Advanced airway management in patients with a known complex disease
Published
Acute
Respiratory
This investigation explores intubation of patients with difficult airways. There are no standards for how an anticipated difficult airway is managed. Failure to provide an adequate airway can result in brain injury or death.
4 recommendations
3 observations
1 action
4 of 4 responded
Safety Recommendations (4)
NHS England
R/2024/013
HSSIB recommends that NHS England identifies and implements a system for sharing clinical information about people with a known difficult airway. This is to improve access to this information for healthcare professionals and reduce the risk of a person’s known difficult airway not being recognised.
NHS England commits to establishing a database for patients with known difficult airways, collaborating with stakeholders to define dataset and data flow, but the timelines for obtaining information governance approval and full platform development are TBC.
NHS England will establish a database of patients in which prior airway management has been difficult, and thereby meet the recommendation above. The work will be undertaken collaboratively with key professional stakeholders (including the Royal College of Anaesthetists (RCoA) and Difficult Airway Society (DAS)), patients, carers and public. Actions planned to deliver safety recommendation: Collaborative work with DAS and RCoA to develop dataset to be included in the database. By: ongoing. Set up a clinical and patient steering group. By: ongoing. Define data flow and data specification. By: October 2024. Obtain information governance approval. By: TBC. Develop and publish platform including pilot phase. By: TBC. Response received on 15 May 2024.
Royal College of Anaesthetists
R/2024/014
HSSIB recommends that the Royal College of Anaesthetists works with the Difficult Airway Society and other key stakeholders to produce a framework on the management of a potentially ‘life threatening’ difficult airway for people with a known difficult airway who require advanced airway management. This work should consider the adoption of a common language which defines and explains principles for treating people with a known potentially ‘life threatening’ difficult airway who require advanced airway management. This could optimise the chances of survival for people who experience a life-threatening airway emergency.
The Royal College of Anaesthetists, in collaboration with partners, is undertaking a scoping exercise by November 2024 to define a framework for managing known difficult airways, considering complexity and resource constraints.
The airway management of patients with a known difficult airway is complex and does not lend itself to the style of guidance that has been developed by the Difficult Airway Society for patients with an unknown difficult airway and adopted throughout UK anaesthetic practice. The scope of any framework therefore needs to be carefully defined in order to ensure that it has the maximum impact to improve airway management practice and thus improve outcomes for patients with a known difficult airway. The Royal College of Anaesthetists (RCoA), the Association of Anaesthetists and the Difficult Airway Society (DAS) are working together to scope a framework that will maximise impact within our resource constraints as charities. Action planned to deliver safety recommendation: Undertake a scoping exercise for a framework for the airway management of patients with a known difficult airway, by November 2024. Response received on 18 April 2024.
Royal College of Anaesthetists
R/2024/015
HSSIB recommends that the Royal College of Anaesthetists makes changes to its Guidelines for the Provision of Anaesthetic Services (GPAS) requirements for all anaesthetists, to include guidance on: requirements for anaesthetists to have access to videolaryngoscopes in all locations where anaesthesia is delivered and airway management takes place requirements for all anaesthetists to be competent and skilled in the use of videolaryngoscopes requirements for anaesthetists to be regularly updated on airway rescue techniques, such as emergency front of neck airway requirements for anaesthetists and anaesthetic assistants to be regularly updated on other equipment that may be used in airway emergencies. This will support anaesthetic staff to become familiar with and competent in the use of airway rescue equipment and techniques available locally.
The Royal College of Anaesthetists will consider and integrate the recommended changes regarding videolaryngoscope use, competence, and airway rescue techniques into the next annual update of its GPAS requirements, due by January 2025.
The Guidelines for the Provision of Anaesthetic Services (GPAS) are updated on an annual basis. This is to ensure that GPAS recommendations are in line with the latest available evidence. The changes recommended will be considered by the authors and integrated into the next version of GPAS. These GPAS recommendations will feed into the standards for our Anaesthesia Clinical Services Accreditation (ACSA) scheme, which will help to promote their implementation. Action planned to deliver safety recommendation: Updated version of GPAS republished, by January 2025. Response received on 18 April 2024.
Royal College of Anaesthetists
R/2024/016
HSSIB recommends that the Royal College of Anaesthetists works with the Association of Anaesthetists and relevant key stakeholders to implement critical incident training for all anaesthetists and anaesthetic assistants. This should include consideration of scenario-based training and include the principles for the management of an expected or unexpected difficult airway using advanced airway techniques, including videolaryngoscopy and emergency front of neck airway.
The Royal College of Anaesthetists will undertake a scoping exercise by November 2024, with partners, to identify ways to improve critical incident training and anaesthetists' access to it, acknowledging current barriers.
The importance of multidisciplinary team training for crisis situations is well embedded in our guidance and the standards of our Anaesthesia Clinical Services Accreditation (ACSA) scheme. We support the provision of local airway training for anaesthetists through our network of airway leads. We know that one of the main barriers for anaesthetists to access regular scenario-based critical incident training is being given the time and support from their employers to undertake this training. In collaboration with the Difficult Airway Society and the Association of Anaesthetists, we therefore plan to undertake a scoping exercise to identify what we can do to improve critical incident training and anaesthetists’ access to it within our resource constraints as charities. Action planned to deliver safety recommendation: Undertake a scoping exercise for improving critical incident training for anaesthetists, by November 2024. Response received on 18 April 2024.
Safety Observations (3)
Healthcare organisations that commission elective (planned) surgical services for people with mucopolysaccharidoses (MPS) can improve safety by involving healthcare professionals from different disciplines who are experienced in airway evaluation and management, before, during and after a person’s surgery.
Healthcare organisations could improve safety of the management of difficult airways by procuring equipment that has evidence of safety by design and robust user testing and assessment.
Healthcare providers can improve patient safety by supporting and encouraging anaesthetic staff, anaesthetic assistants and operating department practitioners to become familiar with and experienced in the use of airway rescue equipment and techniques available locally, including videolaryngoscopy.
Safety Actions (1)
The British Inherited Metabolic Diseases Group has amended the content of their guidance with specific reference to specialist guidance from the Royal College of Anaesthetists and the Difficult Airway Society in relation to videolaryngoscopy and incorporating reference to both planned and unanticipated/acute airway interventions.