National Airway Project

The 4^thNational Audit Project (NAP 4) seeks to increase our knowledge of the frequency and nature of major airway complications occurring in UK hospitals. This ambitious project is being conducted jointly by the Royal College of Anaesthetists (RCoA) and the Difficult Airway Society (DAS) There has been wide consultation before embarking on this project and current partners include the National Patient Safety Agency (NPSA), the Association of Paediatric Anaesthetists (APA) the College of Emergency Medicine (Coll EM), the Intensive Care Society (ICS), the Intensive Care National Audit and Research Centre (ICNARC) and the College of Operating Department Practitioners (Coll ODPs).

The project closely follows the model used for the successful 3^rd National Audit Project (NAP3) of central neuraxial blockade. Between September 2008 and August 2009 NAP4 will determine the incidence of major complications of airway management in UK anaesthetic practice. To achieve this objective we will undertake a snapshot of current airway management techniques in use (providing the denominator), and prospectively collect details of major complications over one year (to provide a numerator). In addition all reported cases will be reviewed to determine patterns and learning points.

The snapshot phase

A short survey will be undertaken to identify the number and variety of airway management techniques used during a two-week period. These data will be needed to calculate annual usage and should provide a valuable insight into current clinical practice.

The prospective phase

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

• Death
  
• Brain damage
  
• Emergency surgical airway or needle cricothroidotomy
  
• Unanticipated ICU/HDU admission

Airway problems with these endpoints are likely to be:

• Difficult or delayed intubation
  
• Failed intubation
  
• Failed mask ventilation (including supraglottic airways)
  
• CICV - the can’t intubate can’t ventilate scenario.

To be successful the project requires that the project team is notified of every such event during the year long project. Complete notification will allow us to most accurately calculate the incidence of major airway complications in UK anaesthetic practice.

The project will also seek reports of these events occurring in the emergency room and intensive care unit whether treatment involves an anaesthetist or not.

All such cases (anaesthesia, ED and ICU) will be reviewed for learning points and used to promote cross-specialty learning.

Local Reporters

A network of Local Reporters (LRs) was established for National Audit project 3 with one LR in every UK NHS hospital. Local Reporters played a central role in ensuring that essential information was passed to the project team. The network of LRs will once again be central in NAP4 and we anticipate that in many cases the existing LR will continue in this role. In some cases the role of LR will pass on to someone with a specific interest in airway management and member of the DAS may wish to use this opportunity to take an active role in the project.

The role of the local reporter will be 1) to collect data for the snapshot phase of the project and 2) to co-ordinate the process whereby each case of major airway complications is notified to the project team. The anaesthetists engaged in this process may have suffered personal trauma arising from an incident they report. It is likely that the LR will also have a role supporting such colleagues. It will be possible for the local reporter to submit information on behalf of another anaesthetist if they are not able to do so for any reason.

NAP4 notification and data submission

Data collection for the prospective phase will be a two stage process; stage 1-notification and stage 2-data submission.

Stage 1Notification

When an event occurs, the project team (at the RCoA) should be informed of any case fitting the inclusion criteria. Notification may be by E-mail (tcook@rcoa.ac.uk) or by telephone. The essential information required will be the hospital name, the date and time of the event and the name of the person reporting it. The identity of the patient must not be submitted. In response, the LR at the hospital where the event took place will be issued with a unique log-on code.

Stage 2 on-line data submission

A full report of the case will be submitted to a secure part of the DAS website. Submission will require the unique code previously sent to the LR. The LR will work with the anaesthetist involved in the patient’s care during submission, both in compiling the report and providing support as necessary. Once a report is complete the link
with the original log-on code will be permanently broken.

Confidentiality

The RCoA will only have access to information on the time and location of events. The DAS will have details of events but no patient or anaesthetist identifying data. No attempt will be made to identify patients or doctors involved. Neither organisation will be able to link datasets without co-operation of the other. All data will be treated as confidential. No data will be passed on to any other organisations outside the review group.

Data collection forms

These are very detailed in order to enable the project team to gain a clear picture of the events that have taken place. Questions are not posed to judge colleagues or to imply criticism. Questions are framed to seek the information necessary to determine themes and learning points arising from reports of these challenging cases. We have designed the process carefully in an attempt to maintain complete anonymity and confidentiality while ensuring a straightforward but detailed reporting process. When data submission is complete the link with the original notifying data will be permanently broken.

Data analysis

The frequency and incidence of complications will be calculated. Anonymous case reports will be reviewed by a selected panel of practising clinicians, in an attempt to maximise learning points. It is anticipated that the full report will be available early in 2010.

Project Approval

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

Additional information

Supplementary up-to-date information on the process will be made available from the both the DAS and RCoA websites or directly from Tim Cook or Nick Woodall, co-leads for the project.