Visible risk, invisible plans: bridging the safety gap in intensive care unit airway management

The publication of the Fourth National Audit Project (NAP₄) in 2011 served as a watershed moment for critical care medicine in the United Kingdom, identifying the intensive care unit (ICU) as the clinical setting with the highest incidence of major airway-related complications and avoidable deaths (1). A key recommendation from that landmark report was that at-risk patients should be clearly assessed, identifiable at the bedside, and have a documented management plan. Yet, fifteen years later, the ‘Identification of Difficult Airways in Critical Care Units’ (ID-ACCT) study published in the British Journal of Anaesthesia (BJA) reveals a sobering reality: a significant ‘safety gap’ persists between our clinical knowledge and our systemic execution (2).

The prevalence of complexity

The ID-ACCT study, a multicentre prospective observational study involving 106 UK ICUs, highlights that airway difficulty is not a rare outlier but a daily reality for the intensivist (2). The researchers found that 55.6% of patients met at least one criterion for a predicted difficult airway. These figures underscore the high-stakes environment of the ICU, where physiological instability often compounds anatomical challenges.

Data from the ID-ACCT study regarding ICU airway prevalence versus preparedness reveal that while 16.1% of patients possessed a known difficult airway, a striking 70% of these individuals lacked a documented management plan. With 35.1% of patients having a body mass index (BMI) ≥30 kg/m², obesity is no longer a ‘special case’ but a daily reality that demands standardized visual alerts at the bedside. We also note that video laryngoscopy was used in 50% of cases but was more likely to be used in known difficult airways (72%). While video laryngoscopy technology is increasingly being adopted across ICUs, these data trends suggest an editorial inference that the technology is frequently utilised as a ‘reactive’ tool for known difficulty rather than establishing a ‘proactive’ standard for all predicted difficulties.

While the authors state that 1,093 patients (55.6%) met one or more criteria for predicted difficulty, only 125 patients (13.6%) were clearly identifiable as at risk to the investigators. This leaves a safety gap of 42% (difference between predicted risk, 55.6% and visible identification, 13.6%) of the total population that represents ‘undetected risk’—patients who meet high-risk criteria but have no visible bedside identification (Table 1). These figures underscore the high-stakes environment of the ICU, where physiological instability often compounds anatomical challenges. Despite this high prevalence, the study identifies a critical failure in ‘Safety-II’ principles—the proactive systems that ensure work goes right (3). Only 34.6% of patients had a documented airway assessment on admission, and even among those with a known difficult airway, only 28.7% were clearly identifiable to the healthcare professionals caring for them. Perhaps most concerning is that only 30.7% of these known high-risk patients had a documented airway management plan in place.

However, a limitation of the primary study’s data collection must be acknowledged: determining whether a patient was ‘clearly identifiable’ relied on the subjective assessment of local clinicians, introducing potential observer bias. Rather than weakening the findings, this limitation reinforces the urgent need for objective, standardised electronic medical record (EMR) flags and highly visible, uniform bedside alerts that eliminate clinician subjectivity entirely.

Beyond technical skills: the systemic perspective

As clinicians, we often focus on technical mastery—the ‘Safety-I’ approach of improving individual intubation success. ‘Safety-I’ focuses on the failed intubation (the anomaly), whereas ‘Safety-II’ focuses on the daily intubation (the 56% of at-risk patients who are managed every day). The ID-ACCT data shows that technology has evolved; video laryngoscopy was used in 50% of tracheal tube insertions, reflecting a significant shift in practice. However, technology alone cannot bridge the safety gap if the system fails to identify the patient at risk before the crisis begins. The authors make a plea for making video laryngoscopy the default tracheal intubation technique and provide guidelines for its universal implementation (4,5).

Moving from individual competence to systemic resilience

To improve, we must shift our focus toward systemic safety science. This involves moving from a ‘policing’ mindset that blames the individual for a failed intubation to a ‘learning’ mindset that examines how work is actually performed. Tools such as Failure Mode and Effects Analysis (FMEA) can be used to prospectively evaluate ICU workflows, identifying potential points of failure in airway identification and planning before they result in patient harm (6).

The human factor and environmental challenges

The ID-ACCT findings suggest that the barriers to safety are likely multifactorial, involving human factors, environmental challenges, and the inherent physiological difficulty of the critically ill (7). For instance, the BJA study (2) found that intubation details were missing from medical notes in nearly 16% of cases, and the intubation technique was undocumented in 17.5% of patients. Furthermore, data are lacking about the location of the tracheal intubation (0.6%); the seniority of the intubator (15.9%), which airway device or approach was used (17.5%), while no airway management plan was available in patients with known difficult airways (69.3%) and in patients with predicted difficult airway management (79%). This lack of informational continuity directly hinders the ability of subsequent teams to prepare for future airway events.

Furthermore, while the use of the MACOCHA score (8,9) is recommended to predict difficulty, ID-ACCT utilised a modified version for hypothetical scenarios, identifying that 31.7% of patients without an airway in situ would be considered ‘high-risk’ if managed by a non-anaesthetist (2). This indicates that the risk nearly triples if a non-anaesthetist performs the intubation, emphasizing the need for expert-led systems. This highlights a crucial training intersection: our safety systems must account for the varying skill sets of those managing the airway in emergent ICU settings. This further suggests that a significant cohort of patients are at risk of being managed by clinicians whose primary training may not match the anatomical or physiological difficulty present.

Visualization of the safety gap in UK ICUs

While McClelland et al. (2) clearly illustrate the disparity between patient risk and clinical recognition, with over half of the ICU population presenting with features requiring heightened vigilance, only a small fraction is effectively ‘flagged’ as having a difficult airway within the clinical environment.

Strategies for improvement

The findings in the BJA suggest several immediate avenues for enhancing patient safety:

• Standardized bedside identification: much like the success seen with the National Tracheostomy Safety Project, ICUs must adopt mandatory, high-visibility bedside alerts for at-risk patients (Table 2). Airway assessment should be a mandatory component of the ‘FAST-HUG’ or similar ICU daily checklist (10).
• Mechanisms of alerting: while medical notes and bedside alerts were used in 62.9% of identified cases, electronic alerts were used in only 10%. Leveraging EMR for automated ‘difficult airway’ flags could drastically improve visibility.
• Universal admission assessment: airway assessment should be a non-negotiable component of the ICU admission bundle to ensure that 100% of patients are screened, rather than the currently observed 34.6%.
• The ‘Theatre-as-Classroom’ model: senior clinicians should adopt a learner-centered approach, involving trainees in the development of ‘Plan A, B, and C’ for every at-risk patient during morning rounds to normalize proactive planning.
• Addressing the obesity epidemic: with 35.1% of the study population having a BMI >30 kg/m², our systems must be specifically calibrated to handle the unique physiological and anatomical challenges presented by this demographic.

Future research

Future research should explore additional strategies to improve compliance with NAP4 recommendations, i.e., targeted multidisciplinary education, training initiatives to improve awareness, and management of patients at risk of airway events.

Conclusions

The ID-ACCT study is a call to action for the global critical care community. Technical excellence at the point of intubation is no longer the sole metric of a high-quality airway service. True safety lies in the invisible work performed hours or days before an intubation attempt: the thorough assessment, the clear bedside alert, and the documented plan. By embracing these systemic improvements and fostering a culture of multidisciplinary education, we can finally close the safety gap identified by NAP₄ and ensure that the ‘difficult airway’ is a managed expectation rather than a catastrophic surprise.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Emergency and Critical Care Medicine. The article has undergone external peer review.

Peer Review File: Available at https://jeccm.amegroups.com/article/view/10.21037/jeccm-2026-0019/prf

Funding: None.

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://jeccm.amegroups.com/article/view/10.21037/jeccm-2026-0019/coif). The author has no conflicts of interest to declare.

Ethical Statement: The author is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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