as the inevitable “cost of doing business” and redefine these complications as preventable iatrogenic harm.

Gaps

The overwhelming majority of hospitals currently lack standardization of airway management among individual providers, teams, units or institutions.  In addition, they have significant vulnerabilities due to inadequate or absent essential safety components such as:

Leadership Plan

Models currently exist for comprehensive airway safety improvement with high leverage interventions.  The Veteran’s Health Administration (VHA) recently initiated the Out of OR Airway Management (OOORAM) directive and the multidisciplinary Safer Airway Program is currently under development.