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Understanding the safety of airway management requires measuring it but improving it requires action

In this issue of the journal, Cumberworth et al. report the results of a service evaluation examining complications of airway management in four hospitals [1]. It is one of a flurry of similar studies recently reported [2–4] or conducted (the Aerocomp study, http://www.uk-plan.net/AeroComp and theNAP7 activity survey, https://www.nationalauditprojects. org.uk/NAP7-Activity-Survey#pt). These studies give us pause to consider where we now are with the safety of airway management, a decade on from the publication of the 4th UK National Audit Project, more popularly known as NAP4, with its legion recommendations [5]. NAP4 studied major complications of airway management throughout a full year in four countries, giving denominators of a little under 3million anaesthetics, 20,000 emergency department intubations and 58,000 intubations in the intensive care unit (ICU) [6–9]. Only high severity complications were included: those leading to death, brain damage, ICU admission or prolongation of stay, or the need for an emergency front-of-neck airway (eFONA). A total of 184 such cases were included, and while the detailed datacapture enabledmany calculations of incidence, the project perhaps thrived mostly due to the detailed case review and thematic analysis which characterises the NAP methodology [10]. The report included narrative reviews of current and new knowledge acquired from the study; detailed numerical analysis, themes that emerged; and recommendations based on the synthesis of all these elements. Recommendations to improve practice – 166 in total –were focused at national, institutional and individual levels. Three years after the publication of NAP4, its impact was measured by a national survey which explored changes to practice made as a direct result of its recommendations [11]. The proportion of departments with a designated airway lead was 95% (almost doubled from before NAP4) and this has now risen to very close to 100%, with the programme also adopted by several countries outside the UK [12]. Individual and institutional practices were reported to have changed extensively. Considering anaesthesia, ICU and emergency departments separately, changes were made in 95%, 80% and 53%, respectively. The extent of implementation of individual recommendations was considered to ‘close the safety gap’ and using thismetric the extent by which this gap was closed in anaesthesia, ICU and emergency departments was 40%, 56% and 48%, respectively. Major changes included: the extent and type of training in eFONA; the development of airway policies and algorithms; widespread implementation of capnography; and improved access to and standardisation of airway trolleys outside operating theatres. Conversely, changes in training and human factor elements appeared less well implemented. Cumberworth et al. undertook a thorough study in four hospitals, in or around Oxford in the UK, and examined the rate of airway complications over 1 y. This is not an easy work, and the authors are to be congratulated on their