NAP4 FAQs

3. Can I get more posters of flyers to advertise NAP4?

These files were sent to local reporters in the initial audit pack. They are also downloadable from the RCoA website.

4. Is there a downloadable presentation about NAP4?

Yes this is available from www.rcoa.ac.uk/docs/NAP4-presentation.ppt. Please feel free to use it, but please do not modify it prior to use or distribution.

5. Can I get another copy of the audit pack?

Yes this is available from the NAP4 section of the website.

6. Are private patients and ISTCs included in the snapshot phase of the audit?

No. As with NAP3 we decided that it was organisationally more practical (and therefore likely to lead to more robust results) to perform the snapshot audit exclusively within NHS hospitals. As ISTCs may or may not be independent we have also excluded them. The critical issue is that the incidence calculations must be based on the same numerator as denominator. Our process and the review stage will ensure this is so.

7. Can cases of complications be reported if they occur in the independent sector or an ISTC?

Yes all such cases will be welcome. While they will be excluded from incidence calculations, they will be reviewed and analysed for learning points in the same manner as all reported cases will.

8. What will the incidence calculation be?

The calculation will be the incidence of major airway complications occurring during anaesthesia. It is important that the numerator and denominator match. So the denominator will be taken from the snapshot phase of the audit and will exclude anaesthetics performed on ICU and in the emergency department. All cases reported to NAP4 as part of year long data collection will be carefully reviewed. Only those that match the denominator population (anaesthesia in an NHS hospital outside ICU and the emergency department) will be only included in the incidence calculation.

9. Why are anaesthetics administered in the ICU and emergency department excluded from the snapshot?

We do not wish to calculate incidence data for these events so it is not necessary to collect snapshot (denominator) data. We are not including these cases in incidence calculation as the personnel administering an anaesthetic in the ICU and emergency department (and perhaps the definition of an anaesthetic) is likely to be different from most other hospital areas. The original prime aim of the project was to determine the incidence of major airway complications associated with anaesthesia delivered by anaesthetists in the UK. Excluding cases that may involve other medical specialties is therefore appropriate.

10. Why report cases of complications from ICU and the emergency department if they’re not being used for incidence calculations?

In addition to calculating the incidence of major complications of airway management during anaesthesia we will be reviewing each reported case in detail. We anticipate that many difficult cases (and therefore complications) will arise from ICU and the emergency department. We anticipate that review of these cases will be of interest and use in generating cross-specialty learning. Please report all relevant cases that occur in ICU or the emergency department.

11. Are neonatal intensive cares included in the audit?

We would be happy to receive reports of cases from NICU.

12. How will local reporters learn about a case that is reported?

Local Reporters may be unaware that an event has occurred in their hospital but when notified of an event the NAP4 team will directly contact the LR of that hospital. The LR will be given the date and time of an event and the name of the person reporting the event. The LR will locate the clinicians involved. The LR will support these clinicians and aid the data collection process. The LR and the involved clinicians will then submit a detailed report to the NAP4 section of the DAS website on behalf of another anaesthetist if that person is unable or unwilling to do so. As long as every event is notified to the NAP4 team at tcook@rcoa.ac.uk the rest will follow. Links to his email can be found on both the DAS and College web-sites. Anyone can tell him of an event, a surgeon, anaesthetist, ODP or nurse.

13. How does the local reporter get their login and password details?

The Local Reporter only needs a login and password when submitting a report on a case to NAP4 (on the DAS website). For each event a specific username will be supplied to the LR by the RCoA. This will enable secure password protected access to part of the DAS website. Before submitting data the person submitting data will need to create their own password. The combination of a username and password will ensure that only the person entering data has external access. Once the data submission is complete the username will be destroyed, thereby unlinking cases 'notified to NAP4' and 'case reports': thereby improving confidentiality and protection of both patient and clinician details.

14. What details will be inputted when the details of a case are reported?

Data to be submitted will be entered online. You will be able to view the forms online shortly and each form will be specific to each event. To enable the project team to gain a clear picture of the event the data collection form is extensive. Questions are not posed to judge colleagues or to imply criticism. Questions are framed to seek the information we believe will allow us to determine themes and learning points arising from these challenging cases.

15. Is there support for doctors involved in these difficult cases?

We are aware that anaesthetists engaged in this process may have suffered trauma themselves, on account of the incident they report. We thank all those reporting these data for their generosity and honesty in reporting their cases. We have gathered some information on support in these circumstances and this is available in the NAP4 section of the website.

16. How are duplicate reports avoided?

We anticipate some cases may be notified to the NAP4 team by more than one person. However in that hospital the Local Reporter will co-ordinate reporting case details and it is likely they will prevent duplicate reports.

The cases are notified to the RCoA NAP4 lead (Tim Cook) who will be aware when one hospital has made more than one notification. Where this occurs the DAS lead Nick Woodall who has access to the full reports on the DAS website (but not to the details of the notification, or the hospital notifying) will be able to screen the relevant reports to ensure there is no duplication.

It sounds complicated but we believe it a robust system that also maintains complete confidentiality for doctors (as neither the RCoA or DAS project lead has all the information, but between them they do!).

In the unlikely event that duplicates do slip through, they will be identified when cases are reviewed in detail by the review panel.

17. Does the 2 week snapshot include inductions by intensivists done out of hospital (i.e. retrievals)?

Please do not include anaesthetics performed in the ICU setting, in the emergency department or outside of hospital in the snapshot. Please do report adverse events meeting our inclusion criteria if they occur at these locations during the year of the NAP4 audit.

18. If an event occurs during a retrieval or a transfer of an ICU patient who reports it?

If an event occurs during a retrieval the report should be submitted by the hospital performing the airway management. Therefore if you go to another hospital for a retrieval and manage a patient who develops an airway problem resulting in cardiac arrest and brain damage your hospital will be asked to provide data on that case. If the intubation and damage had already occurred when you arrived to take the patient, the hospital responsible for managing the airway should submit the report. However you should still notify us that this event had occurred and indeed it would be useful if you would notify us of all events that occur even if they occur outside your own unit.

19. How do you define brain damage?

We ask the individuals providing care for the patient to identify brain damage. Clearly the ability to identify this problem will depend on the measures used to detect it. We request reports where there has been a recognisable deterioration in brain function following the airway event.

20. Does the audit include major complications of percutaneous tracheostomies (PDT), (or other airway events) for patients already on ICU?

Yes. Airway complications (related to intubation, accidental extubation, and PDT) should be reported in the same manner as those leading to ICU admission. So if they meet the criteria (i.e. lead to 1 - Death, 2 - Brain damage and 3 An injury that would have lead to ICU admission if they were not already there) they should be reported.