Using audit to improve provision of analgesia for insertion of permanent pacemakers in children.

Pain has an adverse effect on the patient experience in hospital. The authors' institution used audit to improve the use of analgesia in the paediatric population. The audit cycle was repeated five times. Using education and training the institution was able to improve analgesia provision. A significant reduction in the number of children receiving no analgesia was demonstrated. In addition no further adverse event forms were submitted. Using audit can be an effective way to improve delivery of quality care.

Multidisciplinary difficult airway simulation training: two year evaluation and validation of a novel training approach at a District General Hospital based in the UK.

Our objective was to devise and assess a multidisciplinary simulated course in training junior doctors for possible difficult airway scenarios. The authors have run a multi-disciplinary difficult airway simulation that was designed to simulate the stresses and complications of a live situation. The course comprised of six to eight difficult airway simulations (using a Laerdal SimMan2 mannequin remote controlled by a "driver") with two teams moving through the simulations over half a day. The simulation lasted 20 min and was followed by 40 min of in-depth structured facilitated debrief. The course was set in the anaesthetic room of a district general hospital theatre. Seventy-eight candidates (28 anaesthetic trainees, 18 ENT trainees, 19 theatre nurses and 13 operating theatre practitioners) attended this course over 6 training days set over 2 years. The main outcome measures of candidate feedback scored for eight questions on a 1-6 Likert scale. From the results, Audit of Trust inpatient airway fatalities revealed three deaths in 2 years leading up to the introduction of the simulation course. Re-audit of the subsequent 2 years, during which time the course was running, has shown no airway fatalities. A 100 % candidate feedback response rate was obtained. Delegates gave an average score of 4.8 to the simulator replicating the stress of 'live' situations; 5.5 to the simulator addressing training needs; 5.6 to the course improving clinical knowledge, teamwork, leadership and non-technical skills. In our conclusions, successful management of a difficult airway situation requires rapid evaluation, effective communication, strong leadership and teamwork, as well as knowledge of local environment and equipment. The results show that candidates felt an improvement in clinical knowledge, teamwork, leadership and non-technical skills, as well as the mutual understanding and respect between related medical and non-medical team members. In addition, audit of airway mortality showed a Trust-wide reduction in inpatient airway related mortality following the course. The results emphatically demonstrate the universal success of this multi-disciplinary training method for all team members, regardless of hierarchical position or background.