Critical airway-related incidents and near misses in anaesthesia: a qualitative study of a critical incident reporting system.

BACKGROUND: Many serious adverse events in anaesthesia are retrospectively rated as preventable. Anonymous reporting of near misses to a critical incident reporting system (CIRS) can identify structural weaknesses and improve quality, but incidents are often underreported. METHODS: This prospective qualitative study aimed to identify conceptions of a CIRS and reasons for underreporting at a single Swiss centre. Anaesthesia cases were screened to identify critical airway-related incidents that qualified to be reported to the CIRS. Anaesthesia providers involved in these incidents were individually interviewed. Factors that prevented or encouraged reporting of critical incidents to the CIRS were evaluated. Interview data were analysed using the Framework method. RESULTS: Of 3668 screened airway management procedures, 101 cases (2.8%) involved a critical incident. Saturation was reached after interviewing 21 anaesthesia providers, who had been involved in 42/101 critical incidents (41.6%). Only one incident (1.0%) had been reported to the CIRS, demonstrating significant underreporting. Interviews revealed highly variable views on the aims of the CIRS with an overall high threshold for reporting a critical incident. Factors hindering reporting of cases included concerns regarding identifiability of the reported incident and involved healthcare providers. CONCLUSIONS: Methods to foster anonymity of reporting, such as by national rather than departmental critical incident reporting system databases, and a change in culture is required to enhance reporting of critical incidents. Institutions managing a critical incident reporting system need to ensure timely feedback to the team regarding lessons learned, consequences, and changes to standards of care owing to reported critical incidents. Consistent reporting and assessment of critical incidents is required to allow the full potential of a critical incident reporting system.

Risk patterns of consecutive adverse events in airway management: a Bayesian network analysis.

BACKGROUND: Minor adverse airway events play a pivotal role in the safety of airway management. Changes in airway management strategies can reduce such events, but the broader impact on airway management remains unclear. METHODS: Minor, frequently occurring adverse airway events were audited before and after implementation of changes to airway management strategies. We used two Bayesian networks to examine conditional probabilities of subsequent airway events and to compute the likelihood of certain events given that certain previous events occurred. RESULTS: Independent of sex, age, and American Society of Anesthesiologists physical status, targeted changes to airway management strategies reduced the risk of a first event. Obese patients were an exception, in whom no risk reduction was achieved. Frequently occurring event sequences were identified, for example the most likely event to follow difficult bag-mask ventilation was a Cormack-Lehane grade ≥3, with a risk of 14.3% (95% credible interval [CI], 11.4-17.2%). An impact of the targeted changes was detected on the likelihood of some event sequences, for example the likelihood of no consecutive event after a tracheal tube-related event increased from 43.3% (95% CI, 39.4-47.6%) to 56.4% (95% CI, 52.0-60.5%). CONCLUSIONS: Identification of risk patterns and typical structures of event sequences provides a clinically relevant perspective on airway incidents. It further provides a means to quantify the impact of targeted airway management changes. These targeted changes can influence some event sequences, but overall, the benefit results from the cumulative effect of improvements in multiple events. Targeted airway management changes with knowledge of risk patterns and event sequences can potentially further improve patient safety in airway management. CLINICAL TRIAL REGISTRATION: NCT02743767.

Optimisation of airway management strategies: a prospective before-and-after study on events related to airway management.

BACKGROUND: Poor medical outcomes often result from series of minor events. The present study assessed events related to airway management to determine whether targeted changes to departmental strategies for airway management can reduce the incidence. METHODS: This prospective before-and-after study was performed with ethics committee approval and written informed consent from patients. Major and minor events related to airway management were prospectively recorded for 9 weeks. After implementation of changes to departmental strategies for airway management, events were again prospectively recorded over 9 weeks. Primary outcome was number of cases with events. Secondary outcomes were various predefined events. RESULTS: At study baseline, 3668 cases and at follow-up 3786 cases were assessed. Cases with events decreased from 566 (15.4%) to 433 (11.4%) (risk ratio [RR]=0.74; 95% confidence interval [CI], 0.66-0.83; P<0.01). As secondary outcomes, the following events decreased: Cormack-Lehane grade 3 or 4 (4.3-2.9%; RR=0.67; 95% CI, 0.52-0.85; P<0.01); difficult bag-mask ventilation (3.8-2.7%; RR=0.69; 95% CI, 0.54-0.89; P<0.01); hypoxaemia (3.8-2.9%; RR=0.75; 95% CI, 0.59-0.96; P=0.03); unplanned use of special equipment (3.2-2.0%; RR=0.62; (95% CI, 0.47-0.83; P<0.01); oesophageal intubation (1.3-0.8%; RR=0.61; 95% CI, 0.39-0.96; P=0.03); bleeding (0.8-0.2%; RR=0.30; 95% CI, 0.14-0.63; P<0.01); insufficient spontaneous breathing (0.3-0.0%; RR=0.09; 95% CI, 0.01-0.68; P<0.01); communication errors (0.1-0.0%; RR=0; 95% CI, 0-NA; P=0.03). CONCLUSIONS: Implementation of changes to departmental strategies for airway management significantly reduced cases with events related to airway management. Analysis of events and implementation of strategies that specifically target identified issues might be key to improving airway management. CLINICAL TRIAL REGISTRATION: NCT02743767.

Attitudes towards interprofessionalism among midwife students after hybrid-simulation: A prospective cohort study.

BACKGROUND: Team performance, communication and leadership enhance the quality and effectiveness of interprofessional collaborations between midwifery students and anaesthetists in obstetric emergencies. The realistic setting of hybrid simulation provides practice for interprofessional competencies in a stressful environment without putting women at risk during childbirth. OBJECTIVES: We investigated how full-scale interprofessional hybrid simulation affects the attitudes towards interprofessionalism of final year midwife students. DESIGN: Two-centre prospective cohort study. SETTINGS: Bern Simulation and CPR Centre of the Department of Anaesthesiology and Pain Medicine at the Bern University Hospital (Bern, Switzerland) and Zürich University of Applied Sciences. PARTICIPANTS: Final year midwife students from Bern University of Applied Sciences and Zürich University of Applied Sciences, both from the German-speaking Switzerland. METHODS: One cohort was exposed to hybrid simulation and the other served as control. The simulation group filled in the German Interprofessional Attitude Scale (G-IPAS) before and after simulation, and then again three months later. The control group filled in two sets of G-IPAS questionnaires three months apart. RESULTS: The total G-IPAS score increased significantly towards a more positive interprofessional attitude directly after the hybrid simulation. This increase was not sustained over the observation period of three months, although the score remained significantly higher than the score of the cohort without simulation. CONCLUSIONS: A novel interprofessional hybrid simulation for obstetric emergencies for midwifery students promoted improved attitudes towards interprofessionalism immediately after simulation. These attitudes were improved compared to a control cohort without simulation, and the difference between the two cohorts remained three months after simulation. Future studies might focus on whether improved interprofessional attitudes lead to better healthcare and safety for women and children during childbirth.

The German interprofessional attitudes scale: translation, cultural adaptation, and validation.

Objectives: The implementation of obstetric hybrid simulation and interprofessional collaboration between midwives and anesthetists in labor emergencies fostered the need to evaluate the impact of such a program. The original Interprofessional Attitude Scale (IPAS) assesses interprofessional attitudes among health professional students and includes the 2011 and 2016 Interprofessional Collaborative Practice report competency domains. The purpose of this study was to create a German version of the IPAS (G-IPAS) to use for the education of healthcare students. Methods: We performed the translation and validation of the IPAS in five steps: translation to German according to the International Society of Pharmaeconomics and Outcome Research guidelines; nine cognitive interviews with healthcare professionals and students;calculation of the Content Validity Index (CVI) by expert opinion; exploratory factor analysis (EFA); and internal consistency by Cronbach's alpha. All study participants gave written informed consent and the cantonal ethics committee waived further ethical approval. Results: The cognitive interviews led to replacement of single-item wording. We retained 27 items for CVI analysis. The averaged overall CVI was 0.79, with 15 items ≥0.89. 185 students (70 medicine, 51 nursing, 48 physiotherapy, and 16 midwifery) contributed with data for the EFA and it produced three subscales. "Teamwork, roles, and responsibilities" with factor loadings ≥0.49, "Patient-centeredness" with factor loadings ≥0.31, and "Community-centeredness" with factor loadings ≥0.57. Two items of the total scale were deleted, and four items were redistributed to another subscale. Cronbach's alpha for the overall G-IPAS scale was 0.87. After deleting and redistributing items in subscales, a new Scale-CVI/Average was calculated and was 0.82. Conclusions: Based on a rigorous validation process, the G-IPAS provides a reliable tool to assess attitudes towards interprofessional education among different healthcare professions in German-speaking countries.

Emergency Airway Management in a Simulation of Highly Contagious Isolated Patients: Both Isolation Strategy and Device Type Matter.

OBJECTIVE To compare 6 airway-management devices in 3 isolation scenarios regarding their effect on airway management: portable isolation unit (PIU), personal protective equipment (PPE), and standard protection measures METHODS In total, 30 anesthesiologists working in emergency medical services performed airway management on mannequins in 3 isolation settings using 6 different airway management devices (in random order): (1) standard Macintosh laryngoscope; (2) Airtraq SP-video-laryngoscope; (3) i-gel; (4) LMA-Fastrach; (5) Ambu fiberoptic-aScope; and (6) Melker cricothyrotomy-set. Each was assessed regarding time-to-ventilate (primary outcome) and rating of difficulty handling the device. RESULTS In 86% (standard protection) and 85% (PPE) of attempts, airway management was achieved in <60 seconds, irrespective of the device used. In the PIU setting, only 69% of attempts succeeded within this time frame (P<.05). Median time-to-ventilate was shorter for standard protection (23 seconds) and PPE (25 seconds) compared to the PIU (38 seconds; P<.001). In the PIU setting, the fiberscope took the longest (median, 170 seconds), while i-gel was the quickest (median, 13 seconds). The rating of difficulty (visual analogue scale [VAS], 0-100) differed significantly between the isolation scenarios: Airway management was most difficult with PIU (VAS, 76), followed by PPE (VAS, 35), and standard protection (VAS, 9) (P<.01). CONCLUSION Wearing PPE produced similar times-to-ventilate as standard protection among anesthesiologists, but it was subjectively rated more difficult. The portable isolation unit permitted acceptable times-to-ventilate when excluding fiberscope and cricothyrotomy. Supraglottic airway devices allowed the fastest airway management in all isolation scenarios, thus being highly recommendable if a portable isolation unit is used and emergency airway management becomes necessary. Infect Control Hosp Epidemiol 2018;39:145-151.

Loss of resistance: A randomised controlled trial assessing four low-fidelity epidural puncture simulators.

BACKGROUND: Detecting loss of resistance (LOR) can either be taught with dedicated simulators, with a cost ranging from &OV0556;1500 to 3000, or with the 'Greengrocer's Model', requiring simply a banana. OBJECTIVES: The purpose of this study was to compare three dedicated epidural puncture training simulators and a banana in their ability to simulate LOR. Our hypothesis was that there was a difference between the four simulators when comparing the detection of LOR. DESIGN: Single-blinded, randomised, controlled study. SETTING: Department of Anaesthesiology and Pain Therapy, Bern University Hospital, Switzerland. PARTICIPANTS: Fifty-five consultant anaesthesiologists. INTERVENTIONS: The participants were asked to insert an epidural catheter in four different epidural puncture training simulators: Lumbar Puncture Simulator II (Kyoto Kagaku, Kyoto, Japan), Lumbar Epidural Injection Trainer (Erler-Zimmer, Lauf, Germany), Normal Adult Lumbar Puncture/Epidural Tissue (Simulab Corp., Seattle, Washington, USA) and a banana. The simulators were placed in identical boxes to blind the participants. MAIN OUTCOME MEASURES: The primary outcome was the detection of LOR rated on a 100-mm visual analogue scale, in which 0 mm represented 'completely unrealistic' and 100 mm represented 'indistinguishable from a real patient'. RESULTS: The mean visual analogue scale scores for LOR in the four simulators were significantly different: 60 ±â€Š25 mm [95% confidence interval (CI), 55 to 65 mm], 50 ±â€Š29 mm (95% CI, 44 to 55 mm), 64 ±â€Š24 mm (95% CI, 58 to 69 mm) and 49 ±â€Š32 mm (95% CI, 44 to 54 mm); P less than 0.001, Friedman test. CONCLUSION: Two of the three dedicated epidural simulators were rated more realistic in detecting LOR than the banana, but some participants preferred the banana to the other three simulators. Given the relative cost of a banana compared with a dedicated simulator, we suggest that a banana be used to teach the technique of LOR for epidural puncture. TRIAL REGISTRATION: KEK Nr: Req-2015-z087.