State of the ART Katherine Horner, Joanna Allam, Nazril Nordin and

State of the ART
Katherine Horner, Joanna Allam, Nazril Nordin and Corina Lee
Chelsea and Westminster NHS Foundation Trust, London,UK
Introduction
In recent years, numerous organisations including the Difficult Airway Society (DAS), the
American Society of Anesthesiologists (ASA) and the Association of Anaesthetists of
Great Britain and Ireland (AAGBI) have made recommendations about being prepared
for an unanticipated difficult airway.1-3
Figure 1: The ART in the main theatre complex
Figure 2: The ART in the day surgery unit
A dedicated, checked, portable unit (a trolley) containing equipment for an
unanticipated difficult airway should be readily available in all areas where anaesthesia
is delivered, including the emergency department and critical care unit.1-3 This “Airway
Rescue Trolley” (ART) should be clutter-free and standardised, so that in an emergency
staff will be familiar with equipment availability and layout. The trolley should be
stocked in a logical sequence, providing a visual prompt as to how to progress through a
difficult airway algorithm.1,4
The ARTs we did have were inadequately labelled, missing essential equipment,
cluttered, not laid out in a logical sequence and not standardised. In an airway
emergency it would be difficult for staff to find what they needed on the ART.
We obtained funding for new ARTs (Figure 5), which are sealable with tags. We
structured them based on Plans A-D of the DAS guidelines5 as proposed by Severn
Airway Training Society4. We were guided in our choice of contents by the April 2015
DAS Intubation Guidelines Update6, which specifically recommends videolaryngoscopy,
second generation SADs and surgical cricothyroidotomy.
In 2014, we conducted an audit to see how well our hospital was complying with these
recommendations.
The Audit
We conducted a spot audit of the 8 areas where anaesthesia is delivered at our hospital
including: main theatre complex, paediatric theatre complex, burns unit, day surgery
unit, critical care unit and radiology, endoscopy and emergency departments. We
excluded labour ward, as in 2014 there was no national guidance on how to manage an
unanticipated difficult airway in a parturient.
Discussion
This audit revealed a risk to patient safety. We did not have ARTs readily available in all
areas where anaesthesia was delivered, as recommended by DAS & ASA.1,2 In a
simulated emergency, it took 6 minutes to fetch the nearest ART to the radiology
department, where patients are regularly scheduled for procedures under GA.
For maximum economy & safety, we created a “roving” ART, which is transported
between the interventional radiology, MRI, CT and endoscopy rooms as required.
Updating and increasing the number of ARTs, as well as introducing a “roving” ART, has
made our hospital a safer place for patients to undergo anaesthesia.
Figure 3: The ART in the day surgery unit
Figure 4: The ART in the burns unit
Figure 5: Our new ARTS, which are clearly labelled, sealable with tags and structured in a logical sequence
Results
Main findings were:
1) No ART in peripheral areas (radiology and endoscopy departments)
2) No dedicated ART in the critical care unit
3) Existing ARTs hidden behind other equipment & inadequately labelled (Figures 1,2)
4) ARTs cluttered with inappropriate equipment (Figures 2,3,4)
5) ARTs missing essential equipment (trolleys not checked/restocked)
6) ARTs not laid out in a logical sequence (Figures 1,2,3)
7) Inconsistent layout and equipment across all 8 areas
8) DAS Unanticipated Difficult Intubation Algorithm5 not clearly displayed in all areas
Examples of inappropriate equipment found in the ARTs: glucose meter, portable suction
unit, nerve stimulator needles, eye tapes, endobronchial blockers.
References
1. http://www.das.uk.com/content/difficult_airway_trolley, 2. Apfelbaum JL et al. Anesthesiology 2013; 118(2): 251-270, 3. Hartle A et al. Anaesthesia 2012; 67: 660-668, 4. Thompson C et al. The RCoA Bulletin 2012; 71: 60-61, 5. Henderson JJ et al. Anaesthesia 2004; 59: 675-694, 6. http://www.das.uk.com/content/update_on_new_das_guidelines_2015_3
Summary
• A standardised & clutter-free Airway Rescue Trolley (ART) should be readily
available wherever anaesthesia is delivered
• We identified patient safety issues in relation to our ARTs (or lack thereof)
• Funding was obtained for new sealable ARTs, which we structured according
to DAS Difficult Intubation guidelines
• We focused on videolaryngoscopy,
generation SADs & surgical tracheal
access, as recommended in April 2015 DAS Update
nd
2
• For maximum economy & safety, we created a “roving” ART which can be
transported between peripheral areas as required