Journal of Perioperative Practice

PROCUREMENT GUIDESeptember 2014 Volume 03 Issue 04

01423 881300 www.afpp.org.uk

01423 881300www.afpp.org.uk

02Journal of Perioperative Practice PROCUREMENT GUIDE

September 2014Volume 03 Issue 04www.afpp.org.uk

03Journal of Perioperative Practice PROCUREMENT GUIDE

September 2014Volume 03 Issue 04www.afpp.org.uk Contents

Journal of Perioperative Practice Procurement Guide informationIn print within the AfPP Journal of Perioperative Practice covering national AfPP members, but also with a dedicated print and e-distribution to supplies and purchasing managers.

Key Sectors: NHS Supply Chain, Independent Hospitals, Higher Education. Medical Device Companies.

Published 6 times a year we will focus on procurement issues in every edition as well as specialist subjects which for the following year include:

04Airway management: planning to get it right, when it goes wrong

06Post-anaesthetic care of the paediatric patient

07Product news: TOF Watch Objective Neuromuscular Transmission Monitors

November 2014Safety

January 2015Recovery/Patient Warming

March 2015Medical Devices/Instruments

May 2015Infection Prevention/Control

Contact Information:

Advertising, Sponsorship & Partner Packages.Frances MurphyAccount ManagerOpen Box M&CT: 0121 200 7820E: frances.murphy@ob-mc.co.uk

EditorialChris WilesHead of Publishing / Editorial AfPPT: 01423 882950E: chris.wiles@afpp.org.uk

PR & press material.All press releases welcome and we will feature as many as we can in each issue, all press releases need to be submitted to:

Frances MurphyAccount ManagerOpen Box M&CT: 0121 200 7820E: frances.murphy@ob-mc.co.uk

Welcome to your September 2014 Guide

08Product news: Kerrison Ronguer from DTR Medical

08Product news: BritePro Solo

04Journal of Perioperative Practice PROCUREMENT GUIDE

September 2014Volume 03 Issue 04www.afpp.org.uk Day surgery

The NAP 4 report identified that out of 184 reports, organisational factors contributed to an airway event in 42 (23%) cases. Whilst not all these are related to equipment, the organisational preparedness to deal with them can be considered as an influence.

Let’s set the scene; you are in that anaesthetic room at the end of the corridor, it’s another busy day in the operating department and lists are in full flight with staff committed to tasks and procedures.

In your anaesthetic room it’s the next patient’s anaesthetic procedure, one where the patient will be induced with an intravenous agent and the airway management is a planned tracheal intubation. The surgical safety checklist is completed, is uneventful and the nursing handover conducted. Everything is satisfactory.

The patient is induced with an intravenous agent, all is uneventful, you are vigilant and attentive, monitoring is visible, patient observations are within acceptable parameters. The patient is easily hand ventilated by the anaesthetist through a bag and mask and the airway is patent. A muscle relaxant is administered and all is set for an endotracheal intubation. This is where it all starts to change as intubation attempts fail and ventilation becomes difficult.

Within the following minutes the patient rapidly deteriorates, the calm, planned routine environment has become a fast paced, high pressure, complex clinical procedure involving several people from a qualified, highly skilled multidisciplinary team. It’s a full team response. The decision making, understanding of the situation, knowledge of the difficult airway guidelines, the algorithms and access to the right equipment

right airway devices be improved when rapid ease of access is required? As a reflection on professional practice, in routine day to day anaesthetic activities how familiar are you and your team with difficult airway equipment, its accessibility, and when under pressure what is the capability and familiarity to set it up fit for use minimising delays? Is it located in the most appropriate and accessible location and are all department non anaesthetic staff aware of its presence?

The Difficult Airway Society (2005) produced an equipment list for routine airway management and unanticipated difficult intubation. Where possible, the equipment should be set out to follow the difficult airway algorithm. As each subsequent airway management technique is deployed, the corresponding equipment should be ready for use in sequence, supporting a logical and sequential approach which is likely to reduce delays and confusion.

Scenario led and an all team training approach can lead to improved response under pressure. Time used within this training to review individual medical devices (such as intubating laryngeal masks airways, intubating catheters and high pressure jet ventilation systems) its use, ease of assembly, configuration individually and use in conjunction with other devices are factors which should also be given consideration. Frequent familiarisation, hands on practice, regular training and ongoing skills competence and

Airway management: planning to get it right, when it goes wrong

all align to support a safe and effective patient outcome.

Patient Safety First, Implementing Human Factors in Healthcare 2011, The Royal College of Anaesthetists Difficult Airway Society 4th National Audit Project, March 2011, offer significant guidance on what can and should happen in these scenarios and how to best prepare. There is significant and appropriate focus promoting the skills, communication and appropriate equipment and medical devices required to ensure difficult airway complications are managed correctly.

The NAP 4 report identified that out of 184 reports, organisational factors contributed to an airway event in 42 (23%) cases. Whilst not all these are related to equipment, the organisational preparedness to deal with them can be considered as an influence.

The researched reports, publications and guidelines rightly identify and promote the use of well-equipped difficult airway trolleys across the hospital environment (such as obstetrics, ITU) and not solely within the operating department. Within the anaesthetic environment, one area to challenge is; can access to the

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knowledge development can lead to improved situational awareness and support a learning culture.

Minimising delays such as rapid access to critical equipment should be considered and evaluated against the benefit of having it close to hand for first and second stage options as opposed to relying on the arrival of a difficult airway trolley. Equipment such as McCoy laryngoscope blades and a selection of intubating laryngeal masks (ILMA) readily available within the anaesthetic room or alongside routine airway equipment in post anaesthetic care units have the potential to support a quicker response and enable different stages of progression through the difficult airway algorithms (from A to C) whilst additional support and equipment is located and arrives.

Evaluating how well individual practitioners and teams learn, train and prepare for different scenarios in difficult airway management and others such as sudden hypovolaemia or severe anaphylaxis reflects their ability to reduce the risk of harm alongside balancing effectiveness, safety and efficiency. It can minimise errors, improve teamwork and promote an awareness of risk and constant improvement.

Iestyn FosterMA, PgDipM, CertHSM

Independent ODP

References and Further reading

Difficult Airway Society 2005 Difficult Airway Society Equipment List Available from: http://www.das.uk.com/equipmentlistjuly2005.htm [Accessed August 2014]

Neily J, Mills PD, Young-Xu Y, et al 2010 Association between implementation of a medical team training program and surgical mortality J Am Med Assoc 304:1693-700

Patient Safety First 2010 The How to Guide: Implementing Human Factors in Healthcare Available from: http://www.patientsafetyfirst.nhs.uk/Content.aspx?path=/interventions/humanfactors [Accessed August 2014]

Royal College of Anaesthetists &The Difficult Airway Society 2011 4th National Audit Project of the Royal College of Anaesthetists and The Difficult Airway Society: major Complications of Airway Management in The United Kingdom: Report & Findings Available from: http://www.rcoa.ac.uk/node/4211 [Accessed August 2014]

Sevdalis N, Hull L, Birnbach DJ 2012 Improving patient safety in the operating theatre and perioperative care: obstacles, interventions, and priorities for accelerating progress British Journal of Anaesthesia 109 (S1) i3–i16

The Health Foundation 2011 Evidence scan: High reliability organisations Available from: http://www.health.org.uk/publications/high-reliability-organisations [Accessed August 2014]

Recommended equipment for routine airway management • Facemasks • Oropharyngeal airways: three sizes • Nasopharyngeal airways: three sizes • Laryngeal Mask Airways • Tracheal tubes in a range of sizes • Two working laryngoscope handles • Macintosh blades: sizes 3 & 4 • Tracheal tube introducer (“gum-elastic” bougie) • Malleable stylet • Magill forceps

Recommended equipment for management of unanticipated difficult intubation • DAS guidelines algorithm flowcharts (or modified local version) • Equipment list for re stocking • At least one alternative blade (e.g. straight, McCoy) • Intubating Laryngeal Mask Airway (ILMATM) set (size 3, 4, 5 with dedicated tubes and pusher) • Tracheal tubes – reinforced and microlaryngeal size 5 & 6mm • Flexible fibreoptic laryngoscope (with portable/battery light source) • Proseal laryngeal Mask Airway (ProSeal LMATM) • Cricothyroid cannula (e.g. Ravussin) with High pressure jet ventilation system (e.g. Manujet) OR • Large bore cricothyroid cannula (e.g. Quicktrach) • Surgical cricothyroidotomy kit

(Scalpel with no.20 blade, tracheal hook, 6/7 mm tracheal and tracheostomy tubes)

Difficult Airway Society Recommended Equipment for Management of Unanticipated Difficult Intubation (July 2005)

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The Kennedy Report recommendations for children’s services have implications for all theatre and surgical facilities (DH 2002). A segregated area for children is essential in the PACU/recovery area, with provision for parents to stay with them.

The designated recovery area for post-anaesthetic care of children should be child-orientated and decorated with artwork conducive to a child-friendly healthcare environment. Artwork can be paintings, murals, prints, photographs, sculptures, decorative tiles, ceramics, textile hangings and furniture (NHS Estates 2004).

The advantages of such a therapeutic environment are that it:

invasive blood pressure cuffs and small pulse oximeters.

If children are to be recovered in the area, then a paediatric nurse should be a member of the team, or the area should have access to the advice of a qualified paediatric nurse (RSCN) in accordance with local policy. Children have specific care needs as they are more likely to be disorientated postoperatively and at risk of vomiting and laryngeal spasm.

Post-anaesthetic care of the paediatric patient

• mitigates the stress of the environment • creates a sense of safety and security • promotes a bond between patient and caregiver • perpetuates an image of excellence for the hospital.

Paediatric equipment should include a full range of face masks, breathing systems, airways, nasal sponges and tracheal tubes. Monitoring equipment should include a full range of non-

Paediatric patient postoperative pain should be managed effectively using pain assessment tools. Intramuscular injections should be avoided so as not to distress children.

References

Association for Perioperative Practice 2011 Standards and Recommendations for Safe Perioperative Practice Harrogate, AfPP

Department of Health 2002 Government’s Response to Kennedy Report (Children’s heart surgery at the Bristol Royal Infirmary) London, DH

NHS Estates 2004 Facilities for Surgical Procedures HBN 26 London, The Stationery Office

This is an extract from AfPP’s Standards and Recommendations for Safe Perioperative Practice 2011 (Section 7 – Principles of Anaesthetics)

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September 2014Volume 03 Issue 04www.afpp.org.uk Product News

The project was led by Jonathan Cracknell BVMS CertVA CertZooMed MRCVS from Longleat Safari Park in Wiltshire.

Jonathan said “This is part of a project I have been working on for the charity Free the Bears and would not have been possible without the use of the unit. Once we had overcome the challenge of how to attach the unit to the animals we found

it was very effective and worked well” He also reported that they used the Neuromuscular blocking agents (NMBA) Rocuronium and Sugammedix in what is believed to be a world first in bears.

For more information on the TOF Watch range contact sales@wardray-premise.com or visit our website www.wardray-premise.com

Wardray Premise is proud to have been able to lend one of its TOF Watch Objective Neuromuscular Transmission Monitors to a group that recently carried out cataract operations on Sun Bears in Cambodia.

Wardray Premise

The Association for Perioperative Practice is a registered charity (number 1118444) and a company limited by guarantee, registered in England (number 6035633). AfPP Ltd is its wholly owned subsidiary company, registered in England (number 3102102).

The registered office for both companies is Daisy Ayris House, 42 Freemans Way, Harrogate, HG3 1DH.

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September 2014Volume 03 Issue 04www.afpp.org.uk Product News

Single-use laryngoscopes avoid the problems associated with reusables – potential cross-infection, residual contamination, loss of items, poor function following processing, large stocks needed to ensure availability – and meet all current AAGBI Guidelines.

BritePro Solo offers a high quality single-use alternative with excellent function. The textured handle provides exceptional control and feel, while the high intensity LED light and full range of fibre optic blades give outstanding visualisation.

Sterile packed with fitted batteries and changeable blade, cost-effective BritePro Solo is ready to

Lighting the way

use straight out of the box, provides reliability and convenience, and is processed as contaminated waste after use.

Visit www.BriteProSolo.com or speak to your Flexicare representative for more information.

Flexicare Medical Ltd Cynon Valley, Business ParkMountain Ash CF45 4ER

Tel: 01443 474647Email: enquiries@flexicare.comWeb: www.Flexicare.com

High quality, Single-use Kerrison Ronguer from DTR MedicalWhen your procedure demands a precise and robust instrument that you can rely on, we have developed a high quality, single-use, stainless steel Kerrison Ronguer offering parallel performance to a new reusable.

With a range of tip sizes from 1 to 5mm with 40 degree up bite, DTR Medical provides a cost effective alternative to re-processing or replacement of a damaged or blunt instrument.

We are a leading sterile single-use surgical instruments manufacturer, providing high quality orthopaedic instruments

with excellent service that delivers the clinical value you need.

For more information, please contact the DTR Medical Customer Services, +44 (0) 1792 797 910 or email info@dtrmedical.com

For the latest news on DTR Medical products please visit www.dtrmedical.com or follow on Twitter: @dtrmedical and LinkedIn Contact: DTR Medical