Let's Have a Look at the Airway Trolley
In this article, Mark Milligan, Lecturer in Operating Department Practice at London South Bank University discusses the rationale behind standardising airway trolleys, in response to DAS guidelines for management of unanticipated difficult intubation in adults 2015.
The National Audit Project 4 (NAP4) highlighted the importance of a suitably stocked difficult airway trolley to be available in all relevant areas. The report recommended that difficult airway trolley contents should conform to a local, and ideally, a national standard. The report emphasised the importance of conformity, the difficult airway trolley in for example, main theatres should be the same as the ones found in all other areas.
These recommendations related to difficult airway trollies, but our staff felt that these changes should apply to airway trollies throughout the hospital.
In our hospital we deliver anaesthesia in a range of different locations in addition to the main theatre suite, for example, radiotherapy, endoscopy, ITU, imaging and the emergency department. With a large and regularly changing number of doctors and agency staff who work across these areas, we recognised the importance of standardising both where and how airway equipment is stored.
As you learned in Week 1, the aim of standardised trollies is to make it easier for the anaesthetists and the anaesthetic practitioners to know exactly where to find each piece of equipment. This is an example of improving Human Factors and Ergonomics with good design.
Later this week you will learn about the DAS Difficult Intubation 2015 Guidelines; they are divided into Plan A-B-C-D, and the drawers of the trollies contain the equipment needed for the corresponding plan.
We used a standard five drawer trolley with the DAS A to D drawer stickers and recommended content. The top drawer is used for storage of consumables like lubricants, gauze and eye tapes. We agreed that the top of the trolley should be reserved for the equipment expected for the next case. It is important that this area should not become cluttered with other sundries as it provides focus for the anticipated airway management plan for each patient.
Drawer A contains a small range of sizes of tracheal tubes, making it easier to identify size in an emergency situation. In the obstetric theatres there is also a short-handled Macintosh laryngoscope.
Drawer B contains supraglottic airway devices (SAD). Again, to make finding the right size in a critical situation, choice is limited to one of each size.
Drawer C contains a size three, four and five face mask for bag face mask ventilation. Adjuncts to assist face mask ventilation are contained in this drawer. This includes a choice of size two, three and four oropharyngeal airways and size six and seven nasopharyngeal airways. The items in these drawers are not intended for routine use, but only for airway emergencies.
Drawer D contains the three items required for an emergency front of neck airway (eFONA), as recommended in the DAS Difficult Intubation 2015 Guidelines. This includes a size 10 scalpel, a bougie with a coude tip and a size six cuffed tracheal tube for surgical cricothyroidotomy. You will learn more about this technique later this week.
An important part of rolling out this change to the layout and storage of equipment was a teaching program focussed on airway skills and drills. Anaesthetic staff led weekly teaching sessions looking in detail at the DAS Difficult Intubation 2015 Guidelines, and practical sessions on different skills were provided on audit days. This ensured that all staff were familiar with the DAS Guidelines and the rationale behind the establishment of the A to D system.
It was very important to involve the operating department practitioners (ODPs) and anaesthetic nurses at this stage, as they are responsible for maintaining the trollies with the right equipment at the correct stock level.
Prior to this change, airway trollies were often over stocked which made it difficult to find things when needed. The challenge of changing the layout of the airway trollies in the outside areas was much more manageable with the practitioners behind the move and able to explain to their colleagues the importance of maintaining the trollies correctly.
These changes took about six months to complete. The trollies are regularly audited to ensure that the new layout and recommended stock levels are maintained.
Improving the design of airway trolleys is a simple measure that can help with safety. How is the airway equipment organised in your workplace? What can help to find the correct equipment, when needed? Share your tips in the discussion below.
If you would like to find out more about airway opening manoeuvres, adjuncts, facemasks, tracheal tubes and aids to intubation or SADs, you can have a look and download the infographic summaries here below.