Efficacy of paediatric anaesthetic trolleys: A call for a basic standard and layout

1 Introduction

Airway related problems are the most common critical incidents in paediatric anaesthesia, frequently affecting infants [1, 2]. A recent UK National Audit concluded that a lack of equipment and resources, as well as deficiencies in training, are a major contributor to serious complications of airway management in anaesthesia including paediatrics [3].

Appropriately sized equipment and monitoring is essential to provide safe anaesthesia to children and neonates. It is good practice to have a designated paediatric anaesthetic trolley in areas where children are cared for. The Royal College of Anaesthetists (RCoA) broadly affirms this in its guidance [4]. A globally accepted minimum standard for the safe practice of anaesthesia exists that also refers to the minimum equipment needed [5, 6].

In practice however, the reality is far from this. There is a large variation in the type of trolleys provided and equipment contained therein. This often leads to delays and difficulties in finding appropriate equipment and disposable items in an emergency. This is partly because there is no explicit guidance on minimum equipment that should be contained and its layout in a paediatric anaesthetic trolley.

Staff are expected to be aware of the location of paediatric anaesthetic trolleys and familiar with its contents. However, lack of standardisation and haphazard layouts have hampered this effort.

In order to assess the current status quo, we conducted a survey of equipment available on paediatric anaesthetic trolleys in our hospital. We assessed its variability and adherence to the only descriptive standard available i.e. the checklist provided by the UK Resuscitation Council (UKRC) for emergency trolleys [7]. Having learnt its shortcomings and subsequent expert staff opinions, we report how above difficulties can be overcome by using a standard layout and essential checklist.

2 Methods

We identified all paediatric anaesthetic service areas and the equipment hosted in each area in our tertiary referral hospital where over 3000 paediatric, including neonatal, anaesthetics are given per year. We compared our compliance with the equipment checklist published by the UKRC for emergency trolleys, in a cross sectional observation in 2013. Items were considered present if found within the anaesthetic trolley or located within the anaesthetic room being assessed. In addition, we also looked at the layout of equipment.

We also made a qualitative enquiry from paediatric anaesthetists and operating department practitioners (ODP’s) in our hospital with regard to our paediatric anaesthetic trolleys. We asked two questions: (a) what have you found to be least useful when you use an anaesthetic trolley in paediatric practice and (b) how should we overcome this problem?

As a consequence, a revised checklist comprising minimum and essential items was introduced locally to standardise equipment availability in paediatric anaesthetic trolleys.

3 Results

We identified and included 11 areas in our hospital where anaesthesia is provided to children. We described equipment available against the UKRC checklist separately for airway & breathing, and cardiovascular support. Our findings for respiratory support are illustrated in Fig. 1. Cardiovascular findings were similar.

There was no regular pattern to the layout of items stocked in trolleys although there was ad hoc categorisation and labelling. Across the hospital, there were different types of trolleys that were not always readily identifiable. There was no uniformity, colour coding or equipment categories in its drawers. The layout of equipment was variable with horizontal, vertical or a combination of both being used.

There were considerable deficiencies of items in all areas. Endotracheal tubes, laryngoscope blades, oropharyngeal airways and face masks were the only airway equipment satisfactorily stocked (Fig. 1). None of the trolleys had adequate stocks of cardiovascular equipment even though the trolleys were checked on a daily basis.

4 Discussion

This is a unique survey of paediatric anaesthetic trolleys in an institution where there is a large commitment for paediatric and neonatal services. There has been a similar survey published in adult practice [8] but none in paediatrics.

The Association of Anaesthetists in Great Britain and Ireland (AAGBI) considers that a pre-anaesthetic check to ensure the correct functioning of anaesthetic equipment is essential for patient safety. They state this is primarily the anaesthetist [9]. Anaesthetists are required to check and record this evidence in patient records. An equipment scrutiny seems to be within this mandatory requirement. However, incorporating a pre-operative checklist of the anaesthetic trolley requires considerable additional time. Also, in reality, it is not realistic in emergency situations.

We have demonstrated significant deficiencies in the stocks of items stored on pediatric anaesthetic trolleys in the same hospital similar to the findings for adults [10]. This is despite having theoretical mechanisms in place to ensure a daily stock check. This variation has the potential to compromise patient safety if essential items are missing. The haphazard layouts are a hindrance when locating items in an emergency. It also hampers an efficient stock check.

Overstocking was an additional problem that we noted. It reduced the focus on essential items and the likelihood of finding a required item in a hurry. Our qualitative inquiry also reiterated the need for availability of equipment as well as the importance of the familiarity of the layout in emergency situations. A senior ODP commented: “We need internal dividers in drawers to keep items in place; otherwise it becomes a confusing mess. I hate overstocking with large quantities of unnecessary equipment such as size 4, 5 LMAs”.

Some ODP’s held the opinion that trolleys should contain all of the paediatric equipment to be self-contained and usable in any location. This does not necessarily help. Another experienced paediatric anaesthetist commented: “What annoyed me most was the lack of a T-piece breathing circuit with a 0.5 L bag and oxygen nipple adaptor. Non-anaesthetic staff frequently have no idea what this is, what it looks like or where it’s kept.” What is the use of oxygen if we cannot connect it to the patient?

Standard operating procedures introduced by other industries such as aerospace, have been effectively applied in medicine to improve the culture of safety [11]. Fire fighters have passionately embraced standardisation as part of their safety culture. This enables a fire fighter to function in any unfamiliar building efficiently [12, 13]. Healthcare is following this trait towards standardisation [7]. The introduction of checklists has improved patient safety for example in surgery [14].

Introducing a standard checklist for paediatric anaesthetic equipment will ensure availability of all essential equipment in a standard layout. This will enable those working in any unfamiliar environment, especially during urgent or emergent scenarios, to rapidly identify essential items. This is of particular importance for trainees who rotate between hospitals. A visual layout checklist using photographs was suggested as a means of improving staff awareness, familiarity of equipment and the layout of the stocks.

On the basis of our qualitative enquiry and survey we developed an empirical minimum checklist for paediatric anaesthetic trolleys and layout (Table 1). This will improve the safety of care provided to children. This follows the same principle of standardising a layout for difficult airway trolleys nationally [15]. There are some notable omissions on our list such as items that can be lifesaving or particularly helpful when managing a difficult patient. These include equipment such as emergency cricothyroidotomy needles or a defibrillator that should be stored and readily accessible on the paediatric difficult airway or cardiac arrest trolleys. Other useful items such as video laryngoscopes and ultrasound machines are expensive items and are not required routinely so should not be confused with the ‘essential’ items. Access to this equipment should be readily available by locally agreed mechanisms.

We stress the importance of not overstocking as it confuses and hides other essential equipment. Overstocking is bad practice. Fixed labelling at the bottom of a container quickly and easily alerts the user to the items missing in drawer compartments. This also allows an equipment check at a glance without the need to go through a checklist one by one.

The wide-ranging sizes of equipment for paediatric practice often leads to duplication with adult equipment especially when dealing with adolescents or in mixed service areas. In such environments, anaesthetic trolleys should rationalise equipment or adapt a combined adult and paediatric resuscitation trolley.

During this survey we noted a standard layout of equipment in two areas in our hospital. On these trolleys stock check was quick as items were identified readily. A simple format with concise labelling, colour coding, and combined vertical and horizontal layouts were found to the most user-friendly features. There was no over stocking. Vertically stacked items on the back surface of the top of the trolley in direct eye line enabled a free work surface and instant identification of items. Items that are repeatedly required in a single event (e.g. cannulae, bungs, syringes, 3-way taps, tapes, dressings) were stored in transparent compartments in the vertical layout.

The drawers gave more security. A standard layout within each drawer gave a sense of familiarity to the new user. When items run-out, the empty slots in the drawers with labels at the bottom instantly indicated what was missing. This allowed an instant visual check, without the need to go through an exhaustive checklist and re-stock.

The items that are needed once in a single event are best stored in the drawers (e.g. oropharyngeal airway, endotracheal tubes, masks etc.). The drawers can follow the universally accepted norm and stock A- Airway, B- Breathing, C-Circulation related equipment at separate ordinal levels.

System failures are often the cause of patient safety incidents. The key role that design can play in the NHS was highlighted by a Department of Health report in 2004 [16]. A standardised, consistent approach to equipment and layout makes the working environment more intuitive and safer especially when the user is unfamiliar with the work place or under pressure. Better organisation reduces the risk of human error and accidents especially in stressful situations [17].

A standard equipment checklist for resuscitation trolleys is already available [7]. We feel paediatric anaesthesia trolleys need to be standardised with a minimum requirement check list. We have developed a draft recommendation (Table 1) that needs wider scrutiny.

The NHS Design for Patient Safety report recommends a design-led approach to reduce errors and accidents to improve patient safety [16]. Inadequately designed equipment storage has been implicated in poor efficiency and critical incidents associated with resuscitation leading to trials of new designs [18]. Standardising paediatric anesthetic trolleys is another design led opportunity that cuts across 3 of the 6 healthcare quality domains outlined by the Institute of Medicine namely safe, timely and efficient delivery of care [19].

Conflict of interest

None.