Prevalence and commonality of non-technical skills and human factors in airway management guidelines: a narrative review of the last 5 years.

The primary aim of this review was to identify, analyse and codify the prominence and nature of human factors and ergonomics within difficult airway management algorithms. A directed search across OVID Medline and PubMed databases was performed. All articles were screened for relevance to the research aims and according to predetermined exclusion criteria. We identified 26 published airway management algorithms. A coding framework was iteratively developed identifying human factors and ergonomic specific words and phrases based on the Systems Engineering Initiative for Patient Safety model. This framework was applied to the papers to delineate qualitative and quantitative results. Our results show that human factors are well represented within recent airway management guidelines. Human factors associated with work systems and processes featured more prominently than user and patient outcome measurement and adaption. Human factors are an evolving area in airway management and our results highlight that further considerations are necessary in further guideline development.

Preventing unrecognised oesophageal intubation: a consensus guideline from the Project for Universal Management of Airways and international airway societies.

Across multiple disciplines undertaking airway management globally, preventable episodes of unrecognised oesophageal intubation result in profound hypoxaemia, brain injury and death. These events occur in the hands of both inexperienced and experienced practitioners. Current evidence shows that unrecognised oesophageal intubation occurs sufficiently frequently to be a major concern and to merit a co-ordinated approach to address it. Harm from unrecognised oesophageal intubation is avoidable through reducing the rate of oesophageal intubation, combined with prompt detection and immediate action when it occurs. The detection of 'sustained exhaled carbon dioxide' using waveform capnography is the mainstay for excluding oesophageal placement of an intended tracheal tube. Tube removal should be the default response when sustained exhaled carbon dioxide cannot be detected. If default tube removal is considered dangerous, urgent exclusion of oesophageal intubation using valid alternative techniques is indicated, in parallel with evaluation of other causes of inability to detect carbon dioxide. The tube should be removed if timely restoration of sustained exhaled carbon dioxide cannot be achieved. In addition to technical interventions, strategies are required to address cognitive biases and the deterioration of individual and team performance in stressful situations, to which all practitioners are vulnerable. These guidelines provide recommendations for preventing unrecognised oesophageal intubation that are relevant to all airway practitioners independent of geography, clinical location, discipline or patient type.

Patient and surgery factors associated with the incidence of failed and difficult intubation.

Estimates of the rate and risk-factors for difficult airway rarely include a denominator for the number of anaesthetics. Approaches such as self-reporting and crowd-sourcing of airway incidents may help identify specific lessons from clinical episodes, but the lack of denominator data, biased reporting and under-reporting does not allow a comprehensive population-based assessment. We used an established state-wide dataset to determine the incidence of failed and difficult intubations between 2015 and 2017 in the state of Victoria in Australia, along with associated patient and surgical risk-factors. A total of 861,533 general anaesthesia episodes were analysed. Of these, 4092 patients with difficult or failed intubation were identified; incidence rates of 0.52% (2015-2016) and 0.43% (2016-2017), respectively. Difficult/failed intubations were most common in patients aged 45-75 and decreased for older age groups, with risk being lower for patients aged >85 than patients aged 35-44. The risk for failed/difficult intubation increased significantly for: patients undergoing emergency surgery (OR 1.80); obese patients (OR 2.48); increased ASA physical status; and increased Charlson Comorbidity Index. Across all age groups, procedures on the nervous system (OR 1.92) and endocrine system (OR 2.03) had the highest risk of failed/difficult intubation. The relative reduced risk for failed/difficult intubations in the elderly population is a novel finding that contrasts with previous research and may suggest a 'compression of morbidity' effect as a moderator. Administrative databases have the potential to improve understanding of peri-operative risk of rare events at a population level.

Human factors and the safety of surgical and anaesthetic care.

Safety of patients in the operating theatre relies on a cordial and efficient working relationship between all members of the theatre team. A team that communicates well, defines the roles of its members and is aware of their limitations will provide safe patient care. In this review, we will examine how human factors engineering - the science of how to design processes, equipment and environments to optimise the human contributions to performance - can be used to improve safety and efficiency of surgery. Although these are often dismissed as 'common sense', we will explain how these solutions emerge not from healthcare but from diverse disciplines such as psychology, design and engineering.

Consensus clinical scoring for suspected perioperative immediate hypersensitivity reactions.

BACKGROUND: Grading schemes for severity of suspected allergic reactions have been applied to the perioperative setting, but there is no scoring system that estimates the likelihood that the reaction is an immediate hypersensitivity reaction. Such a score would be useful in evaluating current and proposed tests for the diagnosis of suspected perioperative immediate hypersensitivity reactions and culprit agents. METHODS: We conducted a Delphi consensus process involving a panel of 25 international multidisciplinary experts in suspected perioperative allergy. Items were ranked according to appropriateness (on a scale of 1-9) and consensus, which informed development of a clinical scoring system. The scoring system was assessed by comparing scores generated for a series of clinical scenarios against ratings of panel members. Supplementary scores for mast cell tryptase were generated. RESULTS: Two rounds of the Delphi process achieved stopping criteria for all statements. From an initial 60 statements, 43 were rated appropriate (median score 7 or more) and met agreement criteria (disagreement index <0.5); these were used in the clinical scoring system. The rating of clinical scenarios supported the validity of the scoring system. Although there was variability in the interpretation of changes in mast cell tryptase by the panel, we were able to include supplementary scores for mast cell tryptase. CONCLUSION: We used a robust consensus development process to devise a clinical scoring system for suspected perioperative immediate hypersensitivity reactions. This will enable objectivity and uniformity in the assessment of the sensitivity of diagnostic tests.

Management of a surgical patient with a label of penicillin allergy: narrative review and consensus recommendations.

Unsubstantiated penicillin-allergy labels are common in surgical patients, and can lead to significant harm through avoidance of best first-line prophylaxis of surgical site infections and increased infection with resistant bacterial strains. Up to 98% of penicillin-allergy labels are incorrect when tested. Because of the scarcity of trained allergists in all healthcare systems, only a minority of surgical patients have the opportunity to undergo testing and de-labelling before surgery. Testing pathways can be modified and shortened in selected patients. A variety of healthcare professionals can, with appropriate training and in collaboration with allergists, provide testing for selected patients. We review how patients might be assessed, the appropriate testing strategies that can be used, and the minimum standards of safe testing.

Decision-centred design in healthcare: The process of identifying a decision support tool for airway management.

Current decision support interventions for airway management in anaesthesia lack the application of Human Factors Engineering; leading to interventions that can be disruptive, inefficient and error-inducing. This study followed a decision-centred design process to identify decision support that can assist anaesthesia teams with challenging airway management situations. Field observations, Critical Decision Method interviews and focus groups were conducted to identify the most difficult decisions and their requirements. Data triangulation narrowed the focus to key decisions related to preparation and planning, and the transitioning between airway techniques during difficulties. Five decision-support interventions were identified and positively rated by anaesthesia team members in relation to their perceived effectiveness. An organized airway equipment trolley was chosen as the most beneficial decision support intervention. This study reiterated the key importance of both Human Factors Engineering and data triangulation when designing for healthcare.

Anaphylaxis to intravenous gelatin-based solutions: a case series examining clinical features and severity.

The proportion of patients receiving intravenous gelatin-based colloids has increased in the last decade due to safety concerns about starch-based products. Recent research suggests hypersensitivity reactions to intravenous gelatin-based solutions occur at similar rates per administration as non-depolarising neuromuscular blocking agents such as rocuronium (6.2/100,000 administrations). There are scant published data on clinical features, diagnosis and time course of these reactions. We undertook a review of cases reported and tested at one of the UK's largest drug allergy clinics. All patients seen in the drug allergy clinic at Imperial College Healthcare NHS Trust (London, UK) with a confirmed diagnosis of anaphylaxis to gelatin-based solutions between May 2013 and May 2018 were included. We retrospectively reviewed clinical histories, skin test results and severity of reactions in this cohort of patients. Twelve patients with anaphylaxis to gelatin-based solutions were identified (eight women, mean (SD) age 58 (17) years). Eleven reactions were severe or life-threatening with three progressing to cardiac arrest. Presentation was commonly delayed; only three patients suffered reactions within 5 min of the solution being administered with a further six presenting 10-70 min later. Where measured, tryptase was elevated in all patients (median (IQR [range]) 14.7 (8.2-23.8 [6.5-83.4]) ng.ml-1 ). Reactions to gelatin-based solutions are usually severe and can present with latency uncommon with other intravenous anaesthetic triggers. The use of gelatin-based solutions in the peri-operative setting should be re-assessed given the risk of severe allergy.

Australian and New Zealand Anaesthetic Allergy Group/Australian and New Zealand College of Anaesthetists Perioperative Anaphylaxis Management Guidelines.

Anaphylaxis is an uncommon but important cause of serious morbidity and even mortality in the perioperative period. The Australian and New Zealand College of Anaesthetists (ANZCA) with the Australian and New Zealand Anaesthetic Allergy Group (ANZAAG) have developed clinical management guidelines that include six crisis management cards. The content of the guidelines and cards is based on published literature and other international guidelines for the management of anaesthesia-related and non-anaesthesia-related anaphylaxis. The evidence is summarised in the associated background paper (Perioperative Anaphylaxis Management Guidelines [2016] www.anzca.edu.au/resources/endorsed-guidelines and www.anzaag.com/Mgmt%20Resources.aspx). These guidelines are intended to apply to anaphylaxis occurring only during the perioperative period. They are not intended to apply to anaphylaxis outside the setting of dedicated monitoring and management by an anaesthetist. In this paper guidelines will be presented along with a brief background to their development.

The cognitive aids in medicine assessment tool (CMAT) applied to five neonatal resuscitation algorithms.

OBJECTIVE: The International Liaison Committee on Resuscitation (ILCOR) provides recommendations on neonatal resuscitation training and practice, which includes a template for a decision-making algorithm. We evaluated the design properties of the ILCOR algorithm and four adaptations by member resuscitation organizations using the validated Cognitive Aids in Medicine Assessment Tool (CMAT). STUDY DESIGN: Two experts rated five neonatal resuscitation algorithms against the CMAT and against medical device design criteria. RESULTS: The ILCOR algorithm scored 32 of a possible 60 CMAT points, showing an adherence rate to CMAT of 53%. The ILCOR algorithm scored higher than the design variations by member organizations. Nonetheless, there are design limitations in the ILCOR algorithm. CONCLUSION: In principle, cognitive aids can improve neonatal resuscitation team performance; however, a considered design process that incorporates the full complexity of the 'procedure as performed' is needed to improve future versions of the algorithm for incorporation in international guidelines.