Airway Audit

It’s a funny thing, working as a private practitioner but on contract to a hospital for anaesthetic and emergency services. For one, there’s a constant tension between demands of running own business and the need to be available to the Hospital when required. Effective triage is key to this. Clarity over what is and what is not an emergency is valuable not only for timekeeping, but also for billing!

But one of the hardest things is to establish effective control to help make change happen in the Hospital. Unlike some of my tertiary hospital colleagues, I don’t get paid to participate in education, nor audit. I also have no control over spending decisions – current bugbear is a Hospital that has spent $17K on a new anaesthetic monitor – that we didn’t need..and yet not purchasing an extra monitor for our ED. Such top-down decision-making without consultation is frustrating. Bottomline is that as private rural doctors, we are engaged to provide a service – but not to effect change in the institution – that is ‘not our remit’

I’d love to spend an hour or so each week doing team-training with nursing staff and have recently started running sims in Theatre at the end of each list. Rural nurses have a tough time as they are frontline for whatever comes through the door, and have to manage the patient until the doctor arrives. That said, I am making an effort this year to improve educational resources for rural clinicians (whether doctor, nurse or paramedic) via the ‘Fifty Shades of Brown’ section on KI-Docs.

Audit is one of the areas that has traditionally frustrated me. Our local ‘Principal medical Officer’ (neither local, nor a frontline rural doctor) used to hold compulsory audits every year – I gave up when I realised that all he was doing was auditing expected deaths in the adjacent nursing home, not looking at near-misses or critical incidents in ED or Theatre.

A few months ago I was in email correspondence with Dr Toby Fogg, an ED Physician & Retrievalist over at the Royal North Shore in Sydney – I was fascinated to see that he and colleagues were setting up an Australian Airway registry and wondered if collective data from rural doctors in small rural hospitals would be useful.

It’s no secret that I am mildly obsessional about airway management, particularly as pertains to availability of equipment to manage a difficult airway in an isolated rural environment. Given that critical illness does not respect geography, I don’t think it is good enough to accept a lower standard of care or a higher complication rate in the bush than in the city.

Truth be told, we don’t know if things are worse. Intuitively, I feel that well-trained rural doctors do a good job – both of elective intubations but also for emergency airway management. But we don’t really have the data one way or the other. Although I’ve approached Country Health SA to pursue the idea of a rural airway audit, there was a lack of interest – the sceptic in me says that in these cash-strapped times, Health Depts would rather ‘not know’ than be presented with data that might require them to spend on appropriate kit!

Anyhow, 2013 has started well with results from the RNSH ED airway audit becoming available. You can check results out at http://www.airwayregistry.org.au/results-of-first-18-months/ and see comments over at Cliff Reid’s http://www.resus.me site via http://resus.me/lifting-the-fogg-on-ed-intubaton/ [sic]

But I reckon it’d be interesting to get collective data from rural EDs – despite the well-worn comments from various experts that there is ‘no room for enthusiastic amateurs’, the reality is that in the bush we HAVE to be able to manage such situations…and on the whole we do a good job…

Don’t we?

5 responses to “Airway Audit

  1. Hi Tim
    We started collecting case data using the RNSH emergency intubation tool about 6 months ago. Broome is not the busiest place, but one staffed by GPAs who do what they know well. So looking forward to comparing our data with the outcomes from the bigger centres – that will be a chance to “change practice” if we see a deficit.

  2. Somehow I knew you’d be an early adopter !

    There’s a whole bunch (well, about 450 or so) rural GP-anaesthetists out there…plus a whole lot more (noone knows) rural doctors with rsponsibilities in emergency … ‘Occasional intubators’

    I have heard some criticism of rural docs from some quarters – either that ‘GPs shouldnt be doing anaesthetics’ or ‘GPs should wait til retrieval arrive to intubate’. All well and good motherhood statements from respective experts, but doesnt really help the patient with a threatened airway and the specialist is hundreds of km away in their ivory tower.

    We ARE the specialists in rural generalism.

    But wouldnt it be good to have the data to prove our track record, for both elective and emergency intubations?

    Toby and Co’s airway audit tool is simple and could be easily collected and collated. Perhaps as a bunch we should do this.

    But who to drive it.

  3. agree.
    I launched my second registry study on retrieval airways using RNSH Toby Fogg’s audit tool a few months ago.
    I believe a national database for rural doctors managing airways is a great idea. mAke it simple, online…mAke it part of FOAMEd
    lets do it

  4. I have a dozen tubes from Broome on the audit tool already, lets st up a rural registry. Might have a keen trainee to collate the data also
    Casy

  5. Ok, lets chat about that in Google hangout tomorrow…

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s