Implementing human factors in anaesthesia: guidance for clinicians, departments and hospitals: Guidelines from the Difficult Airway Society and the Association of Anaesthetists: Guidelines from the Difficult Airway Society and the Association of Anaesthetists.

Human factors is an evidence-based scientific discipline used in safety critical industries to improve safety and worker well-being. The implementation of human factors strategies in anaesthesia has the potential to reduce the reliance on exceptional personal and team performance to provide safe and high-quality patient care. To encourage the adoption of human factors science in anaesthesia, the Difficult Airway Society and the Association of Anaesthetists established a Working Party, including anaesthetists and operating theatre team members with human factors expertise and/or interest, plus a human factors scientist, an industrial psychologist and an experimental psychologist/implementation scientist. A three-stage Delphi process was used to formulate a set of 12 recommendations: these are described using a 'hierarchy of controls' model and classified into design, barriers, mitigations and education and training strategies. Although most anaesthetic knowledge of human factors concerns non-technical skills, such as teamwork and communication, human factors is a broad-based scientific discipline with many other additional aspects that are just as important. Indeed, the human factors strategies most likely to have the greatest impact are those related to the design of safe working environments, equipment and systems. While our recommendations are primarily provided for anaesthetists and the teams they work with, there are likely to be lessons for others working in healthcare beyond the speciality of anaesthesia.

Human factors in anaesthesia: a narrative review.

Healthcare relies on high levels of human performance, as described by the 'human as the hero' concept. However, human performance varies and is recognised to fall in high-pressure situations, meaning that it is not a reliable method of ensuring safety. Other safety-critical industries embed human factors principles into all aspects of their organisations to improve safety and reduce reliance on exceptional human performance; there is potential to do the same in anaesthesia. Human factors is a broad-based scientific discipline which aims to make it as easy as possible for workers to do things correctly. The human factors strategies most likely to be effective are those which 'design out' the chance of an error or adverse event occurring. When errors or adverse events do happen, barriers are in place to trap them and reduce the risk of progression to patient and/or worker harm. If errors or adverse events are not trapped by these barriers, mitigations are in place to minimise the consequences. Non-technical skills form an important part of human factors barriers and mitigation strategies and include: situation awareness; decision-making; task management; and team working. Human factors principles are not a substitute for proper investment and appropriate staffing levels. Although applying human factors science has the potential to save money in the long term, its proper implementation may require investment before reward can be reaped. This narrative review describes what is known about human factors in anaesthesia to date.

Fire safety and emergency evacuation guidelines for intensive care units and operating theatres: for use in the event of fire, flood, power cut, oxygen supply failure, noxious gas, structural collapse or other critical incidents: Guidelines from the Association of Anaesthetists and the Intensive Care Society.

The need to evacuate an ICU or operating theatre complex during a fire or other emergency is a rare event but one potentially fraught with difficulty: Not only is there a risk that patients may come to harm but also that staff may be injured and unable to work. Designing newly-built or refurbished ICUs and operating theatre suites is an opportunity to incorporate mandatory fire safety features and improve the management and outcomes of such emergencies: These include well-marked manual fire call points and oxygen shut off valves (area valve service units); the ability to isolate individual zones; multiple clear exit routes; small bays or side rooms; preference for ground floor ICU location and interconnecting routes with operating theatres; separate clinical and non-clinical areas. ICUs and operating theatre suites should have a bespoke emergency evacuation plan and route map that is readily available. Staff should receive practical fire and evacuation training in their clinical area of work on induction and annually as part of mandatory training, including 'walk-through practice' or simulation training and location of manual fire call points and fire extinguishers, evacuation routes and location and operation of area valve service units. The staff member in charge of each shift should be able to select and operate fire extinguishers and lead an evacuation. Following an emergency evacuation, a network-wide response should be activated, including retrieval and transport of patients to other ICUs if needed. A full investigation should take place and ongoing support and follow-up of staff provided.

A trial comparing emergency front of neck airway performance in a novel obese-synthetic neck, meat-modified obese neck and conventional slim manikin.

Conventional emergency front of neck airway training manikins mimic slim patients and are associated with unrealistic procedural ease. We have described previously a pork belly-modified manikin that more realistically simulated an obese patient's neck. In this study, we compared a novel obese-synthetic manikin (obese-synthetic manikin) with a pork belly-modified manikin (obese-meat manikin) and a conventional slim manikin (slim manikin). Thirty-three experienced anaesthetists undertook simulated emergency front of neck airway procedures on each manikin (total 99 procedures). Time to ventilation was longer on both obese manikins compared with the slim manikin (median (IQR [range]) time to intubation 159 (126-243 [73-647]) s in the obese-synthetic, 105 (72-138 [43-279]) s in the obese-meat and 58 (47-74 [30-370]) s in the slim manikin; p < 0.001 between each manikin). Cricothyroidotomy success rate was similar in the both obese manikins but lower when compared with the slim manikin (15/33 obese-synthetic vs. 14/33 obese-meat vs. 27/33 slim manikin). Participant feedback indicated performance difficulty was similar between both obese manikins, which were both more difficult than the slim manikin. The tissues of the obese-meat manikin were judged more realistic than those of either other manikin. Overall, the obese-synthetic manikin performed broadly similarly to the obese-meat manikin and was technically more difficult than the conventional slim manikin. The novel obese-synthetic manikin maybe useful for training and research in front of neck airway procedures.

Universal videolaryngoscopy: a structured approach to conversion to videolaryngoscopy for all intubations in an anaesthetic and intensive care department.

BACKGROUND: Videolaryngoscopy (VL) is increasingly used, but not yet routine practice, for tracheal intubation. Few departments formally trial equipment before adopting it into practice. We describe the decision-making and implementation processes that our department used when introducing universal VL, with the C-MAC© (Karl Storz, Germany), throughout our anaesthesia and intensive care departments. METHODS: We used a structured process to assess the feasibility of a change to universal VL. After departmental training, we undertook a 2 month trial period of mandating VL for all adult in-theatre intubations. Thereafter, VL remained widely available, but not mandated. We regularly surveyed anaesthetists and anaesthetic assistants to evaluate departmental opinion regarding the introduction of universal VL. RESULTS: Before the trial period, one-third of anaesthetists judged that universal VL would be of overall benefit to patient safety, team dynamics, and quality of care. Reservations from both junior and senior anaesthetists focused on training concerns. Support for a changeover to VL, amongst both anaesthetists and anaesthetic assistants, increased throughout the trial period. Six months after the 2 month trial, support had grown further and was almost unanimous. Anaesthetists reported significant benefits in clinical performance, teaching, and human factors, especially teamwork and situation awareness. CONCLUSIONS: Performing a formal and prolonged trial of mandatory VL in theatre led to changes in perceptions and departmental consensus. As a result of the trial, the department agreed to the use of C-MAC© videolaryngoscopy as the default intubation technique throughout theatres and intensive care, with removal of standard Macintosh laryngoscopes from routine use.

Paediatric intensive care and neonatal intensive care airway management in the United Kingdom: the PIC-NIC survey.

In 2011, the Fourth National Audit Project (NAP4) reported high rates of airway complications in adult intensive care units (ICUs), including death or brain injury, and recommended preparation for airway difficulty, immediately available difficult airway equipment and routine use of waveform capnography monitoring. More than 80% of UK adult intensive care units have subsequently changed practice. Undetected oesophageal intubation has recently been listed as a 'Never Event' in UK practice, with capnography mandated. We investigated whether the NAP4 recommendations have been embedded into paediatric and neonatal intensive care practice by conducting a telephone survey of senior medical or nursing staff in UK paediatric intensive care units (PICUs) and neonatal intensive care units (NICUs). Response rates were 100% for paediatric intensive care units and 90% for neonatal intensive care units. A difficult airway policy existed in 67% of paediatric intensive care units and in 40% of neonatal intensive care units; a pre-intubation checklist was used in 70% of paediatric intensive care units and in 42% of neonatal intensive care units; a difficult intubation trolley was present in 96% of paediatric intensive care units and in 50% of neonatal intensive care units; a videolaryngoscope was available in 55% of paediatric intensive care units and in 29% of neonatal intensive care units; capnography was 'available' in 100% of paediatric intensive care units and in 46% of neonatal intensive care units, and 'always available' in 100% of paediatric intensive care units and in 18% of neonatal intensive care units. Death or serious harm occurring secondary to complications of airway management in the last 5 years was reported in 19% of paediatric intensive care units and in 26% of neonatal intensive care units. We conclude that major gaps in optimal airway management provision exist in UK paediatric intensive care units and especially in UK neonatal intensive care units. Wider implementation of waveform capnography is necessary to ensure compliance with the new 'Never Event' and has the potential to improve airway management.

A national survey of videolaryngoscopy in the United Kingdom.

BACKGROUND.: There are increasing numbers of videolaryngoscopes marketed and increasing interest in the technology. The Difficult Airway Society's 2015 guidelines recommend that videolaryngoscopes should be immediately available at all times and that all anaesthetists should be trained and skilled in their use. METHODS.: An electronic survey was sent to all UK National Health Service hospitals to examine availability, use, and attitudes to videolaryngoscopy, and closed in January 2014. RESULTS.: The return rate was 67%. Videolaryngoscopy was available in 91% of operating theatres, ∼50% of intensive care units (ICUs) and obstetric theatres, with lower availability in emergency departments (EDs), paediatric anaesthesia, and independent sector hospitals. The most widely available devices were the Airtraq, the GlideScope, and C-MAC. Approximately one in seven respondents reported availability of videolaryngoscopy in all clinical areas. Most departments imposed restrictions on videolaryngoscopy use, especially the ICU and ED. Device selection was only infrequently based on published literature or formal trial. Structured introduction of videolaryngoscopy into practice was uncommon. Penetration of videolaryngoscopy was highly variable; fewer than a third reported widespread use or enthusiasm, although this increased where the C-MAC and GlideScope were widely available. CONCLUSIONS.: Videolaryngoscopy is available in most hospitals' main operating departments, but in fewer than half of other locations. There is marked variation in device, methods of introduction, usage, and clinical adoption. Most hospitals need to change practice to comply with current guidelines. Selection and implementation vary widely.

A national survey of practical airway training in UK anaesthetic departments. Time for a national policy?

The Fourth National Audit Project (NAP4) recommended airway training for trainee and trained anaesthetists. As the skills required for management of airway emergencies differ from routine skills and these events are rare, practical training is likely to require training workshops. In 2013, we surveyed all UK National Health Service hospitals to examine the current practices regarding airway training workshops. We received responses from 206 hospitals (62%) covering all regions. Regarding airway workshops, 16% provide none and 51% only for trainees. Of those providing workshops, more than half are run less than annually. Workshop content varies widely, with several Difficult Airway Society (DAS) guideline techniques not taught or only infrequently. Reported barriers to training include lack of time and departmental or individual interest. Workshop-based airway training is variable in provision, frequency and content, and is often not prioritised by departments or individual trainers. It could be useful if guidance on workshop organisation, frequency and content was considered nationally.

Rescuing the obese or burned airway: are conventional training manikins adequate? A simulation study.

BACKGROUND: Percutaneous tracheal access is required in more than 40% of major airway emergencies, and rates of failure are high among anaesthetists. Supraglottic airway management is more likely to fail in patients with obesity or neck pathology. Commercially available manikins may aid training. In this study, we modified a standard 'front of neck' manikin and evaluated anaesthetists' performance of percutaneous tracheal access. METHODS: Two cricothyroidotomy training manikins were modified using sections of belly pork to simulate a morbidly obese patient and an obese patient with neck burns. An unmodified manikin was used to simulate a slim patient. Twenty consultant anaesthetists were asked to manage a 'can't intubate, can't ventilate' scenario involving each of the three manikins. Outcome measures were success using their chosen technique and time to first effective breath. RESULTS: Success rates using first-choice equipment were: 'slim' manikin 100%, 'morbidly obese' manikin 60%, and 'burned obese' manikin 77%. All attempts on the 'slim' manikin succeeded within 240 s, the majority within 120 s. In attempts on the 'morbidly obese' manikin, 60% succeeded within 240 s and 20% required more than 720 s. All attempts on the 'burned obese' manikin succeeded within 180 s. CONCLUSIONS: Significantly greater technical difficulty was experienced with our 'morbidly obese' manikin compared with the unmodified manikin. Failure rates and times to completion were considerably more consistent with real-life reports. Modifying a standard manikin to simulate an obese patient is likely to better prepare anaesthetists for this challenging situation. Development of a commercial manikin with such properties would be of value.