1. Human factors in Airway Management – The “SMART” Approach©
Ravi Dravid
Project Lead for Human Factors
Difficult Airway Society
‘copyright © 2009 Ravi Dravid’

2. Concept of an “Airway Team”? NTS training - SMART Approach

3. Mum died after medics failed to act decisively
Daily Mail 12 December 2006 3

4. Airway death… 2005 37 yr for elective nasal surgery
No other health issues and examination unremarkable
Anaesthetic Plan – One routinely used in the UK
Unanticipated difficulty putting tube in the wind pipe (tracheal intubation) and managing Oxygen supply
Didn’t realise ‘no oxygen levels’ for 35 minutes 4

5. FATAL ACCIDENT INQUIRY into the death of Mr. GORDON EWING
Victoria Infirmary ,Glasgow
2006

6. Preoperative assessment
44 yr old, for fixation of fracture right little finger
Previous GA, 6 weeks ago uneventful
Large BMI >40, 124 kgs
Wanted general anaesthetic
Mr Ewing came for .....

7. Anaesthetic Management
Anaesthesia started
Unable to secure tube in windpipe
Sequence of events
Spiralled out of control
Progressive swelling
Could not deliver oxygen
Death
Mr Ewing came for .....

8. Both elective procedures Very experienced clinicians and teams
My views..
Both elective procedures
Very experienced clinicians and teams
Not adequate planning and plans sharing
Deviation from ‘agreed’ procedures
Role delegation to team members
Leadership
Communication
Hierarchy
Situation awareness
There are quite a few similarities in these two cases
Both situations Both were elective procedures
There were very experienced teams managing them – not only anaesthetists but those helping them as well
These experienced anaesthetists got sucked into sequence of events which spiralled out of their control
Team members were unaware of their role in managing the situation – led to ineffective team working
There were communication leadership and hierarchical issues,

9. Easter Brooks Hypothesis (Psychological review Vol 66 No 3 1959)
Why this happens?
Easter Brooks Hypothesis (Psychological review Vol 66 No )

10. Optimum cue utilisation
?? Situation awareness
Arousal (Stress)

11. Concept of an “Airway Team”? NTS training - SMART Approach
Both these cases I have just shown you are post normal scenarios – where events are constantly evolving, outcomes are uncertain and time available is very short
I thought a lot about this – how situation awareness and decision making could be improved in these stressful situations

12. Optimum cue utilisation
Resources and interventions!!
Optimum cue utilisation
I am of the view therefore it is very vital that all the resources, all the interventions and structured inputs are directed very early during arousal
?? Situation awareness
Arousal (Stress)

13. Optimum cue utilisation
Resources and interventions!!
Optimum cue utilisation
Certainly while the anaesthetists is still on the plateau phase so a rational decision is made
?? Situation awareness
Arousal (Stress)

14. Optimum cue utilisation
Resources and interventions!!
Optimum cue utilisation
?? Situation awareness
Arousal (Stress)

15. Optimum cue utilisation
Resources and interventions!!
Optimum cue utilisation
?? Situation awareness
Arousal (Stress)

16. We therefore looked at experiences from other industries

17. Team working Pre-designated roles
All because they are aware of their individual roles and fantastic team working
And they are trained over and over again to carry out all the tasks in 7-8 seconds

18. Another industry – what happens in Aviation

19. SMART©

20. ‘copyright © 2009 Ravi Dravid’
SMART©
S tructured
M anagement
A irway
R esponse
T eam
‘copyright © 2009 Ravi Dravid’

21. Will team approach help? (Improve efficiency)
Airway Response Team (The Johns Hopkins Institute, Boston, Massachusetts) 21

22. SMART approach© (Available in Operating Environment)
1st Anaesthetist
ODP
Nurse 1 / Scrub nurse
Nurse 2 / Floor nurse
Surgical Team member
2nd Anaesthetist
‘copyright © 2009 Ravi Dravid’
My own thinking is why do we need a dedicated team sitting in one corner we have all the staff in theatres why cant we pre-designate roles and we have a number of airway teams in each theatre areas
We wont need extra resources, there would be better staff involvement and patient safety would improve as well 22

23. Airway Team Pilot© (With pre-designated roles for team members)
So we looked if we could apply similar team approach and build our own airway team with pre-designated roles to team members that we assemble on a daily basis
We conducted the Pilot to look at the feasibility of creating our Airway team. We asked our teams to manage an unanticipated difficult airway scenario first then asked them to manage a second time with pre-designated roles for each team members. We video recorded the pilot and asked independent experts who were blinded to the pilot methodology to assess with emphasis on management and non-technical skills
In short WE LOOKED IF members’ awareness or roles structured and streamlined the management
Both team members and independent assessors reported improved management with pre-designated roles to team members
How does the management of this scenario progress?
The first anaesthetist managing anaesthetic with the help of his ODP would calls for help and maintains communication with his colleagues while he manages the airway
If the anaesthetist has not already called for help,
The ODP suggests to the anaesthetist to request for help if
Anaesthetist fails to intubate after four attempts
Or if saturations continue to fall below 90%
Or if a two person bag mask ventilation is unsuccessful
Or even without drop in saturation the anaesthetist struggles for more than 5 minutes
He remains with the anaesthetist all the time to help
When the first nurse arrives she is supposed to re-adjust the monitoring and provide verbal alerts to the anaesthetist at regular intervals about the saturations and vital parameters and maintain a written record of all events and interventions
Second nurse brings in difficult airway trolley and fast bleeps the second anaesthetist and the surgical colleague if he is not nearby
And returns and awaits further instructions
The second anaesthetist takes over the management or helps depending on his seniority or stress levels of the first anaesthetist and helps with appropriate DAS guidelines management plans
When the second anaesthetist arrives he provides a very structured information about the patient, surgery and about the DAS plan A/B/C and reasons for failure
And depending on his or her seniority either continues management or hands over to the 2nd anaesthetist
The surgical colleague helps with venous access, surgical cricothyroidotomy or communication
Presented: Difficult Airway Society Annual Scientific Meeting, Liverpool 2008
‘Copyright © 2009 Ravi Dravid’

24. Introducing SMART in our Trust
Briefing / Debriefing / Pre-designated roles
WHO Checklist implementation
Training teams
We were sure we had to make a start and i will show you how we went about introducing SMART in our own trust 24

25. Pre-flight (Before list) checks Pre-flight (Before list) Briefing (3 Ps) People, Patient, Plan / protocol Roles allocation (During incident) Debriefing and review (After incident)
It is a massive cultural change but we had to make a beginning
For the past 2 years we have developed a clinical model to use in routine anaesthesia practice?
Pre flight checks of equipment trolley and its location confirmed
The anaesthetist would have a short briefing meeting with all the team members to appraise about the patients on the list any one with anticipated difficulty and how he would manage? In case of unanticipated difficulty what would be his priority? What would the ODP do? What would be the roles of the other team members?
Manage the scenario according to the roles allocation We have actually developed laminated prompts for our staff in anaesthetic rooms
Fortunately for us WHO Checklist was god sent 25

26. Difficult Airway
I took over as clinical lead for the checklist implementation

29. SMART (c) Roles Laminates First anaesthetist ODP/ Anaesthetic nurse Theatre staff 1 Theatre staff 2 Surgical colleague Second anaesthetist

30. Does SMART work?
I can not provide you with evidence but i can share with you three incidents which happened in our trust

31. Friday 19 March 2010... Day case unit at Kettering General ..
Anaesthetist late arrival..
Surgeon pacing up and down ...
Three patients on List ..

32. I love my beer!!

33. LMA ProsealTM

34. Tuesday 24 July 2010... General surgery theatre at Kettering...
Thyroidectomy...
BMI 42 / beard / Unanticipated grade 4
Consultant and trainee anaesthetist (4 attempts; all blades tried)..
Oxygenation and ventilation with LMA..
“Staged” Briefing!!
(Equipment/roles/plans up until extubation)

35. SMART – NTS Techniques / highlights
Team formation and role allocation
Briefing - ‘Pre-list’ and ‘staged’
Debriefing
‘copyright © 2009 Ravi Dravid’

36. Day case theatres at Kettering....
SAS doing solo list...
Post-extubation spasm cyanosis...
Consultant called to help...
Nursing team
DA trolley ready,
noting down/alerting time and sats,
getting equipment ready and even assembling Manujet and cric equipment)

37. Ofcourse SMART Improves safety!!

38. National level...

39. SMART course © (For Anaesthetist-ODP team) “Train together those who work together” Free for ODPs
Technical faculty – anaesthetists
and
Non-technical faculty – Human factors experts from Airlines industry
What have we done to train others??
If we were to change culture in NHS we must train teams – absolutely vital and crucial
Theatre staff are our allies and we can not improve safety till we both
‘copyright © 2009 Ravi Dravid’ t

40. Trevor Dale
Trevor Dale
Guy Hirst

41. Evaluation of the Course overall

42. “Involvement and Ownership”
Spinoffs!!
“Involvement and Ownership”
The biggest positive outcome for our society is that it has given a sense of involvement and ownership to our grassroot members, anaesthetists and our ODP colleagues.
They have taken upon themselves to use SMART and the techniques in their respective hospitals – some have already started using them,
Some are arranging DAS technical workshops on our format
People have approached from different centres with simulation facilities to hold these in their centre so a lot of local members could easily attend and they have offered to be local coordinators. That is exactly what our vision was to begin with – to spread it around.
I have a huge number of mails from those who have attended and from their colleagues asking for new dates
We have interest from delegate anaesthetic consultants to learn and facilitate on these courses both on technical and non-technical stations
What I did was keep doors open for senior registrars and some interested consultants to come and observe the proceedings so now they have learnt a lot and are enthusiastic to get involved and take it forward

43. Challenges.. Resources Time off for theatre staff
CHFG support for time off and resources

44. Kettering / Oxford / Coventry (DAS supported SMART Course ©)44

45. ‘SMART’ COURSES One day courses -technical skills & Non-technical skills in airway management   Wales 21 January Kent 11 February Torquay 18 March Coventry April 1, Kent 13 May 2011   For further details

46. Elaine Bromiley Gordon Ewing
Remember everytime you anaesthetise we owe it to them and their families we have to work to change the culture to improve safety

47. “Never doubt that a small group of committed people can change the world, indeed it is the only thing that ever has”.
Margaret Mead