Availability of difficult airway equipment to rural anaesthetists in Queensland , Australia

Introduction: Since 1990 several airway devices have become available to assist in difficult intubation. Multiple surveys have assessed difficult airway equipment availability in international anaesthetic departments and emergency departments. The practice of GP anaesthetists is unique in both its multidisciplinary nature and geographical isolation. Objectives: General practitioners performing general anaesthesia in rural and remote Queensland, Australia were surveyed to assess their access to difficult airway equipment and whether this was related to the remoteness of their location or attendance at continuing professional development activities. Methods: Design: survey. Setting: proceduralists performing general anaesthesia in hospitals categorised as Rural, Remote and Metropolitan Area (RRMA) classification 4 to 7 inclusive were surveyed. Outcome measure: data collected included demographic information, availability of airway management equipment, and attendance at continuing professional development activities. The received data was entered into a Microsoft Excel spreadsheet and analysed in Statistical Package for Social Sciences (SPSS Inc; Chicago, IL, USA) using the frequencies and crosstabs functions. The Fisher’s exact test was used. A p-value of less than 0.10 was considered noteworthy and a p-value of less than 0.05 was considered to be significant. A statistical comparison was made between


Introduction
Since 1990 several airway devices have become available to assist in difficult intubation.Multiple surveys have assessed difficult airway equipment (DAE) availability in anaesthetic departments and emergency departments internationally, allowing comparison with available recommendations [1][2][3] .In Australia, only adult emergency departments have been surveyed regarding airway equipment 4 .
The population distribution in Queensland, Australia results in a concentration of healthcare services.Outside secondary and tertiary centres elective and emergency airway management is performed by non-vocationally trained anaesthetists.Their practice is unique in both its multidisciplinary nature and geographical isolation 5 .
All general practitioners who perform anaesthesia in rural and remote Queensland were surveyed to assess the availability of DAE and whether this was related to practice location or involvement in continuing professional development (CPD) activities.The results may influence future training opportunities and provision of DAE in remote areas.

Methods
Following approval by the Royal Brisbane and Women's Hospital Human Research Ethics Committee, the survey was sent to all rural general practitioners listed with Health Workforce Queensland (HWQ) as proceduralists performing general anaesthesia in rural locations.The HWQ is a rural workforce agency whose key activities are 'to facilitate the recruitment, retention and quality of general medical practitioners and primary health care teams in rural and remote Queensland communities' 6 .Our sample included proceduralists in hospitals categorised as Rural, Remote and Metropolitan Area (RRMA) classification 4 to 7. © V Eley, B Lloyd, J Scott, K Greenland, 2008.A licence to publish this material has been given to ARHEN http://www.rrh.org.au 3 The RRMA system is a remoteness classification that divides Australia into areas according to city status, population, rurality and remoteness 7 .The scale is 1 to 7 with Returned surveys were de-identified and numbered.Seventynine surveys were distributed.An incentive prize was advertised to enhance the response rate.
The first section of the survey covered demographic information including CPD activities specifically related to airway management skills.The next section identified equipment currently available to the practitioner.This was based on the American Society of Anesthesiologists' (ASA) suggested contents of a portable storage unit for difficult airway management 8 (Fig2).The availability of on-site assistance was surveyed, with additional space for general comment on the subject.
The received data were entered into a Microsoft Excel spreadsheet and analysed in Statistical Package for Social Sciences v15.0 (SPSS Inc; Chicago, IL, USA) using the frequencies and crosstabs functions.Due to small cell counts, some categories were combined.Some variables were transformed and re-analyzed as binary variables but this did not always resolve the problem of small cell counts.The Fisher's exact test was used.A p-value of less than 0.10 was considered noteworthy and a p-value of less than 0.05 was considered to be significant.In many cases there were several respondents from each hospital, therefore results were analysed as per respondent, rather than per hospital.
A statistical comparison was made between the known demographics of the target population (n = 79) and the survey responders (n = 35) 9,10 .The known demographics were derived from the Health Workforce Queensland (HWQ) database and included age, gender, practice location and practitioner type.Accurate data for level of experience (in years) was not available.

Results
Thirty-five surveys were returned (response rate of 44%).
Respondents from 21 hospitals returned their surveys.The demographics of the target population and survey responders were compared to determine if the survey results were representative.There was no statistical difference between the two groups in terms of age and gender.There was no statistical difference in terms of practice location, although the small percentage responding from RRMA 6 was notable.
There was a difference between the groups in terms of practitioner type.The responder group consisted of 38% hospital based and 62% Queensland Health salaried.The target population consisted of 58% hospital based and 42% Queensland Health salaried.This was statistically significant (p = 0.0002).
Demographic data are summarised (Table 1).Hospitals classified as RRMA 5 were the most frequently represented (50%).The respondents were experienced practitioners with 25 out of the 35 (71%) having greater than 10 years experience.There was wide variation in number of anaesthetics performed.
Thirty-four out of the 35 (97%) had attended at least one CPD activity specific for airway skills in the last year.
Practitioners in the more remote locations were less likely to have attended an event such as conference, workshop or skills training laboratory (p = 0.058) (Table 2).These were the most commonly attended activities (91%), as shown in Table 3.
Most practitioners had no expert assistance available to them in elective cases (60%) or emergency cases (63%).In the absence of assistance, 13 of the 35 (37%) utilised telephone assistance from larger institutions.There was no relationship between the RRMA category and availability of expert assistance.

1.
Rigid laryngoscope blades of alternative design and size from those routinely used; this may include a rigid fibreoptic laryngoscope 2.
Tracheal tubes of assorted sizes 3.
Tracheal tube guides.Examples include (but are not limited to) semirigid stylets, ventilating tube changer, light wands, and forceps designed to manipulate the distal portion of the tracheal tube 4.
Laryngeal mask airways of assorted sizes; this may include the intubating laryngeal mask and the LMA-Proseal TM (LMA North America, Inc., San Diego, CA) 5.
At least one device suitable for emergency noninvasive airway ventilation.Examples include (but are not limited to) an esophageal tracheal Combitube (Kendall-Sheridan Catheter Corp., Argyle, NY), a hollow jet ventilation stylet, and a transtracheal jet ventilator 8.

An exhaled CO 2 detector
The items in this table represent suggestions.The contents of the portable storage unit should be customized to meet the specific needs, preferences, and skills of the practitioner and the healthcare facility.Data pertaining to equipment is summarised (

Discussion
The majority of rural general practitioner anaesthetists in Queensland felt they have appropriate DAE.This is not reflected in the data collected.Predominantly, there was no relationship between the availability of equipment and the remoteness of the practice location.The isolated nature of rural anaesthetic practice is highlighted with limited on-site assistance for an elective or emergency difficult airway.Surgical airway devices were the most readily available (86%).Less invasive devices (bougies, stylets) used prior to surgical airway were not commonly present, or known by the respondents to be present.
Access to intubating LMA of sizes 3, 4 and 5 was limited.
This non-surgical method allows more efficient ventilation Access to a fibreoptic bronchoscope was higher than expected (7 of 35) and this was not related to remoteness.
Comments reflected difficulties in achieving and maintaining bronchoscopy skills in rural anaesthetic practice.
The cost of maintaining equipment could be prohibitive 14 .
.Rural doctor turnover is well documented 18 and may contribute to unfamiliarity with difficult airway management devices.

Conclusions
Further study is required to strengthen the validity of the data.However, based on our current analysis we suggest a © V Eley, B Lloyd, J Scott, K Greenland, 2008.A licence to publish this material has been given to ARHEN http://www.rrh.org.au 8

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being most remote (Fig 1).The working brief of Rural Workforce Agencies includes locations classified RRMA 4 to 7. The HWQ information is updated annually and is confidential.The authors were blinded to the personal details of the practitioners and mailing was coordinated by HWQ.

Figure 2 :
Figure 2: Suggested contents of the portable storage unit for difficult airway management -ASA Taskforce on Difficult Airway Management 8 .
than a classic LMA and provides a means of subsequent intubation.Minimum training is required for this technique 11 .© V Eley, B Lloyd, J Scott, K Greenland, 2008.A licence to publish this material has been given to ARHEN http://www.rrh.org.au7 The ASA Guidelines for Management of the Difficult Airway recommend using alternative laryngoscope blades in an unanticipated difficult airway.Our survey revealed that straight and McCoy blades were less frequently available than curved blades.The use of a McCoy blade utilises preexisting skills, is non-surgical and has been shown to improve laryngoscopy views in 50% of patients 12 .The infrastructure involved in maintenance is similar to that of standard laryngoscope blades.Size one classic LMA was available in 37% of cases.The use of an LMA in newborn resuscitation was discussed in the most recent resuscitation guidelines 13 .Wider access to size one LMA may be warranted, especially in the setting of obstetric anaesthesia.
standardised collection of user-friendly difficult airway equipment for rural anaesthetists.Expert use of this equipment could be supported by more widely available airway workshops.Simple equipment should be universally available.Provision of fibreoptic bronchoscopes and retrograde intubation kits should be reviewed carefully due to the high cost and difficulty in maintaining skills.Standardising equipment would recognise the specialised environment of rural anaesthetists and has the potential to improve patient safety.Information pertaining to critical incidents in rural anaesthesia and the relationship to available equipment remains an area for future research.
LMA North America Inc; San Diego, CA, USA) in all sizes was low.Seven out of the 35 (20%) reported the availability of a fibreoptic bronchoscope with one stating an inability to use it and another noting difficulty in obtaining and maintaining skills.

Table 3 : Participation in airway-related continuing professional development activities
CPD, continued professional development.