title: Development of the Connecticut Airway Risk Evaluation (CARE) system to improve handoff communication in pediatric patients with tracheotomy.
abstract: OBJECTIVE
  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.
  
  
  METHODS
  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.
  
  
  METHODS
  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
  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.
authors.affiliation: Division of Otolaryngology, University of Connecticut, Farmington.
authors.forename: Amy
authors.initials: A
authors.lastname: Lawrason Hughes
authors.affiliation: Division of Otolaryngology, Connecticut Children's Medical Center, Hartford.
authors.forename: Nicole
authors.initials: N
authors.lastname: Murray
authors.affiliation: Division of Otolaryngology, Connecticut Children's Medical Center, Hartford.
authors.forename: Tulio A
authors.initials: TA
authors.lastname: Valdez
authors.affiliation: Division of Otolaryngology, Connecticut Children's Medical Center, Hartford.
authors.forename: Raeanne
authors.initials: R
authors.lastname: Kelly
authors.affiliation: Division of Otolaryngology, Connecticut Children's Medical Center, Hartford.
authors.forename: Katherine
authors.initials: K
authors.lastname: Kavanagh
mesh_terms: D000293:Adolescent; D001999:Bronchoscopy; D002648:Child; D002675:Child, Preschool; D003142:Communication; D003237:Connecticut; D003266:Continuity of Patient Care / Q000592:standards*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007442:Intubation, Intratracheal / Q000145:classification; D007828:Laryngoscopy; D010865:Pilot Projects; D017064:Process Assessment, Health Care; D015203:Reproducibility of Results; D012189:Retrospective Studies; D018570:Risk Assessment / Q000379:methods*; D014140:Tracheotomy