Paediatric airway foreign body – The human factors influencing patient safety in our hospitals

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Abstract

Foreign bodies in the pediatric airway are an uncommon emergency with a high morbidity and mortality rate. Morbidity ranges from 10 to 20% worldwide and this pathology accounts for up to 7% of accidental deaths in children under 4. Dealing with this emergency safely and effectively is complex, requiring a tight coupling of procedures and processes and optimal anesthetic and operating conditions to prevent errors. These factors are recognized by the World Health Organization as ‘Human Factors’. We perform a multi-center assessment of human factors pertinent to this emergency. Specifically, equipment provision and staff training in this emergency.

Data was collected from 13 sites in the United Kingdom, using two questionnaires for medical and nursing staff. Information including equipment availability, location of equipment, and surgeon and nursing experience was recorded. Royal Manchester Children's Hospital (RMCH) set the study standard.

Our study shows there is huge variability in equipment provision across units. There is a lack of experience, confidence and training amongst middle grade otolaryngology surgeons and emergency theatre staff in handling this emergency.

Issues with equipment and inexperience of both middle grade doctors and nursing staff could result in significant patient morbidity and mortality. We suggest a standardized age appropriate equipment list and staff training in use of this equipment.

Implementation of these simple changes could reduce preventable error in this rare but serious emergency.

Introduction

Foreign bodies in the paediatric airway are an uncommon emergency with a high morbidity and mortality rate. Morbidity ranges from 10 to 20% worldwide and this pathology accounts for up to 7% of accidental deaths in the USA in children under 4 [1], [2].

In the UK there were 571 cases of airway foreign bodies reported in children under 14 from April 2014 to March 2015 and 84% of these cases occurred in children under 4 years of age [3].

Dealing with this emergency safely and effectively is complex, requiring a tight coupling of procedures and processes and optimal anesthetic and operating conditions to prevent errors. In healthcare, major errors and accidents rarely happen as a result of a single event and more often, are the result of a succession of minor errors culminating in an event with significant potential for injury or loss of life [4].

The human and individual characteristics that influence behavior and performance in healthcare in combination with environmental, organizational and job factors are recognized by the World Health Organization (WHO) as ‘Human Factors’ and they have developed a conceptual framework focused on patient safety to address these human factors [5].

The professional body that represents Ear Nose and Throat (ENT) in the United Kingdom (ENTUK), have addressed human factors in this emergency at a senior level, by developing a Paediatric ENT Skills Course for Consultants (PESCC). This provides a framework to improve care and outcomes. However, the human factors influencing successful management of this emergency affect all team members and not just the consultant surgeon in charge as senior medical staff are required to work in tandem with anesthetists, junior doctors and nurses amongst others.

There are few papers assessing human factors in pediatric bronchoscopy. They are predominately single unit studies, focused on proficiency of medical staff at assembling and using bronchoscopes [6] [7] and there is a US study using simulation to improve response times and identify latent safety threats in their unit, in this emergency [8]. Despite these studies and the work done by ENTUK, there is room for improvement in assessment and management of human factors in this condition.

Therefore, we perform a multiregional assessment of human factors pertinent to this emergency, looking specifically at equipment provision and staff training and staff confidence. Our goals are to provide literature on equipment provision and staff training in this emergency. Currently this is very sparse, and has not been addressed on a regional or national scale. These factors, should be consistent across all units in every region in order to help make them emergency safe.

Section snippets

Materials and methods

26 units in the North West, West Midlands and North Wales were contacted via their research collaborative and asked to participate in this project. To be eligible for this study, participating units had to provide out of hours ENT and pediatric care and they had to accept ENT trainees, who were involved in their regional research collaborative. Eligible units could respond either electronically via google forms or by returning a paper-based questionnaire.

Unit results were not anonymized to

Results

26 units were contacted via their regional trainee research collaborative and 13 units responded giving a survey response rate of 50%. These units included Manchester and Birmingham Children's hospitals, 2 tertiary pediatric centers. The remaining 11 units were district general hospitals serving populations ranging from 250,000 to 900,000.

Equipment provision ranged from 6 to 29 of the recommended items (see Fig. 1). Some units were noted to have up to 13 additional items on their pediatric

Equipment

Adequate and appropriate equipment provision is essential for the management of any emergency. Without the appropriate tools regardless of the skills of the staff available it is not possible to safely remove a foreign body from a pediatric airway.

Our study shows there is huge variability in equipment provision, across the regions surveyed. There is no formal guidance in the literature regarding the equipment necessary to successfully remove a foreign body from the airway. Therefore, we

Conclusion

Pediatric airway emergencies are complex cases to manage. Successful outcomes require a multidisciplinary and multifaceted approach. Individual characteristics that play a significant role in successful management of this emergency can be adversely influenced by organizational, environmental and job factors.

There are variations between units in the equipment and staff confidence and experience in managing this emergency. As a result of this work we suggest that there are simple changes that

Decleration of interests

Equipment list has been developed in conjunction with Karl Storz Endoscopy UK.

No funding has been accepted from Karl Storz Endoscopy UK for this study.

Karl Storz have provided half day training sessions on request to several sites that participated in the study.

Karl Storz have had no role in data collection, analysis or manuscript review.

Acknowledgements

Professor Nirmal Kumar – ENT Department, Royal Albert Edward Infirmary, Wigan Lane, Lancashire, WN1 2NN.

Jaya Nichani – ENT Department, Royal Manchester Children's Hospital, Oxford Road, Manchester, M13 9WL.

Huw Jones – ENT Department, Tameside General Hospital, Foundation St, Lancashire, OL6 9RW.

Melanie Dowling– ENT Department, Tameside General Hospital, Foundation St, Lancashire, OL6 9RW.

Omar Mirza – Salford Royal Hospital, Stott Lane, Salford, M6 8HD.

Emma Gosnell - ENT Department, Fairfield

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