Human factors in Airway Management – The “SMART” Approach© Ravi Dravid Project Lead for Human Factors Difficult Airway Society Ravidravid@das.uk.com Ravi.Dravid@kgh.nhs.uk ‘copyright © 2009 Ravi Dravid’

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

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

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

FATAL ACCIDENT INQUIRY into the death of Mr. GORDON EWING http://www.scotcourts.gov.uk/opinions Victoria Infirmary ,Glasgow 2006

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 .....

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 .....

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,

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

Optimum cue utilisation ?? Situation awareness Arousal (Stress)

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

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)

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)

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

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

We therefore looked at experiences from other industries

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

Another industry – what happens in Aviation

SMART©

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

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

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

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’

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

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

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

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

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

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

I love my beer!!

LMA ProsealTM

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)

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

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)

Ofcourse SMART Improves safety!!

National level...

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

Trevor Dale Trevor Dale Guy Hirst

Evaluation of the Course overall

“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

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

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

‘SMART’ COURSES-2011 One day courses -technical skills & Non-technical skills in airway management   Wales 21 January 2011 Kent 11 February 2011 Torquay 18 March 2011 Coventry April 1, 2010 Kent 13 May 2011   For further details www.das.uk.com

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

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