Collaborative intervention to improve airway assessment and safety in management for anaesthesia: The Qualitat & Via Aèria (QUAVA) study

The nature of the response to airway management incident reports in high income countries: A scoping review

Adverse events associated with failed airway management may have catastrophic consequences, and despite many advances in knowledge, guidelines and equipment, airway incidents and patient harm continue to occur. Patient safety incident reporting systems have been established to facilitate a reduction in incidents. However, it has been found that corrective actions are inadequate and successful safety improvements scarce. The aim of this scoping review was to assess whether the same is true for airway incidents by exploring academic literature that describes system changes in airway management in high-income countries over the last 30 years, based on findings and recommendations from incident reports and closed claims studies. This review followed the most recent guidance from the Joanna Briggs Institute (JBI). PubMed, Ovid MEDLINE and Embase, the JBI database, SCOPUS, the Cochrane Library and websites for anaesthetic societies were searched for eligible articles. Included articles were analysed and data synthesised to address the review's aim. The initial search yielded 28,492 results, of which 111 articles proceeded to the analysis phase. These included 23 full-text articles, 78 conference abstracts and 10 national guidelines addressing a range of airway initiatives across anaesthesia, intensive care and emergency medicine. While findings and recommendations from airway incident analyses are commonly published, there is a gap in the literature regarding the resulting system changes to reduce the number and severity of adverse airway events. Airway safety management mainly focuses on Safety-I events and thereby does not consider Safety-II principles, potentially missing out on all the information available from situations where airway management went well.

Recommendations for the evaluation and management of the anticipated and non-anticipated difficult airway of the Societat Catalana d'Anestesiologia, Reanimació i Terapèutica del Dolor, based on the adaptation of clinical practice guidelines and expert consensus

The Airway Division of the Catalan Society of Anaesthesiology, Intensive Care and Pain Management (SCARTD) presents its latest guidelines for the evaluation and management of the difficult airway. This update includes the technical advances and changes observed in clinical practice since publication of the first edition of the guidelines in 2008. The recommendations were defined by a consensus of experts from the 19 participating hospitals, and were adapted from 5 recently published international guidelines following an in-depth analysis and systematic comparison of their recommendations. The final document was sent to the members of SCARTD for evaluation, and was reviewed by 11 independent experts. The recommendations, therefore, are supported by the latest scientific evidence and endorsed by professionals in the field. This edition develops the definition of the difficult airway, including all airway management techniques, and places emphasis on evaluating and classifying the airway into 3 categories according to the anticipated degree of difficulty and additional safety considerations in order to plan the management strategy. Pre-management planning, in terms of preparing patients and resources and optimising communication and interaction between all professionals involved, plays a pivotal role in all the scenarios addressed. The guidelines reflect the increased presence of video laryngoscopes and second-generation devices in our setting, and promotes their routine use in intubation and their prompt use in cases of unanticipated difficult airway. They also address the increased use of ultrasound imaging as an aid to evaluation and decision-making. New scenarios have also been included, such as the risk of bronchoaspiration and difficult extubation Finally, the document outlines the training and continuing professional development programmes required to guarantee effective and safe implementation of the guidelines.

Difficult airway management algorithms: a directed review

The primary aim of this study was to identify, describe and compare the content of existing difficult airway management algorithms. Secondly, we aimed to describe the literature reporting the implementation of these algorithms. A directed search across three databases (MEDLINE, Embase and Scopus) was performed. All articles were screened for relevance to the research aims and according to pre-determined exclusion criteria. We identified 38 published airway management algorithms. Our results show that most facemask employ a four-step process as represented by a flow chart, with progression from tracheal intubation, facemask ventilation and supraglottic airway device use, to a rescue emergency surgical airway. The identified algorithms are overwhelmingly similar, yet many use differing terminology. The frequency of algorithm publication has increased recently, yet adherence and implementation outcome data remain limited. Our results highlight the lack of a single algorithm that is universally endorsed, recognised and applicable to all difficult airway management situations.

Local opinion leaders: effects on professional practice and healthcare outcomes

BACKGROUND

Clinical practice is not always evidence-based and, therefore, may not optimise patient outcomes. Local opinion leaders (OLs) are individuals perceived as credible and trustworthy, who disseminate and implement best evidence, for instance through informal one-to-one teaching or community outreach education visits. The use of OLs is a promising strategy to bridge evidence-practice gaps. This is an update of a Cochrane review published in 2011.

OBJECTIVES

To assess the effectiveness of local opinion leaders to improve healthcare professionals' compliance with evidence-based practice and patient outcomes.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, three other databases and two trials registers on 3 July 2018, together with searching reference lists of included studies and contacting experts in the field.

SELECTION CRITERIA

We considered randomised studies comparing the effects of local opinion leaders, either alone or with a single or more intervention(s) to disseminate evidence-based practice, with no intervention, a single intervention, or the same single or more intervention(s). Eligible studies were those reporting objective measures of professional performance, for example, the percentage of patients being prescribed a specific drug or health outcomes, or both. We included all studies independently of the method used to identify OLs.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane procedures in this review. The main comparison was (i) between any intervention involving OLs (OLs alone, OLs with a single or more intervention(s)) versus any comparison intervention (no intervention, a single intervention, or the same single or more intervention(s)). We also made four secondary comparisons: ii) OLs alone versus no intervention, iii) OLs alone versus a single intervention, iv) OLs, with a single or more intervention(s) versus the same single or more intervention(s), and v) OLs with a single or more intervention(s) versus no intervention.

MAIN RESULTS

We included 24 studies, involving more than 337 hospitals, 350 primary care practices, 3005 healthcare professionals, and 29,167 patients (not all studies reported this information). A majority of studies were from North America, and all were conducted in high-income countries. Eighteen of these studies (21 comparisons, 71 compliance outcomes) contributed to the median adjusted risk difference (RD) for the main comparison. The median duration of follow-up was 12 months (range 2 to 30 months). The results suggested that the OL interventions probably improve healthcare professionals' compliance with evidence-based practice (10.8% absolute improvement in compliance, interquartile range (IQR): 3.5% to 14.6%; moderate-certainty evidence).Results for the secondary comparisons also suggested that OLs probably improve compliance with evidence-based practice (moderate-certainty evidence): i) OLs alone versus no intervention: RD (IQR): 9.15% (-0.3% to 15%); ii) OLs alone versus a single intervention: RD (range): 13.8% (12% to 15.5%); iii) OLs, with a single or more intervention(s) versus the same single or more intervention(s): RD (IQR): 7.1% (-1.4% to 19%); iv) OLs with a single or more intervention(s) versus no intervention: RD (IQR):10.25% (0.6% to 15.75%).It is uncertain if OLs alone, or in combination with other intervention(s), may lead to improved patient outcomes (3 studies; 5 dichotomous outcomes) since the certainty of evidence was very low. For two of the secondary comparisons, the IQR included the possibility of a small negative effect of the OL intervention. Possible explanations for the occasional negative effects are, for example, the possibility that the OLs may have prioritised some outcomes, at the expense of others, or that an unaccounted outcome difference at baseline, may have given a faulty impression of a negative effect of the intervention at follow-up. No study reported on costs or cost-effectiveness.We were unable to determine the comparative effectiveness of different approaches to identifying OLs, as most studies used the sociometric method. Nor could we determine which methods used by OLs to educate their peers were most effective, as the methods were poorly described in most studies. In addition, we could not determine whether OL teams were more effective than single OLs.

AUTHORS' CONCLUSIONS

Local opinion leaders alone, or in combination with other interventions, can be effective in promoting evidence-based practice, but the effectiveness varies both within and between studies.The effect on patient outcomes is uncertain. The costs and the cost-effectiveness of the intervention(s) is unknown. These results are based on heterogeneous studies differing in types of intervention, setting, and outcomes. In most studies, the role and actions of the OL were not clearly described, and we cannot, therefore, comment on strategies to enhance their effectiveness. It is also not clear whether the methods used to identify OLs are important for their effectiveness, or whether the effect differs if education is delivered by single OLs or by multidisciplinary OL teams. Further research may help us to understand how these factors affect the effectiveness of OLs.