human factors in airway management – the “smart” approach © ravi dravid project lead for...
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Human factors in Airway Management – The “SMART”
Approach©
Ravi DravidProject Lead for Human Factors
Difficult Airway [email protected] [email protected]
‘copyright © 2009 Ravi Dravid’
Concept of an “Airway Team”?
NTS training - SMART Approach
Mum died after medics failed to act Mum died after medics failed to act decisivelydecisively
Daily Mail 12 December 2006
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
FATAL ACCIDENT INQUIRY
into the death ofMr. GORDON EWING
• Victoria Infirmary ,Glasgow• 2006
http://www.scotcourts.gov.uk/opinions
• 44 yr old, for fixation of fracture right little finger
• Previous GA, 6 weeks ago uneventful• Large BMI >40, 124 kgs• Wanted general anaesthetic
Preoperative assessment
• Anaesthesia started • Unable to secure tube in
windpipe• Sequence of events • Spiralled out of control• Progressive swelling • Could not deliver oxygen • Death
Anaesthetic Management
• 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
My views..
Why this happens?
Easter Brooks Hypothesis(Psychological review Vol 66 No 3
1959)
Arousal (Stress)
Cue Utilisation
Optimum cue utilisation
?? Situation awareness
Concept of an “Airway Team”?
NTS training - SMART Approach
Arousal (Stress)
Cue Utilisation
Optimum cue utilisation
?? Situation awareness
Resources and interventions!!
Arousal (Stress)
Cue Utilisation
Optimum cue utilisation
?? Situation awareness
Resources and interventions!!
Arousal (Stress)
Cue Utilisation
Optimum cue utilisation
?? Situation awareness
Resources and interventions!!
Arousal (Stress)
Cue Utilisation
Optimum cue utilisation
?? Situation awareness
Resources and interventions!!
Team working
Pre-designated roles
SMART©
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)
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’
Airway Team Pilot©
(With pre-designated roles for team members)
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
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)
Difficult Airway
SMART (c) Roles Laminates
First anaesthetistODP/ Anaesthetic nurse
Theatre staff 1Theatre staff 2
Surgical colleagueSecond anaesthetist
Does SMART work?
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 /
highlightsTeam 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
‘copyright © 2009 Ravi Dravid’ t
Trevor Dale
Guy Hirst
Trevor Dale
Evaluation of the Course overall
Spinoffs!!
“Involvement and Ownership”
Challenges..Resources
Time off for theatre staff
CHFG support for time off and resources
Kettering / Oxford / Coventry(DAS supported SMART Course ©)
‘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 2011Coventry April 1, 2010 Kent 13 May 2011
For further details www.das.uk.com
Elaine Bromiley
Gordon Ewing
“Never doubt that a small group of committed people can change the world, indeed it is the only thing that ever has”.
Margaret Mead