Ololade Olabaju
Action Planned
The Royal College of Anaesthetists and ENT-UK are preparing new guidelines for emergency airway problems in ICU, to be published later this year, and will hold a meeting in April for Airway Leads. They commit to helping anaesthetists achieve competence in surgical cricothyroidotomies through curriculum development, and will raise awareness among surgeons through editorials and curriculum integration requests. (AI summary)
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Dear Mr Barlow,
Re: PFD (Prevent Future Deaths) report touching the death of Ololade Olaobaju
Further to your Regulation 28 Report dated 15th December 2015 regarding this patient, a meeting was convened at the Royal College of Anaesthetists (RCoA) on 13th January 2016 to discuss actions that could be taken to prevent further deaths in similar situations.
In attendance at this meeting were:
* Consultant Anaesthetist and President of the Association of Anaesthetists of Great Britain and Ireland (AAGBI) (Chair) - Consultant Anaesthetist and RCoA Vice- President.
* Consultant Anaesthetist and National Tracheostomy Lead Clinician
* Consultant Anaesthetist and President of the Difficult Airway Society (DAS)
* Consultant ENT Surgeon and Council Member of ENT-UK
Also in attendance were:
- RCOA Director of Clinical Quality
- RCOA Quality and Safety Manager
- PA to Mr McLaughlan
Professor Tim Cook (Consultant Anaesthetist and author of the NAP4 report on major complication of airway management in the UK) was also asked to comment on this response.
We acknowledged that our role was not to discuss specific matters about this particular case, and was to look at educational and practical lessons that could be learned and disseminated. We also noted that any guidelines that Page 1
are in place should be regarded as good practice recommendations, rather than regulations, because of the potential variation in clinical circumstances.
We noted that since last year the guidance on dealing with this situation given by the Difficult Airway Society had changed and updated. This change took place following the publication of the RCoA's National Audit Project (NAP4) that had looked at acute airway problems and the success rates of different techniques.
Current DAS guidance is that, in time-critical situations where front-of-neck access is required, the preferred technique is surgical cricothyroidotomy. This guidance is based on the notion that this technique is faster and easier.
We recognised that this situation is uncommon in non-emergency hospital settings, and that many of the doctors (including ENT surgeons) dealing with this sort of situation would be on unfamiliar territory. Recent changes in the organisation of medical training, together with the routine use of non-surgical tracheostomy techniques in less urgent cases, mean that the current generation of ENT surgeons are much less familiar with carrying out these operations.
We discussed the multidisciplinary nature of the team likely to be dealing with a similar case, which could include various grades of anaesthetists, anaesthetic assistants, nurses, ENT surgeons and other surgeons (such as general surgeons, maxillofacial surgeons, cardiothoracic surgeons etc). We recognised the likely disparity in the seniority and experience of such a team, which would likely be hastily convened, and we also recognised that ENT surgery is not carried out at every hospital in the UK and that an ENT surgeon may not be immediately available in a crisis.
We then discussed the rules governing the hierarchy of such a team. In our opinion, it is not possible to give firm rules determining the leadership of such a group, which would need to be decided at the time in light of the group composition. However we strongly felt that it would be helpful if all the likely members of such a multidisciplinary team were aware of the current DAS guidelines.
We therefore felt that a key action would be to promote the DAS guidelines to a wider audience, including ENT and other surgeons.
DAS currently has a nominated Consultant Anaesthetist representative (the RCOA-DAS Airway Lead) in around 85-90% of UK Hospitals, and we felt that these could be key individuals to help with disseminating this.
Following this discussion we agreed the following plan for the coming year:
* DAS to prepare a shortened version of their guidelines 'Management of Unanticipated Difficult Intubation in Adults' to clearly lay out the protocol and requirement for surgeons to carry out surgical Page 2
* cricothyroidotomies as the preferred technique in emergency 'front of neck access' situations.
* New guidelines are in preparation to cover emergency airway problems in the Intensive Care Unit (these will be published later this year). There are specific patient-related and staff-related differences in the ICU setting, which are both important. These guidelines are currently in joint development with DAS, the RCoA and with the Intensive Care Society.
* DAS to hold a meeting in April for all Airway Leads at UK Hospitals, at which the guidelines will be presented. This meeting will be used as an opportunity to raise awareness of the issue and to encourage anaesthetists to think about how the problem might be addressed in their own hospitals, both in and out of 'working hours'.
* We will work together (DAS, RCoA, AAGBI) to help anaesthetists of all grades (trainee, Consultant, SAS) to achieve and maintain competence in performing surgical cricothyroidotomies. This will be achieved by:-
* Encouraging personal development activities and Continuing Professional Development
* Developing the curriculum for anaesthetists-in-training.
* We will take actions to raise awareness amongst surgeons of the issues discussed, and particularly the best choice of surgical technique. We will do this by:-
* Submitting an editorial to the key ENT journals (Clinical Otolaryngology and The British Journal of Oral and Maxillofacial Surgery (BJOAMS)), as well as the British Journal of Anaesthesia.
* Contacting the President of the Royal College of Surgeons asking for the surgical management of an airway crisis to be incorporated into the training curriculum for surgeons-in-training.
* We will emphasise to surgeons the need for a standard surgical approach in these cases.
Thank you for the opportunity to take this forward. We believe that this PFD report provides us with an opportunity to standardise protocols for these rare, but life threatening emergencies and implement training at a multidisciplinary level.
Re: PFD (Prevent Future Deaths) report touching the death of Ololade Olaobaju
Further to your Regulation 28 Report dated 15th December 2015 regarding this patient, a meeting was convened at the Royal College of Anaesthetists (RCoA) on 13th January 2016 to discuss actions that could be taken to prevent further deaths in similar situations.
In attendance at this meeting were:
* Consultant Anaesthetist and President of the Association of Anaesthetists of Great Britain and Ireland (AAGBI) (Chair) - Consultant Anaesthetist and RCoA Vice- President.
* Consultant Anaesthetist and National Tracheostomy Lead Clinician
* Consultant Anaesthetist and President of the Difficult Airway Society (DAS)
* Consultant ENT Surgeon and Council Member of ENT-UK
Also in attendance were:
- RCOA Director of Clinical Quality
- RCOA Quality and Safety Manager
- PA to Mr McLaughlan
Professor Tim Cook (Consultant Anaesthetist and author of the NAP4 report on major complication of airway management in the UK) was also asked to comment on this response.
We acknowledged that our role was not to discuss specific matters about this particular case, and was to look at educational and practical lessons that could be learned and disseminated. We also noted that any guidelines that Page 1
are in place should be regarded as good practice recommendations, rather than regulations, because of the potential variation in clinical circumstances.
We noted that since last year the guidance on dealing with this situation given by the Difficult Airway Society had changed and updated. This change took place following the publication of the RCoA's National Audit Project (NAP4) that had looked at acute airway problems and the success rates of different techniques.
Current DAS guidance is that, in time-critical situations where front-of-neck access is required, the preferred technique is surgical cricothyroidotomy. This guidance is based on the notion that this technique is faster and easier.
We recognised that this situation is uncommon in non-emergency hospital settings, and that many of the doctors (including ENT surgeons) dealing with this sort of situation would be on unfamiliar territory. Recent changes in the organisation of medical training, together with the routine use of non-surgical tracheostomy techniques in less urgent cases, mean that the current generation of ENT surgeons are much less familiar with carrying out these operations.
We discussed the multidisciplinary nature of the team likely to be dealing with a similar case, which could include various grades of anaesthetists, anaesthetic assistants, nurses, ENT surgeons and other surgeons (such as general surgeons, maxillofacial surgeons, cardiothoracic surgeons etc). We recognised the likely disparity in the seniority and experience of such a team, which would likely be hastily convened, and we also recognised that ENT surgery is not carried out at every hospital in the UK and that an ENT surgeon may not be immediately available in a crisis.
We then discussed the rules governing the hierarchy of such a team. In our opinion, it is not possible to give firm rules determining the leadership of such a group, which would need to be decided at the time in light of the group composition. However we strongly felt that it would be helpful if all the likely members of such a multidisciplinary team were aware of the current DAS guidelines.
We therefore felt that a key action would be to promote the DAS guidelines to a wider audience, including ENT and other surgeons.
DAS currently has a nominated Consultant Anaesthetist representative (the RCOA-DAS Airway Lead) in around 85-90% of UK Hospitals, and we felt that these could be key individuals to help with disseminating this.
Following this discussion we agreed the following plan for the coming year:
* DAS to prepare a shortened version of their guidelines 'Management of Unanticipated Difficult Intubation in Adults' to clearly lay out the protocol and requirement for surgeons to carry out surgical Page 2
* cricothyroidotomies as the preferred technique in emergency 'front of neck access' situations.
* New guidelines are in preparation to cover emergency airway problems in the Intensive Care Unit (these will be published later this year). There are specific patient-related and staff-related differences in the ICU setting, which are both important. These guidelines are currently in joint development with DAS, the RCoA and with the Intensive Care Society.
* DAS to hold a meeting in April for all Airway Leads at UK Hospitals, at which the guidelines will be presented. This meeting will be used as an opportunity to raise awareness of the issue and to encourage anaesthetists to think about how the problem might be addressed in their own hospitals, both in and out of 'working hours'.
* We will work together (DAS, RCoA, AAGBI) to help anaesthetists of all grades (trainee, Consultant, SAS) to achieve and maintain competence in performing surgical cricothyroidotomies. This will be achieved by:-
* Encouraging personal development activities and Continuing Professional Development
* Developing the curriculum for anaesthetists-in-training.
* We will take actions to raise awareness amongst surgeons of the issues discussed, and particularly the best choice of surgical technique. We will do this by:-
* Submitting an editorial to the key ENT journals (Clinical Otolaryngology and The British Journal of Oral and Maxillofacial Surgery (BJOAMS)), as well as the British Journal of Anaesthesia.
* Contacting the President of the Royal College of Surgeons asking for the surgical management of an airway crisis to be incorporated into the training curriculum for surgeons-in-training.
* We will emphasise to surgeons the need for a standard surgical approach in these cases.
Thank you for the opportunity to take this forward. We believe that this PFD report provides us with an opportunity to standardise protocols for these rare, but life threatening emergencies and implement training at a multidisciplinary level.