Chapter 34 – Departmental and Hospital Organisation

Abstract

Although an individual anaesthesia provider secures the patient’s airway, upstream organisational events will influence how airway management is actually performed in any institution. Decisions around equipment purchases, staff training, post-operative care arrangements and even departmental staffing will all influence how an anaesthetic is administered. While standardised equipment, and high quality protocols, guidelines and behaviours ensure better patient outcomes in the event of an airway emergency, this cannot be achieved without input from the institution to facilitate education and training for all airway team members. Organisations should learn from both critical incidents and examples of excellent practice, and have mechanisms to record airway events. Human factors (ergonomics) are a vital component of successful airway management and organisations should incorporate human factors education in their airway training programmes. Communication about patients known to have a difficult airway is vital and must be done effectively, especially when this involves communication between hospitals or even countries.

Chapter 34 Departmental and Hospital Organisation

Lauren Berkow and Alistair McNarry

Airway management does not happen in isolation. Although an individual secures the patient’s airway, many upstream organisational events will influence how airway management is actually performed. Decisions concerning equipment purchases, staff training, post-operative care arrangements and even departmental staffing will all influence how an anaesthetic is administered.

Hospitals and departments should invest in an organised and standardised approach to airway management both inside and outside the operating theatres.

The 4th National Audit Report of the Royal College of Anaesthetists and the Difficult Airway Society (NAP4) is discussed elsewhere in this book. However, it is noteworthy that many of the 168 recommendations were directed towards institutions as much as to individuals.

The ‘Organisation and equipment’ chapter in NAP4 challenges anaesthetic departments to:

Provide leadership for airway management throughout their entire organisation
Standardise equipment across all sites in a hospital where an airway might be managed (e.g. critical care and emergency departments should have the same airway equipment as the operating theatres)

In order to have a full complement of airway devices available for use in any location and at any time, several upstream issues must be addressed:

1. The airway device is available within the institution
2. It is stocked in all locations where it may be needed
3. It is functional (batteries, leads, connectors and blades are available)
4. Documented procedures exist for its cleaning (if appropriate)
5. The clinician is at least proficient in its use
6. An institutional plan exists recognising that all airway devices can fail and that backup equipment must be immediately available if the chosen device proves ineffective.

Role of the Organisation

The responsibility for acquiring training and experience with a particular device may lie with the individual clinician; however, ongoing training and the development of expertise will require departmental and institutional involvement. Adequate time should be allocated for clinicians to receive training.

NAP4 identified deficiencies in areas including preoperative airway assessment, and whilst conduct of the assessment remains an individual responsibility, institutions should provide space to conduct, scheduling to enable and resources to facilitate the necessary assessments and investigations required.

The organisation should allocate time for morbidity and mortality/quality improvement conferences that review challenging cases, address gaps and needs related to safe airway management, and discuss improvement plans and initiatives. As part of these, an environment should be created in which individuals are empowered to report mishaps and near misses. Institutions need to embed and support a ‘no-blame’ culture similar to that seen in the airline industry to avoid the reporting clinician becoming the ‘second victim’ in any adverse airway event. Such meetings must identify and address departmental and institutional factors (e.g. related to staffing, equipment availability or training) that may have contributed to the event, in order to reduce the likelihood of recurrence.

Airway Leads and Airway Teams

Airway Leads in the United Kingdom (UK)

NAP4 also called for an identified individual within an organisation to take responsibility for dealing with the organisational aspects of difficult airway management, a position endorsed by the Royal College of Anaesthetists in 2012. Airway leads were to be appointed in all hospitals and an outline of their duties is shown in Table 34.1. Currently, the airway lead system is essentially universal in UK hospitals. The project has been rolled out in Ireland and New Zealand and is progressing in Australia. Important roles of the airway lead include staff education, coordination between departments (e.g. anaesthesia, intensive care, emergency departments) and liaison with management and procurement to optimise patient safety and ensure availability of appropriate airway equipment. The presence of an airway lead does not remove the need for individual responsibility but does provide a central departmental point of contact for airway-related issues.

Table 34.1 Major responsibilities of a UK airway lead (for complete list see http://www.nationalauditprojects.org.uk/NAPAirwayLeads)

Operations:
Ensure airway equipment is appropriate and standardised as per airway guidelines
Ensure local policies exist for airway management emergencies and facilitate their dissemination
Liaise with other departments (ICU, ED) to ensure consistent standards and practices
Assure consistency with airway assessment and planning

Safety:
Overseeing airway audits and compliance with guidelines
Assist with national surveys and audits

Education:
Overseeing and expanding local airway training for all those involved in airway management

Airway Teams in the United States of America (USA)

Some hospitals in the USA have formed multidisciplinary airway teams to manage difficult airway patients and who focus on improving organisational preparedness. Team success relies on a multidisciplinary approach, education and training of team members on airway devices and algorithms, as well as simulation and team training. Table 34.2 describes several airway teams that have published data on outcomes.

Table 34.2 Examples of multidisciplinary airway teams in the USA

Hospital/Institution	Team Members	Equipment	Education/Training	Outcomes measured
Johns Hopkins Difficult Airway Response Team (DART)	Anesthesiology Otolaryngology Trauma surgery Emergency medicine	Specialised cart (trolley) with flexible and rigid bronchoscopes, supraglottic airways and tracheostomy set	Airway course held quarterly Simulation and skills training In situ simulation Crisis management and team training	Airway-related adverse events and malpractice claims reduced to zero
Grant Medical Center Alpha Team	Anesthesiology Trauma surgery Respiratory therapy Pharmacist	Portable airway case	Simulation training Didactic seminars Equipment training	No deaths related to airway management in first year of programme
Boston Medical Center Emergency Airway Response Team (EART)	Anesthesiology Otolaryngology Trauma surgery Emergency medicine Nursing Respiratory therapy	Airway carts	Simulation training	None published to date