Videolaryngoscopy is now recommended as a first-line technique for tracheal intubation in many clinical settings. However, documentation practises continue to rely on concepts developed for direct laryngoscopy, where the laryngeal view was closely linked to intubation success. In videolaryngoscopy, the link between excellent visualisation and ease of tube delivery may be less direct, limiting the interpretative value of view-based descriptors alone. Rather than proposing new classification systems, this editorial advocates a process-based descriptive language structured around three elements: what was used, what was seen, and what was done. This framework has the potential to complement existing grading systems and clinical guidelines and improve the clarity and usefulness of airway documentation in modern practice.

BackgroundThe exponential growth of Big Qualitative (Big Qual) data in healthcare research presents methodological challenges for traditional analysis approaches. This study evaluates the effectiveness of machine-assisted analysis using artificial intelligence (AI) tools compared to human-only analysis for processing large-scale qualitative datasets, using the Royal College of Anaesthetists' 7th National Audit Project (NAP7) baseline survey as a test case.Methodology/principal findingsWe conducted a comparative methodological study analysing 5,196 free-text responses about peri-operative cardiac arrest experiences. Three researchers established a human-coded reference standard following SRQR guidelines. We then applied machine-assisted analysis using Pulsar for exploratory analysis and Caplena for sentiment and thematic analysis, evaluating performance against the human gold standard using STARD-AI reporting standards. Performance metrics included accuracy, precision, recall, F1-scores, and Cohen's Kappa, with confidence intervals calculated using bootstrap resampling. Machine-assisted analysis substantially reduced analysis time, with particularly dramatic improvements in theme identification speed. The machine-assisted approach achieved good thematic and sentiment classification accuracy compared to the human reference standard, though human analysis identified an emergent 'ambiguous' sentiment category that current AI tools cannot accommodate, highlighting limitations in commercial platforms' flexibility for inductive analysis.Conclusions/significanceMachine-assisted analysis offers substantial efficiency gains with acceptable accuracy trade-offs for large-scale qualitative data analysis. However, human expertise remains essential for capturing nuanced meanings, identifying emergent categories, and providing domain-specific interpretation. This hybrid approach represents a viable methodology for Big Qual research, though current AI tools' constraints in accommodating emergent classification schemes remain a limitation. Our findings establish benchmarks for future development of more flexible AI systems adapted to qualitative research paradigms.

Background: A ‘cannot intubate, cannot oxygenate’ crisis is a rare but life-threatening airway emergency, with an emergency front-of-neck airway (eFONA) required to establish or maintain oxygenation. Episodes of eFONA are rare, with the UK-wide Fourth National Audit Project from the Royal College of Anaesthetists in 2011 reporting 58 cases of eFONA in 1 yr. This registry project aims to collect and analyse data systematically from a cohort of cases where eFONA has been attempted to improve understanding of these rare events. Methods: After appropriate regulatory approvals, the emergency front-of-neck airway registry (eFONAr) will collect details of voluntarily and anonymously reported, de-identified cases in which an eFONA was attempted from hospitals within the UK. The dataset has been developed and piloted using a modified Delphi approach and incorporates pre-, intra-, and post-event data on planning, processes, equipment, and human and team factors. A panel will generate a systems-based analysis of events and decision-making in the process of eFONA. Outcomes: The registry will provide estimates of population characteristics, procedural details, and eFONA incidence. The systems analysis will support future recommendations for research, clinical practice, and organisational policies related to eFONA. Clinical protocol registration: Open Science Framework (https://osf.io/kbmp4).

( Anaesthesia . 2024, 79, 514–523. doi:10.1111/anae.16204) Cardiac arrest (CA) among pregnant women is not common, occurring between 2.78 per 100,000 patients and 1 in 12,000 hospitalizations. Effective management of such situations necessitates modifications to customary resuscitation procedures, like manual left uterine displacement and prompt cesarean delivery (CD), to improve likelihood of maternal survival. In the UK, anesthetic complications such as local anesthetic toxicity and high neuraxial blocks, are the primary reasons for obstetric CA occurring before delivery. On the other hand, in the United States, typical reasons are bleeding, cardiac complications, amniotic fluid embolism, and septicemia.

Background: Patient safety within perioperative care is significant due to the potential for major complications requiring a rapid response. The Royal College of Anaesthetists' National Audit Projects (NAPs) have sought to improve patient safety by investigating serious and rare complications occurring during anaesthesia. The sixth NAP (NAP6), focused on perioperative anaphylaxis, and produced 134 recommendations. Staff perceptions of the impact of NAP6 recommendations have not been studied, which was the purpose of this research. Methods: Semi-structured interviews were conducted with a purposive sample of 21 healthcare professionals across three teaching hospitals in England and with five stakeholders who could share a national perspective. A documentary analysis was conducted with departmental and institutional documents associated with the training for, and management of perioperative anaphylaxis. Results: Examples of perceived impact included: raised awareness on the main culprits of perioperative anaphylaxis, and awareness to consider an event as anaphylaxis; changes in referrals of patients to allergy clinics; increased penicillin allergy de-labelling initiatives; better communication with healthcare professionals and patients; alerts to remind staff on recommended care; and updates to national guidelines. Limited access to allergy clinics; the need for further penicillin allergy de-labelling; the lack of accountability for implementing recommendations; misalignment between disciplines; difficulties removing incorrect allergy labels; and access to launch events were highlighted as areas for improvement in implementation. Whilst access to allergy clinics; good relationships with stakeholders in the field; hospitals engaged with quality improvement initiatives; and the perioperative allergy network were recognised as enablers to implementation. Conclusions: Future areas for consideration based on the perspectives shared by interviewees include improving access to allergy testing, enhancing penicillin allergy de-labelling initiatives, and sharing guidance on how to implement the recommendations (including funding).

We collected blank non-specialist anaesthetic records from 71 National Health Service Trusts in England. A data set was established by collating all data items found in an initial tranche of 28 records. All 71 records were subsequently analysed for each data item in this data set. We found significant variation: the most populated record included 216 data items and the least included 38 data items: a greater than five-fold variation. There was significant variation in the inclusion of data items commonly considered important to patient safety; 42% of records omitted documentation of fasting status, 72% omitted documentation of a discussion around the risk of accidental awareness during general anaesthesia, 92% omitted documentation of quantitative neuromuscular blockade monitoring and 63% omitted documentation for 'Stop Before You Block' when performing regional anaesthesia. The study highlights significant variability in the composition of anaesthetic records across England which may impact on its value as a data repository, an action trigger, a medicolegal account, and a tool to facilitate safe handover. Standardisation of the anaesthetic record or the establishment of standards of recording would help to allay potential risks to patient safety and assist in guiding future procurement of electronic solutions for anaesthetic records.

The 7th National Audit Project (NAP7) of the Royal College of Anaesthetists studied peri-operative cardiac arrest including those that occurred in the independent healthcare sector, which provides around 1 in 6 NHS-funded care episodes. In total, 174 (39%) of 442 independent hospitals contacted agreed to participate. A survey examining provider preparedness for cardiac arrest had a response rate of 23 (13%), preventing useful analysis. An activity survey with 1912 responses (from a maximum of 45% of participating hospitals) showed that, compared with the NHS caseload, the independent sector caseload was less comorbid, with fewer patients at the extremes of age or who were severely obese, and with a large proportion of elective orthopaedic surgery undertaken during weekday working hours. The survey suggested suboptimal compliance rates with monitoring recommendations. Seventeen reports of independent sector peri-operative cardiac arrest comprised 2% of NAP7 reports and underreporting is likely. These patients were lower risk than NHS cases, reflecting the sector's case mix, but included cases of haemorrhage, anaphylaxis, cardiac arrhythmia and pulmonary embolus. Good and poor quality care were seen, the latter including delayed recognition and treatment of patient deterioration, and poor care delivery. Independent sector outcomes were similar to those in the NHS, though due to the case mix, improved outcomes might be anticipated. Assessment of quality of care was less often favourable for independent sector reports than NHS reports, though assessments were often uncertain, reflecting poor quality reports. Overall, NAP7 is unable to determine whether peri-operative care relating to cardiac arrest is more, equally or less safe than in the NHS.

The 7th National Audit Project (NAP7) of the Royal College of Anaesthetists studied peri-operative cardiac arrest. Additional inclusion criteria for obstetric anaesthesia were: cardiac arrest associated with neuraxial block performed by an anaesthetist outside the operating theatre (labour epidural analgesia); and cardiac arrest associated with remifentanil patient-controlled analgesia. There were 28 cases of cardiac arrest in obstetric patients, representing 3% of all cardiac arrests reported to NAP7, giving an incidence of 7.9 per 100,000 (95%CI 5.4-11.4 per 100,000). Obstetric patients were approximately four times less likely to have a cardiac arrest during anaesthesia care than patients having non-obstetric surgery. The single leading cause of peri-operative cardiac arrest in obstetric patients was haemorrhage, with underestimated severity and inadequate early resuscitation being contributory factors. When taken together, anaesthetic causes, high neuraxial block and bradyarrhythmia associated with spinal anaesthesia were the leading causes overall. Two patients had a cardiac arrest related to labour neuraxial analgesia. There were no cardiac arrests related to failed airway management or remifentanil patient-controlled analgesia.

BACKGROUND:We analysed the clinical practice of anaesthesia associates in the UK, as reported to the 7th National Audit Project of the Royal College of Anaesthetists, and compared these with medically qualified anaesthetists. METHODS:We included data from our baseline survey, activity survey and case registry as with other reports from the project. RESULTS:Among 197 departments of anaesthesia, 52 (26%) employed anaesthesia associates. Of 10,009 responding anaesthesia care providers, 71 (< 1%) were anaesthesia associates, of whom 33 (47%) reporting working nights or weekends (compared with 97% of medically qualified anaesthetists in training and > 90% of consultants). Anaesthesia associates reported less training and confidence in managing peri-operative cardiac arrest and its aftermath compared with medically qualified anaesthetists. Anaesthesia associates were less directly involved in the management and the aftermath of peri-operative cardiac arrest than medically qualified anaesthetists, and the psychological impacts on professional and personal life appeared to be less. Among 24,172 cases, anaesthesia associates attended 432 (2%) and were the senior anaesthesia care provider in 63 (< 1%), with indirect supervision in 27 (43%). Anaesthesia associates worked predominantly in a small number of surgical specialties during weekdays and working daytime hours. Complication rates were low in cases managed by anaesthesia associates, likely reflecting case mix. However, activity and registry case mix data show anaesthesia associates do manage high-risk cases (patients who are older, comorbid, obese and frail) with the potential for serious complications. Registry cases included higher risk cases with respect to the clinical setting and patient factors. CONCLUSION:Anaesthesia associates work in enhanced roles, relative to the scope of practice at qualification agreed by organisations. Recent changes mean the Royal College of Anaesthetists and Association of Anaesthetists do not currently support an enhanced scope of practice.

Kevin Fong, Charlotte Summers, and Tim Cook unpick arguments that the NHS was not overwhelmed by covid-19, highlighting its legacy effects on healthcare and lessons for future health crises

It is a pleasure to see several editorials accompanying the Anaesthesia publications relating to the 7th National Audit Project of the Royal College of Anaesthetists (NAP7), which studied peri-operative cardiac arrest. The latest of these is by Dr Ahmad and Professor El-Boghdadly [1] and relates to the publication exploring airway and breathing events leading to peri-operative cardiac arrest in NAP7 [2]. We write to correct a factual error which unfortunately could lead readers to misunderstand the nature of NAP7 and any comparisons made to the 4th National Audit Project (NAP4) which studied complications of airway management [3]. Dr Ahmad and Professor El-Boghdadly correctly describe the criteria for inclusion for NAP4 (broadly, airway complications leading to death, brain damage, front of neck airway, a new ICU admission or prolongation of an existing ICU stay). They then describe the NAP7 inclusion criteria as (their italics) "a wider range of airway complications was collected that did not necessarily lead to harm, but were likely, or had the potential, to be associated with significant patient harm." Based on this they dissect (using extensive sporting analogies) whether a comparison between NAP7 and NAP4 is justified. Unfortunately, the authors have confused the definitions we used for collecting (airway and other) complications during the activity survey phase of the project [4] with those used as entry criteria for the registry [5]. When comparing themes in NAP7 with NAP4 we have only used a comparison of cases in the registry phases of each project, so it is the entry criterion for this that is relevant. In NAP7 this was a peri-operative cardiac arrest, requiring defibrillation or at least five chest compressions, occurring during a period of care by an anaesthetist for a procedure, or in the 24 h afterwards [6]. We agree that any comparison between the projects has limitations and needs very careful discussion (as we provided) but it is important that such discussion is based on an accurate understanding of the entry criteria for each project. It was once famously said (one hopes tongue in cheek) that "football is much, much more important than life and death" [7]. In the case of NAP7, life and death are exactly what we are studying. The rules must be understood to play the game properly, as when comparing one NAP with another. Without wishing to extend the authors sporting analogies to breaking point, and at the risk of courting great controversy, we call 'offside' and appeal to the video assistant referee (VAR) to ensure the correct outcome.