1. Sydney Clinical Skills and Simulation Centre Management of the Critically Obstructed Airway Session 6: Managing Transition - 7 failure factors and strategies Acknowledgement: Leonie Watterson

2. Background Incidence of CICO 1/50,000 NAP4 While I am not satisfied that any one person caused or contributed to the problems incurred, I do consider the community does not expect a (healthy young person) to die in a major teaching hospital from airway compromise in these circumstances. Coroner for Jankowski case

3. CICO – 7 failure factors UncertaintyAmbiguous communicationHuman factorsTeam assertivenessPreparationTimeNeglect of supraglottic rescue

4. CICO: 7 failure factors – 7 strategies 1 Uncertainty

5. CICO: 7 failure factors – 7 strategies 1 Uncertainty Make decisions methodically - Reduce uncertainty with systems design - Use an algorithm - Speak up and share information so everyone understands the situation - Invite input from people - Seek help from experts as time permits

6.  Have clear triage criteria for the obstructed airway  Prioritise urgency of surgery  Do a good pre-op assessment and choose an intubation technique that corroborates with pre-op findings  Have a clinical guideline for steroids, Abs, drains etc  Be aware of risks of extubation and have broad criteria for extubation  Be aware of delayed obstruction from and have broad criteria for discharge from ICU and post-op monitoring  Have some agreed principles of activating a CICO Reducing uncertainty with system design (avoiding CICO)

7. Best attempt at: Face-mask ventilation? LMA ventilation? Endotracheal intubation? AND Oxygen saturations falling or persistently low? Is this a CICO situation? INFRAGLOTTIC RESCUE YES Continue Supraglottic rescue Consider waking patient Review again in 1 min Continue Supraglottic rescue Consider waking patient Review again in 1 min With permission A. Heard and Working group for the Rural Health Continuing Education (RHCE) (Stream 1) ‘Critically Obstructed Airway Workshop’. Contact smsc@nsccahs.health.nsw.gov.au. 2013smsc@nsccahs.health.nsw.gov.au NO TRANSITION ‘Transition’ protocol - CICO MOBILISE RESOURCES FOR CICO

8. CICO: 7 failure factors – 7 strategies 2 Ambiguous communication

9. CICO: 7 failure factors – 7 strategies 2 Ambiguous communication Commit to your decision Declare CICO clearly

10. CICO: 7 failure factors – 7 strategies 3 Human factors

11.  Inadequate experience  First time with a situation  Time pressure  Bad ‘learnt’ behaviours  Cultural norms  Reckless/disrespectful attitude  Complex system (inheriting bad situations)  H.A.L.T (Hungry, Angry, Late, Tired)  IM SAFE (Illness, Medication, Stress, Alcohol, Fatigue, Emotion) Anxiety Human factors - What drives us to underperform?

12. CICO: 7 failure factors – 7 strategies 3 Human factors Practice mindfulness to manage your performance - Manage your stress - Control your voice - Ask for assistance - Accept input from others

13. Staying calm and in control  Appear calm Speak calmly: a low and slow voice Use calming body language (lowering hands) Avoid offensive language Use humour Provide updates and reassure people E.g., ‘Everything is going well’, ‘That’s great’, Everything’s fine’, ‘The situation is under control’  Stay calm Apply H.A.L.T Take deep breaths Practice self-talk (Don’t lose control!!!!)

14. CICO: 7 failure factors – 7 strategies 4 Team assertiveness

15. Assertiveness – Why is it difficult to speak up?  Personality factors  Cultural factors Fear of confrontation, ostracism, chastisement from management  Situational factors Shock Uncertainty Not in the best interests of the patient Opportunity passes

16. Mitigation – ‘Hint & Hope’ 1.Command – ‘You must...’ 2.Crew obligation statement – ‘We need to...’ 3.Crew suggestion – ‘Why don’t we...?’ 4.Query – ‘What would you like to?’ 5.Preference – ‘I think It would be a good idea to...’ 6.Hint – (obtuse reference to cause of problem) In the event of a hypothetical evolving potentially fatal accident pilots indicated they would:  Captains - command (Level 1)  First officers - hint (Level 6) Judith Orasanu

17. Graded assertiveness Express initial concern (‘I’ statement) ‘I notice that…that seems a little unusual’ Make an enquiry or offer an alternative ‘Why don’t we try …’ Ask for an explanation ‘I don’t understand – please explain your actions to me’ Demand a response or take control of the case ‘Stop - you must listen to me!’

18. 7 failure factors – 7 strategies 4 Team assertiveness Keep the situation calm Think aloud Invite colleagues to speak up Have a non-procedural teamleader Avoid conflict - negotiate differences

19. CICO: 7 failure factors – 7 strategies 5 Preparedness

20. CICO: 7 failure factors – 7 strategies Equipment – familiar to all and readily available Staff – trained Plan – known to everyone Teamwork – roles and leadership clarified Resources – assistance on standby 5 Preparedness

21. CICO: 7 failure factors – 7 strategies 6 Time

22. Can the plan be carried out in 45 secs?  Call it a CICO and call for help  Get the cricothyroidotomy kit, set it up  Get the jet ventilation device and set it up  Perform the technique and oxygenate the patient

23. CICO: 7 failure factors – 7 strategies 6 Time During supraglottic rescue… - Ensure that help has been called for - Mobilise resources - Forecast the (possible) need for infraglottic rescue

24. CICO: 7 failure factors – 7 strategies 7 Neglect of supraglottic rescue

25. CICO: 7 failure factors – 7 strategies 7 Neglect of supraglottic rescue Continue supraglottic rescue in parallel with infraglottic rescue

26. CICO: 7 failure factors – 7 strategies 1 Uncertainty2 Ambiguous communication3 Human factors4 Team assertiveness5 Preparation6 Time7 Neglect of supraglottic rescue 1 Use an algorithm2 Declare CICO clearly 3 Practice mindfulness to manage your performance 4 Invite input from team members 5 Always be prepared for CICO and infraglottic rescue 6 Mobilise resources for infraglottic rescue during supraglottic rescue 7 Continue supraglottic rescue in parallel with infraglottic rescue