National Airway Project

Major Complications of Airway Management in the UK

National Audit Project 4

The National Audit Project 4 (NAP4) is an ambitious project being conducted jointly by the Royal College of Anaesthetists (RCoA) and the Difficult Airway Society (DAS). There was wide consultation before embarking on this project which has gained support from the Association of Anaesthetists of Great Britain and Ireland (AAGBI), the Association of Paediatric Anaesthetists (APA), the Association for Perioperative Practice (AfPP), the College of Emergency Medicine (CEM), the College of Operating Department Practitioners (CODP), the Intensive Care Society (ICS), the Intensive Care National Audit and Research Centre ICNARC), the National Patient Safety Agency (NPSA), the Obstetric Anaesthetists Association (OAA) and the Paediatric Intensive Care Network (PICANet).


This project closely follows the model used for the successful NAP3 audit of central neuraxial blockade. NAP4 will start on 1st of September 2008 and run for one year. It will determine the incidence of major complications of airway management in the UK. To achieve this objective it will be necessary to undertake a snapshot of current airway management practice, providing the denominator and a year-long data collection of major complications to provide a numerator.


Snapshot of current practice


The snapshot will enable annual usage to be calculated for the number of; intubations, facemask anaesthetics and supraglottic airways. This should take place in September/October 2008. The exact timing in each hospital will be determined by the Local Reporter. The snapshot should provide an interesting and valuable insight into current airway management practice.


Prospective data collection of airway management complications over one year


Data will be collected on all patients in whom airway management problems result in:


  • Death

  • Brain damage

  • Emergency surgical airway or needle/cannula cricothroidotomy

  • Unanticipated ICU admission resulting from a complication of airway management



Airway problems with these endpoints are likely to be:


  • Difficult or failed ventilation (via facemask, airway or tracheal tube)

  • Difficult or failed intubation

  • Tracheal tube misplacement or displacement

  • CICV - the can’t intubate can’t ventilate scenario.


Data will be used to calculate the incidence of major airway complications in UK anaesthetic practice and to look for problem areas. Events occurring in the emergency room and ITU should also be submitted but they will not be used to calculate the incidence of these complications in the practice of anaesthesia. Analysis of cases will be educational and used to promote cross specialty learning.


NAP4 airway event notification and data submission


In order to ensure complete confidentiality data collection on airway management complications will be a two part process; 1 Notification and 2 Data submission.


1/ The RCoA will be notified of an event. 2/ The Local Reporter will be issued with an event specific username to enable on-line data submission via the DAS website.


Notification


It will be possible for anyone to notify or inform the RCoA of a case fitting the inclusion criteria shown above. Notification should be by email to tcook@rcoa.ac.uk . The only information required will be the date and time of the event and the hospital name. The identity of the person informing the RCoA will also be required in order to prevent malicious reporting. The identity of the patient must not be sent and the identity of the anaesthetist is unnecessary and unwanted.


Local Reporters


Local Reporters may be unaware that an event has occurred in their hospital but when supplied with information on the date and time of an event the Local Reporter will locate the clinicians involved. The Local Reporter will support these clinicians and aid the data collection process. It will be possible for the Local Reporter to submit information on behalf of another anaesthetist if that person is unable or unwilling to do so. In addition the Local Reporter will coordinate the snapshot of activity.


Local Reporters were vital for the NAP3 project. Their work and support has been greatly appreciated by the RCoA. Many have agreed to continue in this very important role to support this new project, others have passed this task to DAS members. All UK hospitals have a Local Reporter in place. It would be very useful if all DAS members would locate their local reporter via their Audit Lead anaesthetist and offer help and support. Alternatively if you do not know the identity of your local reporter please contact Shirani Nadarajah of the Professional
Standards Directorate at The Royal College of Anaesthetists by email at: snadarajah@rcoa.ac.uk .


On-line data submission


After notification of an event the Local Reporter will work with the anaesthetists involved in the patient’s care. For each event a specific username will be supplied to the Local Reporter 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. The DAS project lead will be able to read the entered data and judge if more data is required, but the RCoA will not. If more data is needed, the DAS project lead will ask the College (using the username for identification) to inform the Local Reporter that more data is needed on the web-based form. When a report is complete the log-on code will be destroyed and the link between the log-on code and the submitted data will be broken which will mean that there is
no longer an identifiable connection between RCoA reporting and data on the DAS website.


Confidentiality


The RCoA will have access to the date and hospital location of every notified event. The College or its representatives will be prevented from linking these data to events within the database by the password selected by the individual submitting data. The DAS will have access to the username and specific details within the database but will have no information on hospital location, identity of the patient or of the doctors. No data identifying a patient or anaesthetist will be requested, and if entered it will be removed. Neither organisation will be able to link the two without active co-operation of the other. No attempt will be made to identify patients or doctors involved.


Data collection forms


To enable the audit 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.


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 attempted to make this process as simple and straightforward as possible whilst remaining robust and maintaining confidentiality. When data collection is complete the link with the original notifying data will be broken.


Moderator


Dr Ian Calder will act as a moderator. His role will be to advise Local Reporters if they are unsure about inclusion criteria or the data to be submitted. He will be independent both of the RCoA and DAS and may be contacted by telephone on 0207 829 8711 or by email at nap4moderator@rcoa.ac.uk .


Data analysis


The reported cases will be analysed by the DAS and RCoA with input from other specialist societies.


Project Approval


This project has the support of the Chief Medical Officers of England, Scotland, Wales and Northern Ireland. The project is also supported by the Medical Defence Union and the Medical Protection Society. The process also has the approval of the National Research Ethics Service and the National Research Ethics Service (NRES) and the Patient Information Advisory Group (PIAG).


Additional information


Supplementary up-to-date information on the process will be made available from the both the DAS and RCoA websites. Information packs will be sent to the Local Reporters but will also be downloadable from the DAS and RCoA web-sites. Information can be located on the internet by searching for NAP4 + airway. The DAS and RCoA URL’s are listed below.


DAS http://www.das.uk.com/natauditproject


RCoA http://www.rcoa.ac.uk/index.asp?PageID=1089


Powerpoint presentation


You will find a Powerpoint presentation with speaker notes is downloadable from the RCoA and DAS web sites. The same presentation was sent out electronically to the DAS members for whom we have an email address and to Local Reporters. It would be useful if you would contact your Local Reporter and arrange for one of you to present this at an audit meeting within your Department.


Thank-you for your help.


Dr Nick Woodall e-mail: nicholas.woodall@nnuh.nhs.uk


Dr Tim Cook e-mail: tcook@rcoa.ac.uk

Co-Audit Leads, 4th National Audit Project (NAP4)