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 started on the 1st of September 2008 and ran for one year. It will determine the incidence of major complications of airway management in the UK. To achieve this objective it was necessary to undertake a snapshot or census of current airway management practice, to provide the denominator and a year-long data collection of major complications to provide a numerator.
Census of current practice
This enabled annual usage to be calculated for the number of; intubations, facemask anaesthetics and supraglottic airways. It took place in September/October 2008 or September 2009. The exact timing in each hospital was be determined by the Local Reporter. The snapshot provides an interesting and valuable insight into current airway management practice.
Prospective data collection of airway management complications over one year
Data were 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 were 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 are currently being 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 were also submitted but not used in the calculations of incidence of these complications in the practice of anaesthesia. Analysis of cases should be educational and could 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 was split into two separate halves; 1 Notification and 2 Data submission.
Notification
It was possible for anyone to notify or inform the RCoA of a case fitting the inclusion criteria by email, telephone or by post. The only information required was the date and time of the event and the hospital name. The identity of the person informing the RCoA was also required in order to prevent malicious reporting. The identity of the patient or anaesthetist was not required and was unwanted.
Local Reporters
Local Reporters may have been unaware that an event had occurred in their hospital but when supplied with information on the date and time of an event the Local Reporter was able to locate the clinicians involved. The Local Reporter supported these clinicians and aided the data collection process. It was be possible for the Local Reporter to submit information on behalf of another anaesthetist if that person was unable or unwilling to do so. In addition the Local Reporters coordinated the Census of activity.
All UK hospitals had a Local Reporter in place for the duration of the project. 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: [email protected] .
On-line data submission
After notification of an event the Local Reporter worked with the anaesthetists involved in the patient’s care. For each event a specific username was supplied to the Local Reporter by the RCoA. This enabled secure password protected access to a secure area of the DAS website. Before submitting data the person submitting data was required to create their own password. The combination of a username and password ensured that only the person entering data had external access. The DAS project lead was able to read the entered data and judge if more data was required. If more data was needed, the DAS project lead re-opened the file and issued a request via the DAS website to the Local Reporter for more data on the web-based form. The DAS project lead was blind to the identity of the recipient of the electronic communication. When a report was closed and complete the link between the log-on code and the submitted data was broken and there was no identifiable connection between RCoA reporting and data on the DAS website.
Confidentiality
The RCoA audit lead had access to the date and hospital location of every notified event. The College or its representatives was prevented from linking these data to events within the database by the password selected by the individual submitting data. The DAS audit lead had access to specific details within the database but had no information on hospital location, identity of the patient or of the doctors. No data identifying a patient or anaesthetist was be requested, and if entered it was be removed. Neither organisation will be able to link the two separate sets of data.
Data collection forms
To enable the audit team to gain a clear picture of the event the data collection form was extensive. Questions were not posed to judge colleagues or to imply criticism. Questions were framed to seek the information we believed would 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 who reported 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 was complete the electronic identity of each file was changed.
Moderator
Dr Ian Calder acted as a moderator. His was available to advise Local Reporters if they were unsure about inclusion criteria or the data to be submitted. He was independent both of the RCoA and DAS.
Data analysis
The reported cases are currently being 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. The information packs and forms are still available for examination on the DAS and RcoA web-sites.
Powerpoint presentation
A Powerpoint presentation about the project 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.
Publication Dates
The Census will be published online by the British Journal of Anaesthesia in October or November 2010.
It is anticipated that the final paper will, if accepted, be published in Early 2011.
A Launch Day is planned for March 30th at the RcoA in London.
The Final detailed report of the NAP4 audit will be presented at the Launch meeting in March 2011.
Thank-you for your help.
Dr Nick Woodall e-mail: [email protected]
Dr Tim Cook e-mail: [email protected]
Co-Audit Leads, 4th National Audit Project (NAP4)
