Two months ago, we held our first Tweet Chat of the year where the preliminary results from The Airway App, a new tool for capturing eFONA experiences,were discussed. We heard from the authors of the paper, researchers, clinical experts, users of the app and other interested parties. There is uncertainty regarding which eFONA technique(s) is/are most effective, yet previous research and audit strategies have arguably increased rather than resolved this uncertainty. Studying rare events such as eFONA is notoriously difficult, with many barriers to capturing such cases in sufficiently accurate detail. The Airway Appis a smartphone application, freely available to download, that permits the anonymous reporting of eFONA experiences to a central database. In their paper, Duggan et al. report 99-real patient eFONA procedures as reported from 21 countries around the world. Interestingly, only 32% of procedures were carried out by anaesthetists, 65% were for ‘cannot intubate, cannot oxygenate’ and the most popular technique was ‘scalpel-bougie cricothyroidotomy’, with 37/45 successful at first attempt for all 99 cases.
In their editorial, Greenland and Irwin discuss the strengths and weaknesses of The Airway App in the context of other strategies to study cases of eFONA. Although the use of modern innovative research methods such as The Airway Appmay reach the places traditional methods cannot, they argue the successful management of a ‘cannot intubate, cannot oxygenate’ scenario is strongly influenced by complex psychological aspects together with technique familiarity over and above the method chosen. Regardless, we call for all to download the application and to spread the word to colleagues. Additionally, if you hear of a case of eFONA in your hospital, please ask the individuals involved to anonymously report it using The Airway Appso we may collectively learn from such cases.
We are now accepting applications for a one-year Fellowship attached to the Journal, starting at the AAGBI Annual Congress in September 2018. The deadline is the 31stof May 2018 and the advert for the post can be found here. This month, our previous fellows Annemarie Docherty and Kariem El-Boghdadly report their paper, which is the first to study the distribution and scholarly output of individual anaesthesia research grants. Data on 121 grant awards accounting for £3.5 million were collected, of which 91 completed studies resulted in 140 publications and 2759 citations. The overall cost per publication and citation was £14,970 and £1515 respectively. In response, the NIAA issued a press release stating although UK anaesthesia receives significantly less research funding than other speciality areas, the cost per publication represents superior value for money in comparison to these other speciality areas.
Figure 1 Geographical location of NIAA grant applications from the UK (a) and London (b) as well as grants awards in the UK (c) and London (d). The size of the dots represents the amount of money applied for, and the colour of the dots reflects the number of applications (a and b) or the success rate (c and d) Because London had >80% of grant applications and awards, it has been plotted separately.
In their accompanying editorial, Pandit and Merry discuss these results in the context of research waste, the link between funding and publication and the building of academic capacity. They argue if we are truly to serve our patients as anaesthetists, we need our practice to be informed by well-conducted research. The results of El-Boghdadly highlight many areas in which this research can be improved. In their editorial, Smith and Irwin also discuss the results of El-Boghdadly, but this time in the context of potential dilemmas for the NIAA, the responsibilities of funders and meaningful measures of impact. They argue it is disappointing that 20% of grant recipients (representing ~£700,000 of funding) did not respond to the survey. The centres concerned are listing in an online appendix which can be found here.
Table 1 Forms of research waste
Recently, the ‘Get it right first time’ (GIRFT) report for cardiothoracic surgery was published and a number of quality improvement recommendations were highlighted. Quality improvement through reducing variation with initiatives such as enhanced recovery after surgery (ERAS) often meets many barriers, despite good evidence of benefit from such protocols. This paper by Smirk et al. studies the use of a ‘Greenie Board’ from The US Navy as adapted to the scenario of adherence to the anaesthesia-related components of an established ERAS protocol. They conclude the use of an audit and visual feedback system for anaesthetists, such as the Greenie Board, can improve and sustain compliance to process measures, such as an ERAS protocol, with potential for improved surgical outcomes.
Figure 2 The components of the ERAS protocol assessed for compliance and how each anaesthetist’s score is translated to a colour block on the Greenie Board.
Figure 3(a) The baseline audit of Greenie board data (pre‐implementation). (b) The post‐implementation Greenie board (six months after implementation).
In their editorial, Levett and Grocott argue this low-cost intervention could improve the reliability of delivery of anaesthetic care. For example, we would be disappointed if our garage mechanic chose to only complete some aspects of a required car service, so why should the perioperative care patients receive be subject to such variation? In the era of marginal gains and continuous gradual incremental improvements in healthcare, such initiatives as those presented by Smirk et al. may do much more to improve patient outcomes than any randomised controlled trial. (…but more on the why, when and how of pragmatic trials in perioperative medicine next month!)
Another important study this month is this narrative review of nerve blockade for the early management of elderly patients with hip fracture. (You may also want to head over to early to read this new consensus statement on the principles of anaesthesia for patients with hip fracture.) A key conclusion is the recommendation that nerve blocks, such as the fascia iliaca block, should be incorporated into routine multi-modal acute pain management protocols. Overall, this fresh approach to hip-fracture pain management, through an up-to-date evidence synthesis, is essential reading for all routinely caring for such patients, whether in the emergency department, on the orthopaedic ward, in theatre or elsewhere.
In this month’s Statistically Speaking, Choi and Wong discuss statistical prediction in relationto a previous study of gastric ultrasound vs. clinical assessment in paediatric patients. They conclude that, according to the results of the study, judging gastric content by asking patients about their recent intake is no better than tossing a coin! Elsewhere this month there is a clinical guideline on pre-operative exercise training in patients awaiting major non-cardiac surgery(this has already proved popular on Twitter!); a case-report of ECG failure in the operating room; a study of the association of postoperative mortality with time of day, week and year; a study of tranexamic acid in trauma patients; and muchmore!
We began with a clarion call for all clinicians to download The Airway Appand spread word of its existence. We end with two further such requests. Firstly, if you know any trainees with an interest in the research process who may be interested in applying for our one-year fellowship programme, please ask them to get in touch. Finally, if you have recently managed an interesting case please consider writing it up for our sister journal, Anaesthesia Cases! Recent cases include the use of THRIVE for rigid bronchoscopy in a nonagenarianand a neurogenic tumour of the posterior mediastinum with symptoms of sympathetic ganglia block.
That’s all for this month. We hope you enjoy the June issue as much as we did. See you over on Twitter!
Mike Charlesworth Andrew Klein
Trainee Fellow Editor-in-Chief