Investigation of difficult airway trolley provision and characteristics in areas of anaesthesia provision: the difficult airway trolley (DATA) audit, a cross sectional study of public hospitals in the Republic of Ireland. P Geoghegan, J Vinagre, E Kelliher, J Gilroy, C Black, C McCaul, G Curley. On behalf of the SATARN group, CAI, Ireland

Airway management can be complicated by life-altering morbidity and even mortality1 2. Preparation for anticipated and unanticipated difficult airway management is regarded as a key component in preventing morbidity and mortality in anaesthesia. The Difficult Airway Society (DAS) has published guidelines for setting up Difficult Airway Trolleys (DATs). Previous multicentre studies5–7 have identified wide variation in the provision of DATs but these have been limited by primarily questionnaire-based methodologies as well as focus on particular areas of anaesthesia provision (e.g. intensive care units). Background

Objective Our objective was to audit DAT provision in areas of anaesthesia provision in public hospitals in the Republic of Ireland. We hypothesised that there would be wide variation in the provision, layout/design and composition/contents of DATs

Methods This was a cross-sectional study of DAT provision in public (state funded) hospitals in the Republic of Ireland (ROI). The study was performed between December 1st 2017 and January 31st 2018 by the Specialist Anaesthesia Trainee Audit and Research Network (SATARN), a collaborative research group comprised of anaesthesiology trainees associated with the College of Anaesthesiologists of Ireland (CAI).

All eligible hospitals were approached for inclusion. Methods All eligible hospitals were approached for inclusion. A local co-ordinating trainee (LCT) and local co-ordinating consultant (LCC) were appointed at each site that agreed to participate. The LCT and LCC were responsible for data collection, which was co-ordinated by a central team of investigators. Briefly, initially the LCT and LCC for each site identified clinical areas within the site where anaesthesia was routinely induced – these were termed areas of anaesthesia provision (AAPs).

Methods LCT and LCC attended each clinical area identified as an area of anaesthesia provision. Each AAP was examined for the presence of a DAT. Structured assessment including photographic record

Methods Data from each site, including the photographic records, were submitted to a central database for storage and processing. All submitted data was validated by a central study investigator using the photographic records submitted. Missing or queried data were resolved by inspection of the photographic data or discussion with LCC as appropriate. Finally, a qualitative description of themes of DAT variation was generated by group discussion between study investigators who had reviewed the photographic data from the individual sites.

Outcomes of interest The main outcome measures were intra and inter-centre variation in the following key domains: Provision of DATs in AAPs Physical characteristics of DATs Contents of the DATs provided.

Results: Participating hospitals A total of 23 individual public (state funded) hospitals were associated with the CAI for the purposes of training in anaesthesiology when the study was conducted. A single hospital declined the invitation to participate. Another hospital agreed to participate but never submitted data. This left 21 hospitals which were CAI affiliated, submitted data and were included in the main analysis.

Results: Prevalence of DATs in areas of anaesthesia provision In the 21 included hospitals, the median number of areas of anaesthesia provision (AAPs) per hospital was 4 (IQR 3 to 5, Range 1 to 9) yielding 87 clinical areas in total examined for the presence of a DAT across all sites. Of these 87 AAPs, 66 (75.9%) had a DAT. The median percentage of AAPs with a DAT per hospital was 83.3% (IQR 75% to 100%, Range 33% to 100%).

Results:Prevalence of DATs by type of clinical Area DAT provision was best in the theatre environment (97.0%). A lower level of provision was observed in dedicated maternity facilities (81.8%), ICU/HDU (81.3%), and emergency departments (73.3%). The lowest rates of DAT provision were observed in areas where remote anaesthesia is practiced – radiology facilities (14.3%), ECT suites (0%), and miscellaneous clinical areas such as cardiac catheterisation laboratories (16.7%). Results:Prevalence of DATs by type of clinical Area

Results: General characteristics of DATs While the DAS guidelines were being used as the primary difficult airway algorithm in 93.9% of AAPs, a copy of the guidelines was attached to the trolley in only 54.5% of DATs. Only 77.3% of DATs had all drawers labelled, with only 30.3% having labels that indicated the components of the DAS plan that drawer contents related to. Only 27.8% of DATs had a visual guide to the DAS algorithm on the drawers. Only 62.1% of DATs had a checklist for restocking, while only 53.0% had a logbook to confirm stock checks. Results: General characteristics of DATs

Results: Contents of DATs. Surprisingly high prevalence of video laryngoscope provision (78.7%) Surprisingly low prevalence of 2nd generation LMA provision (80.3%). Some DATs did not have all the equipment for “scalpel, bougie, tube” technique (18.1%), while equipment for seldinger-technique based cricothyroidotomy was common (71.2%).

Results: Themes of errors. A variety of error types emerged on group discussion of DATs within the study including but not limited to Absence of DATs Absent labelling Ambiguous labelling Labelling not corresponding to contents Drawers containing elements from multiple components of the DAS plan Different DATs in different clinical areas of the same hospital Absence of essential equipment Overstocking

Conclusions DAT provision varies significantly both within and between public hospitals in the ROI. DAT provision was highest in traditional areas of anaesthesia provision such as operating theatres, but very low in areas of remote anaesthesia. DATs commonly failed to meet many basic DAS recommendations on how DATs should be configured. Several interesting themes relating to DAT configuration errors were identified in group discussions. DAT provision is an area of anaesthesia provision with potential for improvement

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