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Chrimes N, Higgs A, Hagberg CA, Baker PA, Cooper RM, Greif R, Kovacs G, Law JA, Marshall SD, Myatra SN, O'Sullivan EP, Rosenblatt WH, Ross CH, Sakles JC, Sorbello M, Cook TM. Preventing unrecognised oesophageal intubation: a consensus guideline from the Project for Universal Management of Airways and international airway societies. Anaesthesia 2022; 77:1395-1415. [PMID: 35977431 DOI: 10.1111/anae.15817] [Citation(s) in RCA: 71] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/12/2022] [Indexed: 01/07/2023]
Abstract
Across multiple disciplines undertaking airway management globally, preventable episodes of unrecognised oesophageal intubation result in profound hypoxaemia, brain injury and death. These events occur in the hands of both inexperienced and experienced practitioners. Current evidence shows that unrecognised oesophageal intubation occurs sufficiently frequently to be a major concern and to merit a co-ordinated approach to address it. Harm from unrecognised oesophageal intubation is avoidable through reducing the rate of oesophageal intubation, combined with prompt detection and immediate action when it occurs. The detection of 'sustained exhaled carbon dioxide' using waveform capnography is the mainstay for excluding oesophageal placement of an intended tracheal tube. Tube removal should be the default response when sustained exhaled carbon dioxide cannot be detected. If default tube removal is considered dangerous, urgent exclusion of oesophageal intubation using valid alternative techniques is indicated, in parallel with evaluation of other causes of inability to detect carbon dioxide. The tube should be removed if timely restoration of sustained exhaled carbon dioxide cannot be achieved. In addition to technical interventions, strategies are required to address cognitive biases and the deterioration of individual and team performance in stressful situations, to which all practitioners are vulnerable. These guidelines provide recommendations for preventing unrecognised oesophageal intubation that are relevant to all airway practitioners independent of geography, clinical location, discipline or patient type.
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Affiliation(s)
- N Chrimes
- Department of Anaesthesia, Monash Medical Centre, Melbourne, Australia
| | - A Higgs
- Department of Anaesthesia and Intensive Care, Warrington Teaching Hospitals NHS Foundation Trust, Cheshire, UK
| | - C A Hagberg
- Department of Anaesthesiology and Peri-operative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - P A Baker
- Department of Anaesthesiology, University of Auckland, New Zealand.,Department of Anaesthesiology, Starship Children's Hospital, Auckland, New Zealand
| | - R M Cooper
- Department of Anesthesiology and Pain Medicine, University of Toronto, ON, Canada
| | - R Greif
- Department of Anesthesiology and Pain Medicine, Bern University Hospital, University of Bern, Switzerland.,Department of Medical Education, Sigmund Freud University, Vienna, Austria
| | - G Kovacs
- Departments of Emergency Medicine, Anesthesia, Medical Neurosciences and Division of Medical Education, Dalhousie University, Halifax, Canada
| | - J A Law
- Department of Anesthesia, Pain Management and Peri-operative Medicine, Dalhousie University, Halifax, Canada
| | - S D Marshall
- Department of Critical Care, University of Melbourne, VIC, Australia.,Department of Anaesthesia and Peri-operative Medicine, Monash University, Melbourne, VIC, Australia
| | - S N Myatra
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - E P O'Sullivan
- Department of Anaesthesiology, St James's Hospital, Dublin, Ireland
| | - W H Rosenblatt
- Department of Anesthesia, Yale School of Medicine, New Haven, CT, USA
| | - C H Ross
- Department of Emergency Medicine, Mercy Health, Javon Bea Hospital, Rockton and Riverside Campuses, Rockford, IL, USA.,Department of Surgery, University of Illinois College of Medicine, Chicago, IL, USA
| | - J C Sakles
- Department of Emergency Medicine, University of Arizona College of Medicine, Tucson, AZ, USA
| | - M Sorbello
- Anesthesia and Intensive Care, AOU Policlinico San Marco University Hospital, Catania, Italy
| | - T M Cook
- Department of Anaesthesia and Intensive Care Medicine, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK.,School of Medicine, University of Bristol, Bristol, UK
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Paterson E, Sanderson PM, Loeb RG, Paterson NAB. Improving pulse oximetry auditory displays: Anaesthesiologists' perceptions. Acta Anaesthesiol Scand 2022; 66:1027-1028. [PMID: 35781875 DOI: 10.1111/aas.14114] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 05/28/2022] [Indexed: 11/27/2022]
Affiliation(s)
| | - Penelope M Sanderson
- School of Psychology, The University of Queensland, Australia.,School of Clinical Medicine, Faculty of Medicine, The University of Queensland, Australia.,School of Information Technology and Electrical Engineering, The University of Queensland, Australia
| | - Robert G Loeb
- School of Psychology, The University of Queensland, Australia.,Department of Anesthesiology, University of Florida School of Medicine, Gainesville, Florida, USA
| | - Neil A B Paterson
- School of Clinical Medicine, Faculty of Medicine, The University of Queensland, Australia.,Anaesthesia and Pain Management Services, Queensland Children's Hospital, South Brisbane, Queensland, Australia
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3
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Sanderson PM, Loeb RG, Liley H, Liu D, Paterson E, Hinckfuss K, Zestic J. Signaling Patient Oxygen Desaturation with Enhanced Pulse Oximetry Tones. Biomed Instrum Technol 2022; 56:46-57. [PMID: 35671368 PMCID: PMC9767428 DOI: 10.2345/0899-8205-56.2.46] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Manufacturers could improve the pulse tones emitted by pulse oximeters to support more accurate identification of a patient's peripheral oxygen saturation (SpO2) range. In this article, we outline the strengths and limitations of the variable-pitch tone that represents SpO2 of each detected pulse, and we argue that enhancements to the tone to demarcate clinically relevant ranges are feasible and desirable. The variable-pitch tone is an appreciated and trusted feature of the pulse oximeter's user interface. However, studies show that it supports relative judgments of SpO2 trends over time and is less effective at supporting absolute judgments about the SpO2 number or conveying when SpO2 moves into clinically important ranges. We outline recent studies that tested whether acoustic enhancements to the current tone could convey clinically important ranges more directly, without necessarily using auditory alarms. The studies cover the use of enhanced variable-pitch pulse oximeter tones for neonatal and adult use. Compared with current tones, the characteristics of the enhanced tones represent improvements that are both clinically relevant and statistically significant. We outline the benefits of enhanced tones, as well as discuss constraints of which developers of enhanced tones should be aware if enhancements are to be successful.
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Affiliation(s)
- Penelope M Sanderson
- Penelope M. Sanderson, PhD, is professor of cognitive engineering and human factors in the Schools of Psychology, Clinical Medicine, and Information Technology and Electrical Engineering at The University of Queensland in Queensland, Australia.
| | - Robert G Loeb
- Robert G. Loeb, MD, is an honorary professor in the School of Psychology at The University of Queensland in Queensland, Australia, and an emeritus clinical professor at University of Florida-Gainesville
| | - Helen Liley
- Helen Liley, MBCh, FRACP, is a senior staff specialist at Mater Mothers' Hospital and a professor in the Faculty of Medicine at The University of Queensland in Queensland, Australia
| | - David Liu
- David Liu, MBBS, PhD, is an anaesthetics registrar at Sunshine Coast University Hospital in Queensland, Australia, and a senior lecturer in the Faculty of Medicine at The University of Queensland in Queensland, Australia
| | - Estrella Paterson
- Estrella Paterson, PhD, is a postdoctoral fellow in the School of Psychology at The University of Queensland in Queensland, Australia
| | - Kelly Hinckfuss
- Kelly Hinckfuss, MPhil, is a clinical masters student in the School of Psychology at The University of Queensland in Queensland, Australia
| | - Jelena Zestic
- Jelena Zestic, PhD, is a human systems engineer at Boeing Research and Technology in Brisbane, Australia
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Sanderson PM, Loeb RG, Liley H, Liu D, Paterson E, Hinckfuss K, Zestic J. Signaling Patient Oxygen Desaturation with Enhanced Pulse Oximetry Tones. Biomed Instrum Technol 2022. [PMID: 35671368 DOI: 10.2345/1943-5967-56.2.46] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Manufacturers could improve the pulse tones emitted by pulse oximeters to support more accurate identification of a patient's peripheral oxygen saturation (SpO2) range. In this article, we outline the strengths and limitations of the variable-pitch tone that represents SpO2 of each detected pulse, and we argue that enhancements to the tone to demarcate clinically relevant ranges are feasible and desirable. The variable-pitch tone is an appreciated and trusted feature of the pulse oximeter's user interface. However, studies show that it supports relative judgments of SpO2 trends over time and is less effective at supporting absolute judgments about the SpO2 number or conveying when SpO2 moves into clinically important ranges. We outline recent studies that tested whether acoustic enhancements to the current tone could convey clinically important ranges more directly, without necessarily using auditory alarms. The studies cover the use of enhanced variable-pitch pulse oximeter tones for neonatal and adult use. Compared with current tones, the characteristics of the enhanced tones represent improvements that are both clinically relevant and statistically significant. We outline the benefits of enhanced tones, as well as discuss constraints of which developers of enhanced tones should be aware if enhancements are to be successful.
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Affiliation(s)
- Penelope M Sanderson
- Penelope M. Sanderson, PhD, is professor of cognitive engineering and human factors in the Schools of Psychology, Clinical Medicine, and Information Technology and Electrical Engineering at The University of Queensland in Queensland, Australia.
| | - Robert G Loeb
- Robert G. Loeb, MD, is an honorary professor in the School of Psychology at The University of Queensland in Queensland, Australia, and an emeritus clinical professor at University of Florida-Gainesville
| | - Helen Liley
- Helen Liley, MBCh, FRACP, is a senior staff specialist at Mater Mothers' Hospital and a professor in the Faculty of Medicine at The University of Queensland in Queensland, Australia
| | - David Liu
- David Liu, MBBS, PhD, is an anaesthetics registrar at Sunshine Coast University Hospital in Queensland, Australia, and a senior lecturer in the Faculty of Medicine at The University of Queensland in Queensland, Australia
| | - Estrella Paterson
- Estrella Paterson, PhD, is a postdoctoral fellow in the School of Psychology at The University of Queensland in Queensland, Australia
| | - Kelly Hinckfuss
- Kelly Hinckfuss, MPhil, is a clinical masters student in the School of Psychology at The University of Queensland in Queensland, Australia
| | - Jelena Zestic
- Jelena Zestic, PhD, is a human systems engineer at Boeing Research and Technology in Brisbane, Australia
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Patterson ES, Rayo MF, Edworthy JR, Moffatt-Bruce SD. Applying Human Factors Engineering to Address the Telemetry Alarm Problem in a Large Medical Center. HUMAN FACTORS 2022; 64:126-142. [PMID: 34011195 DOI: 10.1177/00187208211018883] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
OBJECTIVE Address the alarm problem by redesigning, reorganizing, and reprioritizing to better discriminate alarm sounds and displays in a hospital. BACKGROUND Alarms in hospitals are frequently misunderstood, disregarded, and overridden. METHOD Discovery-oriented, intervention, and translational studies were conducted. Study objectives and measures varied, but had the shared goals of increasing positive predictive value (PPV) of critical alarms by reducing low-PPV alarms in the background, prioritizing alarms, redesigning alarm sounds to increase information content, and transparently conveying who initiated alarms. An alarm ontology was iteratively generated and refined until consensus was achieved. RESULTS The ontology distinguishes five levels of urgency that incorporate likely PPV, three categories for who initiates the alarm (hospital staff, patient, or machine), whether it is clinical or technical, and clinical functions. CONCLUSION This unique collaboration allowed us to make progress on the alarm problem by making unintuitive leaps, avoiding common missteps, and refuting conventional healthcare approaches. APPLICATION Hospitals can consistently redesign, reorganize, reprioritize, and better discriminate alarms by priority, PPV, and content to reduce nurse response times.
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6
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Liley HG, Zestic J. Reaching for improvement in newborn resuscitation. Resuscitation 2021; 167:407-409. [PMID: 34400270 DOI: 10.1016/j.resuscitation.2021.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 08/05/2021] [Indexed: 11/16/2022]
Affiliation(s)
- Helen G Liley
- Faculty of Medicine and Mater Research, The University of Queensland, Australia.
| | - Jelena Zestic
- School of Psychology, Cognitive Engineering Research Group, The University of Queensland, Australia
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